Pelvic Organ Prolapse
Pelvic Organ Prolapse
Assessment, Treatment, and Prevention with Physical Therapy
This past week, I gave a presentation on physical therapy for pelvic organ prolapse to a group of women at the Cancer Support Communities in Redondo Beach. The interest in the topic for many within this particular group was for women to understand their risk and treatment for prolapse after hysterectomy due to cancer. However, after the presentation, the organizer told me, "Your presentation is for all women regardless of what type of cancer they have. I found your presentation to be very informative." Pelvic organ prolapse, or POP, is a topic that is very relevant to all women as 45% of women between the ages of 45 and 85 have some form of POP. Does that statistic surprise you? The number is even higher among women who have had children, at 66%. So, why have many women not heard of it, or even understand that they are at risk for it? One reason is that, despite 45% of women having POP upon exam, only 12% of them are having symptoms. That may be because it is not severe enough for them to have symptoms, because they are not aware of what to look for, or because they think these changes are normal. Another reason is that many doctors don't want to scare patients by telling them when they have a mild prolapse. While it's not something women need to be scared of, I do hear from women all the time saying they wished someone would have told them this was possible and telling them how to prevent it before it had gotten so bad.
Before we get too much further, though, let's talk a little bit about what pelvic organ prolapse (POP) is. POP is when one of our pelvic organs, typically the bladder, uterus, or rectum, drops from its normal place in the pelvis into the vaginal canal, and in severe cases, outside of the body through the vaginal canal. If you're finding this hard to picture, check out this video of a bladder prolapse, or Cystocele, from the American College of Obstetricians and Gynecologists:
For more great videos of other types of prolapse, please visit the ACOG website. As you can see from the above video, in a bladder prolapse, the bladder drops down through the front vaginal wall. However, in most cases, it does not leave the vaginal canal as it does in the video. So, even though it looks pretty scary, it doesn't have to be. Remember only 12% of women over 45 have symptoms of prolapse, despite 45% of them having some degree of prolapse on exam. But what most women want to know is, what are the risk factors for pelvic organ prolapse, and if I am at risk or may already have a mild form of it, how can I keep my organs inside my body!?
Risk factors: Some of the biggest risk factors have to do with childbirth. If you've had a baby, you're automatically at a higher risk than someone who hasn't. That risk gets higher the more babies you have, with vaginal delivery vs. c-section, if you had large babies, had complications or injury during birth, or if you were >35 when you had your first baby. In addition to birth-related factors, other things that put you at risk are being overweight, age>60, chronic constipation or cough, frequent heavy lifting, smoking, and diabetes.
Symptoms: Many women are also not familiar with the symptoms of prolapse. These can vary widely, depending on what type of prolapse you may have. For any type of prolapse, many women complain of feeling pressure, pain, or heaviness in the vaginal area that worsens toward the end of the day or with a lot of walking or standing. They may also notice a bulge or something there that wasn't there before. For a bladder prolapse (cystocele), women may have increased frequency or urgency to go to the bathroom, may drip after going to the bathroom, or have other forms of urinary incontinence. They may also complain of feeling like they didn't empty their bladder all the way. For a rectal prolapse (rectocele), women may have a strong urgency for bowel movements, may feel like they are not emptying all the way or have difficulty completing bowel movements, and may have to use their fingers to push from their vagina or perineum to complete a bowel movement.
The Pelvic Floor: Now, with that out of the way, what the heck can we do about it? The answer comes down to our pelvic floor, as it so often does around here. If we are having prolapse, that means that there is a weakening of the connective tissue (ligaments, fascia) that are supposed to hold up our pelvic organs. This happens with birth, menopause, and the other factors mentioned above. So, when the connective tissue is weak, what's left to pick up the slack is our pelvic floor muscles. Our pelvic floor becomes our primary defense against our organs falling outside our body when other systems fail. A strong pelvic floor that contracts when it needs to can counter pressures that come from coughing, sneezing, lifting, standing, or walking.
Solutions: So, where does physical therapy come into this? Can't I just do kegels? Well, yes and no. First off, upwards of 60-75% of women don't know how to do a kegel correctly, despite over 65% of them feeling confident about their ability to do one. This makes sense, right? No one ever showed you how, and it's not necessarily intuitive. We can't see these muscles, and can't necessarily tell if they're strong or weak, unless we are leaking urine or having other symptoms. So, a physical therapist can help tell you if you're doing them correctly. In addition, even though over 90% of women knew they were supposed to do kegels after childbirth, less than 50% actually did them, and more than half didn't know they were supposed to continue them past that time. Physical therapy can help you establish an exercise routine that includes pelvic floor exercises (kegels), that's hopefully not boring and is easy to implement into your daily routine.
In addition, and as always, kegels alone are not the whole picture. You need to be able to use these muscles during functional activities. A physical therapist will also talk to you about how to modify or build up to activities you enjoy so that you don't make prolapse worse. These activities may include running, jumping, or lifting. Also, if constipation is an issue, we can talk about strategies to avoid constipation and why that's important (because the pressure from the full bowel and from straining to go can cause or worsen an existing prolapse). In addition, we will often work on strengthening other core and pelvic/hip muscles because we want a strong and stable structure for our organs to live in, and that helps in the long run to maintain your improvements.
So, will physical therapy fix prolapse? While it can improve the anatomical severity, we are not completely "fixing" the issue. But what we can do is drastically improve any symptoms of prolapse and prevent the prolapse from getting worse. And even if someone ends up needing surgery (11% of ALL women will have surgery for prolapse by the time they reach 80), they will have improved outcomes if they participate in physical therapy first. This becomes important because of those 11% of women who end up having surgery for prolapse, 30% of them have to have surgery again later.
Contact us to learn more about pelvic organ prolapse and physical therapy treatments available.