Prolapse – Pandora’s Box


pandora's boxProlapse can be the elephant in the room… the gym… the relationship… in someone’s self esteem. Because this subject is so important, so under-discussed, this blog avoids my usual amusing musings, and is intended to get the facts straight, provide information that’s clear and useful, and give suggestions on what to do next if you think you might have one.

N.B. This is a HUGE area, fascinating and complex. The below is a long but hopefully straightforward and detailed introduction to prolapses. Please do get in touch at mail@arcadia-therapy.com if you would like more detailed information.

What is a Prolapse?
What is it Like Having a Prolapse?
What Types of Prolapse are There?
Why does it Happen?
Can it happen through lifting weights?
If it’s Happened Once will it Happen Again?
What Options are there for Managing a Prolapse?

What is a Prolapse?

Simply put, a prolapse is a shifting downwards or outwards of a structure. In pelvic health, this applies to all or part of an abdominal organ.This could be a bladder, womb, or rectum (back passage). The common acronym in healthcare circles is POP: Pelvic Organ Prolapse.

In women, our anatomy unfortunately predisposes us to reduced support of the pelvic organs compared to men. We have a vagina and a urethra (bladder outlet), both tubes from outside to in. Rather than a continuous pelvic floor group of muscles, women have to accommodate these tubes within the space of their pelvic floor. Men have helpfully outsourced their urethra away from the undercarriage and don’t need to work around a vagina.

pelvic floor anatomynormal female pelvic anatomy

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The abdominal organs are usually supported by:

– the pelvic floor muscles (above)
– ligaments and fibrous connections within the abdominal cavity. Organs will be ‘connected’ to organs, blood vessels, nerves, all suspended and supported in their own space, and gently moving with our body movements and breathing.

When these supports are either removed (e.g. in gynaecological surgery), damaged (e.g in childbirth) or weakened (e.g. the pelvic floor, by disuse, overuse, or trauma), a prolapse can result.

What is it Like Having a Prolapse?

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Typically, there are a variety of symptoms which, if you’re not generally aware of your pelvic workings, can seem unrelated, or insignificant. However, each symptom is worth investigating in its own right, because the body works as a whole and by addressing warning signs you may prevent the prolapse worsening or even becoming an issue.

Symptoms Include:

Vaginally – a feeling of bulging or heaviness. Often described as a feeling of ‘pushing downwards’ or ‘dragging’

Bladder – stress incontinence or urgency incontinence. Some women who have had these a while might also find they have to change their position to start urinating, and their stream is weak. Others experience incomplete emptying, or frequent visits to the loo at night as a result.

Bowel – difficulty evacuating bowels, ironically leading to straining (discussed below). There may be flatal incontinence (unable to control gas) or faecal incontinence. Some women might find they have to use their fingers to either support the undercarriage or press against the back vaginal wall to enable a poo to come out. Urgency to empty the bowels is also a feature.

Sexually – intercourse might be obstructed, or painful. There may be a feeling of laxity in the vaginal tissues, and vaginal ‘wind’ is another common issue.

However, a prolapse will wax and wane – symptoms may come and go, depending on activity, monthly cycles, and in different ways in different women.
It is entirely possible to have a prolapse and enjoy pain-free sex, or have a prolapse with urinary continence issues but not faecal. Each person has a unique set of factors – it’s not one size fits all.

N.B. If you do not experience any of these symptoms, but do have a prolapse, it is termed an “Anatomic Prolapse”. Unfortunately, if you are not experiencing symptoms, the current healthcare system may not treat you. Undoubtedly, if you have a prolapse but no symptoms, this is a great scenario, considering! However, the view at Arcadia is that women in this situation would benefit hugely from education around their prolapse to ensure they are looking after their bodies and preventing worsening and onset of symptoms.

What Types of Prolapse are There?

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Each organ can prolapse, and unfortunately in rare cases, more than one organ can prolapse.

prolapse typesCystocele: Anterior Prolapse
An anterior prolapse is when the bladder is not fully supported by the structures it normally would rely on. It usually tips backwards and gravity takes it downwards, pressing on the front vaginal wall. All prolapses have different stages (and these vary depending on which scale you use). The basic bladder prolapse stages are show below, but suffice to say right here, a grade one prolapse will not show outside your body or necessarily affect your day to day life. A grade 4 prolapse is more likely to be visible and cause significant discomfort.

Rectocele: Posterior Prolapse

This is when the support of the rectum is compromised. This could happen after childbirth if a woman tears, or after injury or surgery. You can see on the left how the colon tends not to bulge out of the body, but rather pushes at the back wall of the vagina and creates a deeper pocket for itself just inside the anus. This can lead to feelings of incomplete emptying, pressure or discomfort, and unfortunately straining to try to get a stool out is likely to worsen it.

Apical: Uterine Prolapse

It is normal for the cervix (at the entrance of the womb) to raise and lower a small amount at different times throughout a monthly cycle. After childbirth, it is also common for the cervix to sit happily a bit lower than it did previously, and some women’s cervixes have always sat higher or lower than others – it’s an individual thing. However, the womb itself can lose support and descend, pushing downwards through the vagina, thus shortening it and in rarer cases, protrude outside the body.
Some women prolapse after having surgery to remove their uterus – the vaginal vault descends, folding in on itself – this is called ‘apical’ or ‘vault prolapse’.

What Stage is my Prolapse?

Each of these different types of prolapse have different levels of severity. The below picture is an example, showing the different grades of cystocele (anterior prolapse) grades 1-3. There are different grading systems in use in different healthcare environments, this is just one of the most common.

cystocele grades

If you can see your prolapse at the opening of your vagina or protruding outside, what you will actually see is not your bladder. It will be your vaginal wall, which is being pushed out and down by the prolapsed organ. Sometimes this is smooth, which indicates that the vagina itself has integrity and is supporting the prolapsed organ – not a situation that could continue forever, but it gives an idea of what structures are doing what. If the prolapse looks loose and wrinkled, there is likely a loss of support for the vagina itself.

Why does it Happen?

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There can be numerous contributing factors, and divided into a couple of categories:

Pre-Disposing Factors:

Family history – strong link with mothers’ and grandmothers’ experiences
Collagen types and changes in the body – there are numerous different types of collagen in the body, many of which are not yet fully understood. So far, this is just a correlation, and there isn’t much you can do about it.

Inciting Factors – life events that increase your risk of having a prolapse at some point in your life:

Age – the risk increases ten-fold with each decade
Childbirth – giving birth once to a baby over 24 weeks increases a woman’s risk eleven-fold. This risk doesn’t dramatically increase with additional children until the fourth child.
Radical pelvic surgery – e.g. hysterectomy, with all sorts of factors such as the type of surgery, how much tissue is removed, the kind of support then installed (stitching, mesh, types of mesh, etc), the surgeon themselves, contributing to success rates and re-occurence.

However, it is worth noting that some women who have never had surgery, given birth, or has any significant family history, can also experience prolapse…

Promoting Factors: Lifestyle choices, habits, other pathologies that contribute to risk:

Constipation – there is a strong correlation between straining on the toilet, infrequent bowel movements (less than twice a week) and posterior POP.
Obesity – this is simply a matter of gravity and fitness – the heavier load the organs and body tissue present to the supportive tissues, the more likely they are to lose capacity over time and as tissues change as we age.
Occupation / Recreation / heavy lifting – There are many courses on correct lifting, but this tends to focus on the muscles on the exterior of our body. The support of the pelvic floor is intricately connected to your breathing. Many people hold their breath on exertion (e.g. on lifting something heavy – we ‘brace’ against the load) – this is the worst thing for the pelvic floor and the organs it supports. Try exhaling as you lift – this allows the diaphragm to lift upwards, creating room for your abdominal organs to move upwards as the pelvic floor contracts to support them.
Lung disease / chronic cough / smoking – the repeated downwards pressure of the diaphragm on the abdominal organs, often with no conscious awareness of the load on the pelvic floor and ligaments, can, over time, reduce the integrity of these structures, leading to POP.
Posture – This is a fascinating area of research. Though the tendency is to focus on the affected body area, the whole body contributes to the situation of the local parts. Research shows that a flattened lower back, and a hunched / curved forwards upper back, can both contribute to risk of developing a POP. In a very simplified way, compromised posture affects the contraction potential of the pelvic floor, alters our breathing mechanics, and can increase our risk. It’s also one of the easiest things to change.

Managing this last set of factors are the key ways in which we can promote our own abdominal health and avoid experiencing prolapse.

Can it Happen through Lifting Weights?

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abdominal cylinder diagramSimply put, YES. However, this doesn’t mean you can’t lift! It just means you have to be mindful of good posture and being consistent with excellent breathing dynamics while lifting (and throughout life!).

The abdominal ‘cylinder’ holds your internal organs, but this moves constantly as you do and as you breathe in and out. Your diaphragm moves down and flattens as you breathe in, pushing your organs south. This is NORMAL and not something we want to restrict! However, as you breathe in, your pelvic floor naturally ‘gives’, while remaining supportive of the organs. If we hold our breath, our pelvic floor will get over-worked, and eventually fail. Simply by breathing out and allowing that space for the pelvic floor to contract, will reduce your risk of POP from lifting.

Here’s a video I’ve made to explain the principle in a bit more detail:

If it’s Happened Once will it Happen Again?

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Unfortunately, YES. Surgical repair has a significant failure rate – at around 25%.

The reasons are unclear, but recent articles suggest, generally, that techniques are still being developed, materials used such as mesh are still fairly new and therefore untested in the longer term, and it seems the sheer delicacy and complexity of the female pelvis is still being discovered. Fundamentally, the body functions are controlled by the nerves and muscles. Despite essential structural support being provided by the surgery, the patient will still need to retrain the nerves and muscles to regain full control of their function.

Surgery can give women back their lives and independence, and is a great blessing for some. Have a look at this video for an idea of the different types of surgery for bladder incontinence (and associated prolapse).

However, it is not something to be take lightly: the recovery is long and painful and can have added complications (e.g. immobility in later life, even in the relatively short term after an operation, can affect balance and falls rates – another game-changer). Some women find when a prolapse is repaired it can reveal other issues that were ‘blocked’ by the prolapse – it is possible for an over-active bladder or poor bowel habits to continue or reveal themselves as issues despite successful surgery.

Though patients report that surgery plus pelvic physiotherapy feels better than surgery alone, the evidence itself is not conclusive: there simply isn’t much of it at the moment. Nevertheless, physiotherapists are invaluable in educating women and supporting rehabilitation as a conservative option – even if surgery is deemed ultimately necessary, knowing your options and your own anatomy will help you get the best out of surgery and recovery.

Finally, unless the true cause of the prolapse is discovered, it will be at risk of happening again. That is why a whole-body approach is increasingly being used to assess and diagnose prolapses in physiotherapy, and why a whole-body approach is the best solution for overall long term success.

What Options are there for Managing a Prolapse?

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There are a few very simple, yet effective, ways of addressing prolapse, or risk of prolapse, from the outset. The Promoting Factors are key to identifying the individual’s root cause. Yes, the prolapse may have occurred after a difficult labour, but many small prolapses actually do resolve in the months after giving birth. Why do some improve and not others?
The body always works to bring itself back to harmony – part of physio is discovering what is holding back your body in its own unique situation. As mentioned above, something as simple as posture can affect the supporting tissues, something as commonplace as your position on the toilet, or your levels of hydration, can make a huge difference.

Physiotherapy will include a full assessment of the pelvic floor muscles, their strength and function. Sometimes it’s as simple as a weakened pelvic floor. Other times it might be a tight, over worked pelvic floor. It’s essential to be assessed as an individual. The session will also include a whole body assessment to cover the other contributing factors. To read more on what to expect, click here.

pessariesPessaries are another option. Lots of women have taken matters into their own hands already and use tampons to support their vaginal walls during exercise. Though the principle makes sense, tampons bring their own risks (e.g. toxic shock syndrome) and should never be worn while you aren’t on your period.

Pessaries come in a huge range of shapes and sizes, and many women swear by them for support, comfort and peace of mind. Others however find them difficult to insert, remove, clean and manage generally. Some have great reviews on Amazon, but from a professional point of view can cause rather than solve longer term issues, e.g. repeated bladder infections, suction on the vaginal walls etc.

Visit this website for more information on all things pessary! There’s a great downloadable brochure (or online interactive) giving lots of detail about different types and how to use them. (at 10/11/16 ignore the website under developement sign – the download link is still there, the writing’s just a bit pale).

But please do consult your GP or gynaecologist if you are considering getting one. It’s easy to ignore the advice leaflet but it is so important to get it right. The best option is to have one fitted by a qualified professional (usually a gynaecologist).

And Finally…

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If you suspect you might have a prolapse, or have any of the symptoms described above, go and speak to someone about it.

In my line of work, it is the most heartbreaking thing to hear a woman say she has been incontinent for 20 years… and her husband doesn’t know.

It is so sad to hear ladies ‘just put up with it’, or look shameful when they tell me they have to use their fingers to help themselves go to the loo, or burst into tears because they are afraid of what is happening to them.

It is the most heartbreaking thing to know that so many women are unaware of the help and knowledge they could so easily get.

And it’s the most wonderful thing to see women gain back that control of their lives and their bodies and start to blossom again – at any age. So please, speak to someone. Spread the word!

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