Prolapse Types, Symptoms, Risk Factors, Prevention and Management

Pelvic Organ Prolapse. So much lack of awareness about it, yet so many women are struggling because of it. In fact, it affects about 50% of women who have had children (but it can also affect women who have not had children)

What is pelvic organ prolapse? Put ‘simply’ it is when one (or more) of your pelvic organs, i.e. the rectum, bladder, or uterus, drops down into the vagina. It happens when there is a lack of support by the pelvic floor muscles, ligaments, and fascia.

What are the symptoms of a prolapse?

For some women, there are not many symptoms, and they get on with their daily lives without knowing they have a prolapse until a gynae maybe mentions it to them at a visit. This is usually in the initial stages, or for mild prolapses. This was my case during a smear test before my 2^nd child. However, I felt disappointed by the lack of information and guidance, and was simply told

“Wow, how many kids did you have? Only one? He must have been big. Better start doing your pelvic floor exercises”.

I left feeling confused, disheartened and so worried. This is where my interest and studies in pelvic floor and core training began.

So, back to the symptoms, or ‘tell-tale’ signs that signal you may have a prolapse. This is not meant as a self-diagnostic tool, but just to raise awareness. Always check with a women’s health physio who can properly assess, diagnose, and guide you.

• A ‘heavy’ or dragging feeling in the pelvic area (that same kind of feeling you get in the last weeks of pregnancy when the baby has started to engage)

• Lower back pain (however, remember, many things can cause lower back pain)

• Inability to hold in or insert tampons

• Incontinence problems

• Changes with sexual intercourse: painful sex; difficulty with penetration; a loose feeling during intercourse

• A feeling that you never have complete emptying of the bowels

• A lump or bulge in the vagina (can feel like a tampon that moved out of place or that you are sitting on a ball)

• The most ‘obvious’ sign – tissues protruding (or a bulge) from the vagina or anus

The different types of pelvic organ prolapse

There are different kinds of pelvic organ prolapse, depending on which organ is involved. The main types are:

• Bladder Prolapse (Cystocele/Anterior wall prolapse) – when the bladder bulges into the front wall of the vagina
• Rectal Prolapse (rectocele/posterior wall prolapse) – when the rectum bulges into the back wall of the vagina
• Uterine prolapse – the uterus ‘falls’ down into the vagina
• Vaginal Vault Prolapse – when the vagina descends from its optimal position

There are also other types such as urethrocele (urethra protrudes into vagina) or enterocele (small intestine protrudes into the vagina).

It is possible to have more than 1 type at any given time. At an assessment, your prolapse may be ‘graded’ on a scale of 1-4, depending on its severity.

What increases the risk of prolapse?

Several things can lead to, or increase the chances of getting a prolapse, the most common being:

• Childbirth through vaginal delivery – this is because of something called Levator Avulsion (this is when there is a disconnection of the levator ani muscles from the bony parts of the pelvis)

• Chronic constipation and repetitive straining

• Menopause – this is due to many factors, including change or reduction in collagen

• Doing lots of heavy lifting without controlling intra-abdominal pressure

• Hypermobility or hyperflexibility

• Hysterectomy (especially for vaginal vault prolapse)

Preventing and Managing Pelvic Organ Prolapse

There are certain lifestyle strategies and exercises that can be done to prevent a prolapse in the first place. These strategies should be learnt by every woman at an early age – many of them come through awareness of our body and how we move.

These same strategies can also help to manage the pelvic organ prolapse by improving the symptoms and preventing it from worsening. Even women who have undergone or are going to undergo surgery for pelvic organ prolapse, should learn these strategies, as they are vital in managing the prolapse long-term.

Lifestyle strategies

1. Pelvic floor exercises for pelvic floor muscle training – this starts with the ‘squeeze and lift’ kegel but must also go beyond that, and incorporate it with functional movement

• Strengthening and learning to activate the deep core muscles – the core provides support and stability for the whole body, and is connected to the pelvic floor and so also plays a vital role in pelvic organ prolapse

• Engaging (activating) and also relaxing the pelvic floor muscles along with the core muscles synergistically at the appropriate time

• Improving your gut health – straining and constantly being ‘backed up’ will put more and more strain on your already weakened pelvic floor and will only push organs further down.

• Learning how to exercise with the pelvic floor in mind, to prevent excessive intra-abdominal pressure that puts strain and excessive downward forces onto the pelvic floor and supporting structures

• Learning about and being conscious of pelvic floor safety and dangers in everyday activities, e.g. bracing when lifting or standing (or even coughing), not-breath holding, prolonged squatting, doing too much at once (e.g. moving heavy furniture, lifting things) especially without proper form

• Relieving the heaviness and low back pain – lie down on your back with a pillow under your knees, or with your legs straight up against a wall (at a 90 degrees angle). This reverses the centre of gravity and can provide short-term relief.

Pessaries and Surgery

In some cases, a well-guided pelvic floor and core training programme can be enough to manage a prolapse and ease its symptoms. In some cases, further help is needed through the use of pessaries, inserted by your gynae.

The pessary can be useful in providing relief from symptoms, however, the above strategies should still be implemented, i.e. learning to control intra-abdominal pressure, and a good pelvic floor and core programme.

In some cases, surgery may be recommended if the conservative routes and/or pessaries are not providing enough relief and improvement in symptoms. Your gynaecologist will guide you on this.

Also, remember to ask your gynae to check for pelvic organ prolapse at your regular visits, so that you may catch it when it is mild and implement these preventative strategies.