Pelvic Organ Prolapse
What is pelvic organ prolapse (POP)?
Pelvic organ prolapse is experienced as the dropping of parts of the vaginal wall towards the vaginal opening. The parts of the wall can be close to the bladder, the rectum, cervix/uterus, or the vault/cuff after hysterectomy.
What causes pelvic organ prolapse?
When the front part of the vagina is dropping, near the bladder, you may also experience urinary leakage. This is caused by weakness or injury of the pubocervical fascia with resulting dropping of the bladder or the bladder neck.
The pubocervical fascia is connective tissue support from the perineum to the cervix.
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.
What are the risk factors for POP?
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 are the symptoms?
Even if you have a mild pelvic organ prolapse, you may not have symptoms. In fact, some symptoms can be caused by pelvic floor muscle dysfunction, not the prolapse. In other words, you may have a mild prolapse that can be asymptomatic if you have well functioning pelvic floor muscles.
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, difficulty starting urine stream, and incomplete bladder emptying or leaking after peeing and feeling like you have to pee after you have already peed.
You may have constipation, or incomplete bowel movements. You may need to manually press on the back part of your vagina to empty your rectum completely. You may experience fecal or urinary incontinence, and pain with penetrative sex.
Urinary and bowel symptoms can be very embarrassing. It is not uncommon to isolate socially due to the discomfort or pain caused by these symptoms and restrictions.
What would a pelvic physical therapy exam be like for prolapse?
If your prolapse is worse during your menstrual cycle or when your pelvic floor muscles are fatigued, it is ideal to schedule the exam at a time when prolapse is most likely to be evident.
Your external genitalia is first inspected, and then the opening of the vagina and urethra. You will be screened for estrogenization of your tissues and if you have any scarring.
You may be asked to complete a bladder voiding diary, questionnaires, or to get a referral for a urodynamic study.
What could it mean to get surgery?
Interestingly, urinary incontinence is a frequent development after a pelvic organ prolapse surgery in up to 44% of patients. This is likely because the prolapse was masking pelvic floor dysfunction. If you experience urinary incontinence after prolapse surgery, please reach out to a pelvic floor physical therapist!
Overactive bladder may resolve after surgery for moderate to severe prolapse cases.
Surgery is not for everyone and is often indicated for those experiencing significant bother and desiring a definitive treatment.
Surgery should be done when childbearing is complete, and depending on the case, after a thorough and comprehensive trial of conservative measures, including pelvic floor therapy.
What is pelvic floor physical therapy treatment like?
You will receive education about your anatomy and function. You will get tips on how to reduce excessive stress on the pelvic floor from constipation, coughing, and heavy lifting.
If your vulvar tissues are symptomatic from thinning and decreased estrogenization, you may be referred out to get a prescription for a topical estrogen.
Management includes continued observation, and pelvic floor exercises for prolapse.
If you are only mildly bothered by your symptoms, watch for the following:
Urinary retention
Severe bowel dysfunction
Hydronephrosis
Whether you have mild pelvic organ prolapse, or advanced prolapse, communicate with your doctor if any of the above develop, to avoid risk of complications.
Does pelvic floor therapy work?
Pelvic floor muscle training, or pelvic floor exercises for prolapse, “either self-directed or under the guidance of a therapist with specialty training, is typically suggested as an initial non-surgical modality for stages 1‒3 pelvic organ prolapse.”
“Pelvic floor muscle training, under the guidance of a therapist, provides superior results, with significant numbers demonstrating an improvement in symptoms and by one stage on POP-Q examination.”
(2017 Bureau and Carlson)
What about pessaries?
If you are significantly bothered by your prolapse, but do not want surgery, or you are not medically fit or planning to become pregnant again, a pessary can be tried.
“In women successfully fitted with a pessary, 40‒60% will continue use for more than 6‒12 months.”
“Potential complications of these devices are vaginal discharge, bleeding, erosion, pain, constipation, and incontinence (including unmasking SUI). In the absence of contraindications, the concomitant use of topical estrogens is usually recommended.”
(2017 Bureau and Carlson)