Pelvic Organ Prolapse (POP)
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What is Pelvic Organ Prolapse?
Pelvic organ prolapse (POP) is not uncommon although many women haven’t heard of the condition prior to experiencing it. Millions of women around the world will develop POP at some point in their lives. Statistically 50% of women who deliver a baby vaginally will have some degree of prolapse in their lifetimes, although many of those won’t notice it, or won’t be bothered by a small prolapse.
Prolapse is a hernia of pelvic organs through the opening in the pelvic floor muscle. It is harmless but can cause frustrating symptoms. Keeping it simple, it is when an organ (or organs) such as the bladder, uterus or bowel loses some of its support and moves downwards through the vagina.
Organs that may be affected by prolapse include:
Large bowel most commonly the rectum
What are the symptoms?
Many women with POP do not experience any symptoms. However, when women do have symptoms they can range from minor changes to completely life-altering consequences. The most common symptom is feeling or seeing a bulge or lump at the opening of the vagina. Sometimes it may cause difficulties with intercourse. Women may also feel a dragging sensation as if something is going to fall out of the vagina. There can also be a feeling of pressure due to the pelvic organs pressing against the walls of the vagina.
Additional symptoms can include some or all of the following:
Lower back ache
Constipation or difficulty having a bowel movement
Pain or difficulty having sex
A sense that something is ‘falling out’ – this symptom is increased by standing, lifting, tiredness or at period time
Difficulty passing urine
If you are experiencing any of the above symptoms we suggest you speak to your doctor or make an appointment with a women’s health physiotherapist. If you have visited or spoken with a doctor or midwife who has dismissed your concerns then find another health professional. Your women’s health physiotherapist or family doctor may suggest you see a gynaecologist or urogynaeologist which needs a referral from your GP. A urogynaecologist may conduct some of the following tests:
An internal exam
A 3D/4D Ultrasound
Prolapse is assessed by describing the extent to which the bladder, uterus, small bowel or back passage move downwards. Sometimes doctors use staging, that is, they will talk about ‘Stage 1 prolapse’ and mention the organ involved. We have recently learned that a Stage 1 prolapse of the bladder or rectum is actually normal, but a Stage 1 prolapse of the uterus definitely is not.
However, what really matters is not the stage of prolapse, but rather the severity of the symptoms you are experiencing. Usually, a prolapse that is not noticed by the patient does not need to be treated, unless it causes problems with bladder or bowel emptying.
Treatments for POP
Pelvic floor physical therapy, especially pelvic floor muscle training, includes bracing and correcting the position for defecation. Recent research has shown that these strategies may make a significant difference in reducing prolapse symptoms. However, long term efficacy is not known.
Women’s health (Pelvic floor) physiotherapist
Your first appointment with a women’s health physio would ideally involve:
Education about normal and abnormal bladder and bowel function, regardless of your condition. This will ensure that you do not continue with bad habits which may lead to other problems in the future.
An internal muscle examination. This is routinely performed by specially trained physiotherapists to assess your muscle strength and teach you the correct action of the pelvic floor muscle. This is invaluable in giving you feedback about your pelvic floor muscles after childbirth. Not all Women’s health physiotherapists will perform an internal examination, so make sure you are referred to one who does, or a specialized pelvic floor physiotherapist.
You may be asked to keep a 1 to 2 day bladder diary.
An example summary of a treatment program may include:
Pelvic floor muscle training which includes learning the importance of relaxing the pelvic floor muscles as well as contracting them
Practising the knack and habit of bracing with all activities which increase intra-abdominal pressure, such as coughing and sneezing and also bigger tasks such as lifting your baby
Making positive changes to your diet to ensure a soft, easy to pass stool
Specific strategies to help if you have pelvic pain issues
A series of exercises to improve the strength of your pelvic floor muscles
A pessary is a silicon device that it inserted into the vagina and acts as a splint by holding the pelvic floor organs in place. They come in a variety of shapes and sizes and fitting one will be a case of trial and error. A pessary can take some time to adjust to, however, many women find these a useful alternative to surgery and that they can manage their day to day life well while using one.
There is a range of health practitioners qualified to fit pessaries.
If the prolapse is significant and not responding to conservative measures, a urogynaecologist or gynaecologist will assess which surgical option will best suit your needs.
Surgical approaches vary, depending on the type of prolapse, but can include:
Posterior prolapse surgery, in which the surgeon secures the connective tissue between the vagina and rectum.
Anterior prolapse surgery, in which the surgeon pushes the bladder back up into place and secures connective tissue between the bladder and vagina.
Uterine prolapse surgery, to remove the uterus (for women who don’t plan on having any, or any more, children).
Vaginal vault prolapse surgery, to correct prolapses of the top end of the vagina (the vault).
A series of exercises to improve the strength of your pelvic floor muscles
Implants may be used in prolapse repair. There has been some controversy in the use of synthetic mesh implant in prolapse repair. There are upsides and downsides of using a mesh implant. Only some women would benefit from mesh use and not all mesh implants are effective. Talk to a specialist or a Urogynecologist in regard to mesh use.
You can get a referral from your GP to see a urogynaecologist. Urogynaecology is a sub-specialty of Gynaecology, and in some countries is also known as Female Pelvic Medicine and Reconstructive Surgery. In Australia and New Zealand it is a formal subspecialty of Obstetrics and Gynaecology which requires at least three years of additional training on top of specialist training. Such doctors have a ‘FRANZCOG’ and ‘CU’ after their name. A urogynaecologist manages clinical problems associated with dysfunction of the pelvic floor, bladder and bowel. However, there are also many general gynaecologists who are very experienced in this field.
Before making any decisions regarding surgery we suggest you seek a second opinion. Before considering any surgical procedure you may wish to try a pessary that can be fitted by either your doctor or a Women’s Health Physiotherapist (pessaries are not fitted by physiotherapists in New Zealand).
Information on Mesh
Prolapse surgery has involved different types of implantable mesh. Now, after a number of years, problems have been reported with certain types of mesh products, including erosion of the mesh into the vagina, and chronic pain. Commonly reported symptoms of mesh complications include:
Pain in the surgical area
Recurrent bladder infections
Feeling a “poking” sensation or spasms in pelvic area
Pain during intercourse
Below you will find a some useful information and questions you may wish to ask your physician prior to surgery taken from the Association of Pelvic Organ Prolapse Support.
Women often have considerable anxiety when considering surgery for pelvic organ prolapse if mesh will be utilised for their repair.
Prior to surgery, clinicians typically explain the surgical procedure they are considering and ask if you understand the nature of the procedure to be performed; you will then be required to give written permission for the operation you will have. While a formality, it is important to take the process very seriously and ask any and all questions you have regarding the procedure, post-surgical healing, and possible complications that could occur. There is great value in getting answers to all your questions regardless of the type of surgery being considered.
Mesh plays a valuable role in maintaining POP repairs long-term; it is important however to research the physician who will be providing your surgery to verify the degree of experience and quality of their surgical skill. An informed patient will have less anxiety and greater opportunity for the best outcome. Important mesh questions to consider asking your physicians prior to POP surgery are:
Do you plan to use mesh for my POP repairs?
How many mesh procedures like mine have you done?
What surgical alternatives do I have to mesh for repair?
Is there any reason I would be a bad candidate for mesh?
Will my POP repair be successful without mesh?
How long has the mesh product you use been on the market?
How long have you been using this particular mesh product?
Is there a chance mesh surgery won’t fix my POP?
What complications should I be concerned about after mesh surgery?
Will my partner be able to feel mesh during intimacy?
What are the chances mesh will erode through my vaginal wall?
If mesh erodes through the vaginal wall, how do you fix it?
If I have mesh complications, will you be able to address them?
Can I have access to information on the mesh you will be using prior to having my surgical procedure?
Exercise with Pelvic Floor Dysfunction
During the postpartum period, and prior to commencing exercise, it is important to seek professional advice. Seeing a health professional such as a women’s health (pelvic floor) physiotherapist before commencing any physical activity could prevent further injury to the pelvic floor.
For many of us, exercise is a way of maintaining some of our identity after having a baby, and crucially it can be a way to manage our mental health. As a result, we feel it is vital to emphasise that you need to know how to exercise effectively after childbirth, to allow your body time for optimal healing as well.
Like many women you may have a personal trainer that you’ve worked with during pregnancy. Regardless of your experience with that trainer prior to having your baby, it is crucial that your personal trainer asks the right questions before you commence exercise again.
Unfortunately the fitness industry as a whole doesn’t recognise the risk that postpartum women face. As Robin Kerr, women’s health physiotherapist says, ‘If you’ve had a baby and feel like you’ve played a game with the All Blacks then consider managing your pelvic floor like you would a sporting injury’.
If you have been diagnosed with pelvic floor dysfunction or POP, then learning to exercise effectively will become a part of your motherhood journey. It isn’t about what you can’t do, it’s about how you can safely continue to do the exercise you enjoy doing. It is important that you seek out a personal trainer who works collaboratively with a women’s health/pelvic floor physiotherapist and has a proven track record for safe pelvic floor training, rather than relying on websites or just fitness trainers in the gym to help.
For more information try www.pelvicfloorfirst.org.au
Sexual dysfunction is another common, yet taboo subject. Women with prolapse are often very self-conscious about the changes their bodies have gone through. They are often concerned that intercourse may worsen their prolapse (which is not true) and therefore intimacy can often be forgone, in turn placing extra pressure on relationships.
Many women notice some vaginal laxity after childbirth, and to a degree this can be alleviated with muscle strengthening exercises. It is not the vagina that’s the problem, but the pelvic floor muscle (which lies behind the vagina) which determines vaginal tone and pressure. If the pelvic floor muscle has been overstretched or torn in childbirth (which is common) vaginal tone is reduced, and both partners may notice this during sex. Pelvic floor muscle exercises can help, but if it is a major problem you may want to see a pelvic floor physio, gynaecologist or urogynaecologist. Sometimes vaginal laxity is an early symptom of prolapse.
If there is ongoing scar tissue discomfort or pain following childbirth (or if you have had a significant tear) or gynaeacological repair surgery, it is crucial that you seek help. Simple effective education can help women with this (often embarrassing) topic. The following list provides some tips to improve sexual dysfunction, but it is also important to talk to your GP, gynecologist or physio to get help for specific problems.
Tips for improved sexual function:
Talk about issues with your partner
Take more time for arousal
Concentrate on relaxing your inner thighs, buttocks and lower tummy
Use a lubricant
Use non-latex condoms
Use local oestrogen pessaries or cream
Don’t forget ‘outercourse’
Seek professional help early
Finding someone you trust and feel able to talk to about this topic can often be the first step to getting help. In our experience a good women’s health physio can often be the starting point. However, further help from a couples counsellor or sex therapist may be useful.
If you have had gynaecological repair surgery, check with your surgeon as to when you can have intercourse. Due to pain and discomfort after major surgery, there is often a reluctance (from both partners) to resume intercourse. It can take up to 8 weeks for the pain to disappear. If there is ongoing chronic pain you should see a specialist.
Some of this information is taken with consent from Sue Croft’s ‘Pelvic floor essentials’ book.