How to Recognize the Early Signs of Prolapse in Pregnancy
Authored by Dr. Maryssa Steffen, PT, DPT and Board-certified pelvic specialist
Pelvic organ prolapse (POP) refers to the “bulging of the uterus, bladder, and/or bowel as a result of impairment of the supporting tissues surrounding the vagina.”
As your baby grows and the volume of your uterus increases during your second and third trimester, this added weight can overload your perineal tissues. Your pelvic floor muscles, nerves, connective tissues, and blood vessels can be stressed by the extra pressure, especially during activities.
Pelvic floor muscles support your bladder, vagina, rectum, and lower back.
Reduced strength in your pelvic floor can lead to dysfunction, including pelvic organ prolapse symptoms and urinary leakage during a cough, sneeze, or running.
What are the symptoms of prolapse in pregnancy?
How do you answer the following questions from the Pelvic Floor Distress Inventory?:
How often do you experience pressure in your lower abdomen?
Do you experience heaviness or dullness in your pelvis?
Do you usually have a bulge or something falling out that you can see or feel in your vaginal area?
Do you ever have to use your hands to push on your vagina or around your rectum to have a complete bowel movement?
Do you usually experience a feeling of incomplete bladder emptying?
Do you ever have to use your fingers to push on a bulge in your vaginal area to start or complete urination?
If you answered “yes” to most of the above questions, then reach out to your doctor or a pelvic physical therapist.
Pelvic organ prolapse symptoms are often described as the “sensation of a bulge, heaviness or pressure in the vagina, the feeling of “sitting on a ball,” or that “something is falling out.”
Other symptoms include urinary urgency and feeling like you have to pee after you have already peed.
You may have constipation, or incomplete bowel movements. You may experience fecal or urinary incontinence, and pain with penetrative sex.
Urinary and bowel symptoms can be very embarrassing. But your POP is fairly common. The prevalence of POP in women varies from 3% to 50%.
It is known that pregnancy and childbirth are risk factors for developing POP.
If you continue to read this blog, you will learn the importance of exercise to prevent or manage pelvic floor dysfunction.
However, commonly, the amount of exercise decreases as pregnancy progresses, for very understandable reasons. You may be in pain, experience swelling, or have nausea.
You may be concerned that exercise may cause pregnancy complications, even though your doctor has not advised you to pelvic rest. (If your doctor says it is safe to exercise, then most exercise is safe. If you need more guidance, reach out to a pelvic floor therapist!)
Do you lack motivation to exercise?
Do you need more education about what type of exercise is safe for you and your baby?
Do you need specific guidance?
If you answered “yes” to any of the above questions, a physical therapist trained in pregnancy exercise can help!
Risk factors for prolapse in pregnancy:
Age and number of pregnancies increase the risk. Other risk factors include forceps delivery, infant birth weight more than 10 lbs, constipation, smoking, connective tissue disease, occupation involving heavy lifting, previous hysterectomy, and stress.
What causes pelvic organ prolapse?
When the front part of the vagina is dropping near the bladder, it can be can be caused by weakness or injury of the pubocervical fascia with resulting dropping of the bladder or the bladder neck.
When the back part of the vagina is dropping, it is caused by weakness or injury of the rectovaginal septum, or the space between the vagina and rectum. As a result, the rectum or small bowel may protrude into the vagina.
When the topmost part of the vagina is dropping, the uterus/cervix/vaginal cuff may be vulnerable.
Most commonly, prolapse involves more than one part.
Treatment options for prolapse during pregnancy:
A meta-analysis (4,609 ciswomen) found that structured pelvic floor muscle training, compared with watchful waiting, showed a reduction in vaginal bulging in late postpartum. In other words, pregnant bodies who already have pelvic floor dysfunction during pregnancy or postpartum should be guided to a physical therapist or other health care professional who specializes in the pelvic floor.
A meta-analysis (41,275 women) showed there may be a reduction of stage II or greater POP within 12 months postpartum when pelvic floor muscle training in late pregnancy is implemented. The severity of their pelvic organ prolapse reduced after pelvic floor training from a pelvic specialist.
Pelvic floor muscle training during pregnancy increases pelvic floor muscle strength and reduces the degree of anterior vaginal wall prolapse at 6 weeks postpartum. The benefits of pelvic floor muscle training during pregnancy lasts for several months after delivery.
Two more ways to help prevent prolapse during pregnancy:
Manage constipation.
Constipation strains your pelvic floor and contributes to POP.
Eat fiber and drink water!
The American Heart Association Eating Plan suggests eating a variety of food fiber sources. Total dietary fiber intake should be 25 to 30 grams a day from food, not supplements.
Soluble fiber helps to bulk your stool. Water-soluble fibers absorb water during digestion. They increase stool bulk and may decrease blood cholesterol levels. Soluble fiber can be found in fruits (such as apples, oranges and grapefruit), vegetables, legumes (such as dry beans, lentils and peas), barley, oats and oat bran.
Insoluble helps to soften stools and promote more frequent bowel movements. Water-insoluble fibers remain unchanged during digestion. They promote normal movement of intestinal contents. Insoluble fiber can be found in fruits with edible peel or seeds, vegetables, whole grain products (such as whole-wheat bread, pasta and crackers), bulgur wheat, stone ground corn meal, cereals, bran, rolled oats, buckwheat and brown rice.
Drink water when you are thirsty. Stay hydrated!
Wait for an urge for a bowel movement, but do not postpone bowel movements. If you do not poop when you get an urge, you may get backed up and constipated.
During bowel movements, use a foot stool so your knees are higher than your hips when you sit on the toilet. This position helps to relax and lengthen your pelvic floor muscles.
Breathe when you push.
Get off the toilet after 5-10 minutes. If it is not complete, either get up and wait until the next urge, or you can use your hands to gently push your perineum, pictured below:
Continue a consistent walking practice, with rest breaks as needed. Swimming and aquatic exercise are great, too, and the water helps to reduce swelling when the depth of the pool is above your heart.
Practice strengthening your posture so that your abdominal pressure is better managed to prevent POP. Contact us to learn more about our exercise programs!
How pelvic floor exercises can reduce prolapse risk:
“Exercise and pelvic floor muscle training (PFMT) can be recommended for pregnant and postpartum women because they prevent and treat urinary incontinence and POP symptoms. The highest level of evidence was found on preventing the symptoms of postpartum urinary incontinence through exercise and PFMT during pregnancy.”
“Women are encouraged to be physically active and to do aerobic exercise and muscle strengthening activities, including PFMT, to prevent and treat symptoms of the dysfunctions of PFM.”
Included in PFMT is assessing your performance of a pelvic floor contraction and relaxation. “Therefore, it is recommended that women who already have symptoms of pelvic floor dysfunction should receive more individualized guidance.”
If you are in the state of California, book a discovery call to learn more about our prenatal pelvic therapy. We offer Telehealth and in person visits. Our office is located in Oakland, CA.
References
Ryhtä, Iina et al. “Effectiveness of exercise interventions on urinary incontinence and pelvic organ prolapse in pregnant and postpartum women: umbrella review and clinical guideline development.” JBI evidence implementation vol. 21,4 394-408. 1 Dec. 2023, doi:10.1097/XEB.0000000000000391
He, RuiJu et al. “The effect of pelvic floor muscle training and perineal massage in late pregnancy on postpartum pelvic floor function in nulliparas: A randomised controlled clinical trial.” Complementary therapies in medicine vol. 77 (2023): 102982. doi:10.1016/j.ctim.2023.102982
