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My What is Going Where?

Pelvic Organ Prolapse is only an issue for older women who have had lots of babies vaginally...right?

 

Your pelvis is a complicated network of muscles and connective tissues working to keep your bladder, uterus, and bowels in their proper places. When these tissues become compromised, a problem may result in which the organs begin to descend or bulge downward. This condition is known medically as Pelvic Organ Prolapse (POP) and can happen to one or multiple organs within the pelvis. In advanced cases, the organ begins to drop outside of the opening of the vagina and/or rectum and can be felt or seen.


The types of pelvic organ prolapses are named for the organ that is dropping:

  • Cystocele: Bladder

  • Urethrocele: Urethra

  • Rectocele: Rectum ·

  • Uterine prolapse: Uterus ·

  • Vaginal prolapse: Roof of the vagina

  • Enterocele: Small intestine drops between the vagina and rectum.


Risk for POP is increased by many conditions such as tearing or prolonged pushing during childbirth, having multiple pregnancies, post-menopausal hormone changes, chronic coughing, chronic straining from constipation, repeated heavy lifting (the wrong way), hysterectomy (surgical removal of the uterus and/or ovaries), and obesity. Breast cancer can also place women at risk for POP if they are ER/PR+ and have taken Tamoxifen or Arimadex. This is to say, POP is not necessarily just an "old lady" condition. I have treated many women with varying forms of POP, and many of them, in their 20s or 30s following the birth of their first baby (including those who have had only C-sections). It may sound scary, but POP is both preventable and treatable, and ultimately nothing to fear at all! I hope this information will help you to recognize the symptoms, give you some tools for prevention and self-management, and teach you that there is a happy and active life waiting ahead of you - even if you have POP. (Guess what...I have POP!) You have an interdisciplinary team of physicians, surgeons, and specialized therapists to help guide you down your path, no matter which direction you are headed!


Symptoms

Symptoms of POP can range from I-didn't-even-know-I-had-prolapse to a combination of the following issues:

  • Urinary and/or fecal incontinence (leakage)

  • Increased urinary and/or fecal urgency and/or frequency

  • Incomplete emptying of bowel and/or bladder

  • Post-void dribble (I peed, wiped, walked a few steps, and leaked...eff!)

  • Needing to push on the belly or vagina in order to empty

  • Dull ache in the pelvis, groin, lower belly, or lower back

  • Recurrent UTI (bladder infections)

  • Heaviness or fullness in the pelvis or vaginal region

  • A palpable bulging in the vaginal or rectal opening

  • Painful sex

Medical Diagnosis

A physician will typically perform evaluation and diagnosis of POP, but there are special tests that your Women's Health Physical Therapist may also conduct if they suspect POP may be present. I have often been the first practitioner to identify prolapse during an initial internal evaluation in which we are looking for impairments related to the other symptoms above. Severity of POP is graded based upon position of the organ relative to the vaginal opening. Grading also helps your team to determine the best course of treatment specific to you. In general, Grades I and II are still within the vaginal opening, and Grades III and IV extend beyond.


Treatment and Prevention

Pelvic Floor or Women's Health Physical Therapy can help to improve organ support by strengthening the muscles, addressing body awareness, teaching core muscle coordination, correcting potential movement dysfunction and/or poor breathing patterns, decreasing symptoms, and preventing need for surgery. I have also seen prolapse decrease by a grade or even two! (Mine went from a very detectable Grade III to a completely asymptomatic Grade II). In more advanced cases where surgery is recommended, Physical Therapy has been shown to greatly improve outcomes related to recovery time, pain, swelling, and prevention of a second surgery in the future.


Your Women's Health Physical Therapy treatment plan will likely include:

  • Nutrition counseling to treat and/or prevent straining from constipation

  • Breath training to establish better mechanics with function

  • Core and pelvic stabilizing exercises to increase pelvic floor strength (notice I didn't just say Kegals)

  • Biofeedback training for muscle control

  • Skilled manual therapy techniques to address any pain or muscle spasm you might be having

  • Bladder and/or bowel re-training to decrease urgency and frequency

  • Training for proper lifting and carrying of light to heavy objects - yes, with training you can continue your weight-lifting hobby with POP!

Your medical provider may also recommend a special support device called a pessary. This is a plastic or rubber piece that fits inside the vagina to support the organs. Think of it as an internal bra for your vagina. It can assist with bladder emptying by unblocking the urethra, but may cause pelvic pain and trouble with bowel movement, so it is important to discuss the pros and cons related to its use. It may also take multiple trials to determine which shape and size is best for you.


You can reduce your risk of developing POP by:

  • Remaining active performing some kind of daily movement exercise - this can mean walking, swimming, biking, Tai Chi, QiGong, Yoga, hiking...whatever strikes your fancy! The number one way your pelvic floor becomes weak is via disuse. So, get up and move for the sake of your internal organs!**

  • Establishing a daily pelvic floor/core strengthening routine – Women's Health Physical Therapy will help you design the best program for you!

  • Working on specific breathing techniques to expand and activate the deep core

  • Decreasing and preventing bloating and constipation by maintaining a healthy gut via a diet rich in whole plant-based foods

  • Staying well hydrated (with water).

**Some women find that heavy lifting, ab workouts, and high impact sports like running increase their symptoms. Listen to your body, and work with your therapist to train you back up to these activities as appropriate.

Potty Dancing

POP can place pressure on the urethra and bladder, making it difficult to urinate completely or initiate the flow of urine. Prolonged retention of urine can lead to recurrent infections and pelvic pain. With rectocele, the rectum is leaning into the bladder (and uterus), creating a pocket for stool to become slowed down. Splinting, rocking, and double voiding are methods you can use to assist with movement of the prolapsed organs in order to maintain bowel and bladder health.

  • Splinting: Put on a glove (or not, I mean, it is your vagina) and sit on the toilet in a supported position (both feet flat and ideally elevated slightly - think Squatty Potty). Reach between your legs and apply pressure upward and inward on the perineal body (it's the taint, ladies). This directs stool backward toward the anus. Another method is to place your thumb into the vagina and push backward toward the rectum. Then use the belly muscles and deep breathing to empty the rectum of feces.

  • Rocking: While sitting on the toilet, gently move the upper body forward and backward as if you are in a rocking chair. You might find you can empty a few more drops of urine or complete defecation (pooping).

  • Double Void: After urinating, hold some toilet tissue to the vaginal area while you stand for a moment (maybe do a little wiggle), then sit back down. A lot of my patients find this helps a lot with the post-void dribble issue.

As always, the best message I can give to you is that you are not alone, and that speaking up is the best possible course of action you can make in your own health. Seek out information, advocate for yourself, and never accept 'you're a woman' as an answer to your concerns.

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