Written by Reshma Rathod, MSPT, MBA
May 11, 2014
Co-author Joanna Hess, PT, DPT, Physical Therapist at Restore Motion
Editor’s Note: In honor of Mothers’ Day, we thought we’d discuss a common problem that can affect all women, although it is more commonly seen in those who have given birth — one of the less rewarding consequences of motherhood.
“Something is falling out!” You’re in good company with 50% of mothers and many other women who have pelvic organ prolapse (POP). Without appropriate support, the pelvic organs will descend toward the vagina and cause discomfort. Prolapse can present as heaviness around the vagina, a weak urinary stream, decreased bladder control, incomplete emptying, difficulty with bowel movements and discomfort or pain with intercourse. In more extreme cases, the organs can actually be visualized coming out through the vagina or rectum. POP is also correlated with higher rates of lower urinary tract problems, including bladder infections and upper tract kidney distension.
Many factors contribute to prolapse, but fall into the categories of weakening of either 1) the ligaments that suspend the intestines, bladder and uterus from above, or 2) the muscles lining the very bottom of the pelvis, creating a stable shelf for the organs. Prolapse can include descent of the bladder, uterus, small intestines and/or rectum. It is more common with a history of vaginal delivery, multiple pregnancies, hysterectomy, decreased estrogen with menopause, obesity, repetitive heavy lifting, chronic constipation and chronic coughing.
The treatment of prolapse depends on symptom severity and classification. Less severe prolapse usually is due to weakness of the muscles that support from below. These patients can benefit from pelvic floor muscle training and improve the degree of prolapse. In post-menopausal women with less severe prolapse, symptoms can improve on their own without intervention. Some things lift as other parts drop?! It’s difficult to understand, but that’s what the literature shows.
More severe prolapse usually represents a weakening of the ligaments that suspend the organs from above and will usually require external support such as a pessary or surgery for symptom management. The literature supports both options for improved symptoms with variable levels of discomfort and complications.
Conservative treatment involves watchful waiting, improving body mechanics, particularly for moving heavy objects, and treating chronic constipation and cough. Other lifestyle modifications include improving breathing patterns during exercise and encouraging smoking cessation. Although weight loss may be recommended for general health, surprisingly, it has not been shown to improve prolapse.
Pelvic floor muscle training can improve symptoms. At the most basic level, Kegel exercises help strengthen the pelvic floor musculature, the shelf on which the pelvic organs rest. Abnormal function of the pelvic floor will alter stability and movement patterns in other parts of the body. The nature of the problem of the pelvic floor needs to be addressed in the type of pelvic floor contraction exercises in order to see meaningful results. Also consider the position you are in when you do the strengthening exercises as this will alter the effects of gravity (if you are lying down versus upright), and the recruitment of the hip-pelvic floor muscles (hips bent or straight).
The instructions for correct pelvic floor strengthening are written in a previous post about urinary incontinence. Kegels are often done incorrectly with substitutions that include glut (buttocks) contractions, breath holding, bearing down and pelvic tilts. In these cases, it is helpful to consult a pelvic floor physical therapist to help isolate and identify the biomechanical reasons why it is difficult to recruit specific portions of pelvic floor muscles. Pelvic floor physical therapists use biofeedback to assist with the learning process of isolating the pelvic floor muscles, use manual therapy to align the body to facilitate the recruitment of the appropriate muscles, and prescribe an exercise routine to re-train them to work properly.
Addressing prolapse symptoms is part of keeping our bodies healthy and moving. If lifestyle modifications and Kegels are insufficient to manage your symptoms, talk to your physician to explore more options.
References:
Brækken I H, Majida M, Ellström Engh M, Bo K. Pelvic floor muscle trainign in treatment of pelvic organ prolapse – a single blind randomised controlled trial. Int Urogynecol J Pelvic Floor Dysfunct. 2009;20(1):45-51.
Hagen S, Stark D. Conservative prevention and management of pelvic organ prolapse in women. Cochrane Database Syst Rev. 2011;(12):CD003882.
Handa VL, Garrett E, Hendrix S, et. al. Progression and remission of pelvic organ prolapse: a longitudinal study of menopausal women. Am J Obstet Gynecol. 2004;190(1):27-32.
Pelvic Organ Prolapse. In DynaMed [database online]. EBSCO Information Services. http://search.ebscohost.com.proxygw.wrlc.org/login.aspx?direct=true&site=DynaMed&id=113862. Updated 2014 Mar 18. Accessed 2014 Apr 17.