Pelvic Organ Prolapse Definition
Pelvic Organ Prolapse (POP) occurs when there is slippage, sinking, or in advanced stages a falling out of an organ through the pelvis. This condition is nearly as common as incontinence, but the scary part is that a woman may not know she has this condition until an advanced stage! The most common symptoms are a feeling of heaviness; however, this symptom does not occur until the later stages! That is why this discussion is so important.
Anatomy review
The pelvic floor muscles are a group of muscles that create the “floor” of the pelvis. They provide continence (the opposite of incontinence), sexual appreciation, and support. Your pelvic organs do have ligamentous support, however, this is not enough. They also need the pelvic floor muscles to provide support. The picture next to this text is a side view of a human and shows the relationship of the bladder in front, the uterus, cervix (the connection between uterus and vagina), and vagina in the middle, and the rectum in the back. Think of the pelvic floor muscles as a “shelf” that holds these organs up. There are outlets/ “holes” in the pelvic floor that are just large enough to create a passageway for the lower section of the organ to exit the body. The verbiage used in the literature is confusing. It is common to read that an organ “falls in the vagina”. With the exception of Uterine and Vaginal Prolapse, a more accurate description for the other types of prolapse is when the organ slumps against the outer vagina causing the vaginal tissue to descend inward. There are 6 types. They are listed here simply as a reference. Your Pelvic Health Provider will diagnose yours.
Bladder slumps posteriorly against the outer vagina = Cystocele (most common)
Uterus slumps downwardly into the vagina =Uterine Prolapse (2nd most common)
Rectum slumps forward into the outer vagina = Rectocele (3rd most common)
Vaginal prolapse
Small Intestines slump into the space between the rectum and the vagina = Enterocele
Urethra slumps posteriorly into the outer vagina = Urethrocele
Causes
Anything that causes thinning and weakening of the pelvic floor reduces the support of the organs turning our “shelf” into a “ramp”! Below are some examples:
Pregnancy: the Pelvic Floor muscles thin and decrease in resting tone in preparation for vaginal delivery. Back pain is common in the later stages of pregnancy if the muscles become too weak because these muscles pull downward at their posterior attachment site of the sacrum and coccyx (the lowest portion of the spine).
Vaginal Delivery: During vaginal childbirth, the Pelvic Floor muscles are maximally stretched creating weakness. It is also possible for pelvic ligaments to tear based on the size of the baby.
Menopause: The decreasing estrogen causes thinning of the Pelvic Floor muscle tissue and decreased elasticity and moisture in the muscles when the connective tissue proteins decline
Increased abdominal pressure: This can occur with a chronic cough, heavy lifting, strenuous exercise, pushing to start with urination, and straining during bowel movements which is magnified with constipation.
Obesity: This is simply because the extra weight the pelvic floor muscles must hold up in standing positions.
Hysterectomy: When the uterus is removed there is extra space and the remaining organs may slide into the excess space. This has not been proven but is a widely held belief.
Diagnosis of a POP by Stages?
When you go see a Pelvic Health Provider, they may ask you to perform a Valsalva Maneuver / “bear down as though having a bowel movement”. If a prolapse is present a bulging can be seen in the vagina. The stages are as follows:
Stage 0: No organ movement observed
Stage 1: Organ descends 1 cm or higher above the vaginal opening. Women are asymptomatic still
Stage II: Organ descends 1 cm above to 1 cm below the vaginal opening. Women can be asymptomatic at this stage or have mild discomfort or heaviness
Stage III: Organ descends 1 cm beyond the vaginal opening but still retreats back into the vagina when the Valsalva Maneuver is complete. The most common symptom at this stage is a moderate heaviness that occurs after certain activities. This is sometimes described as a “tampon falling out” sensation
Stage IV: Organ descends well past the vaginal opening and does not retreat back once the Valsalva Maneuver is complete and must be repositioned manually. At this stage, women feel a heavy downward pulling sensation. The organ has descended past the pelvic floor, so the woman no longer has access to her “shelf” in standing. At this stage surgery or a pessary (an internal device that is placed in the vagina to block the organs from slumping into the vagina) is the usual treatment. Pelvic Floor muscle training isn’t enough at this stage.
Treatment for Stages I-III
Proper strengthening and development of endurance of the Pelvic Floor muscles with light activity.
Proper strengthening and development of endurance of the Pelvic Floor muscles with moderate to strenuous activity requires coordination with our deep abdominal muscles. What is strenuous varies from person to person. For one person it may be rising from a chair and for another, it may be a spirited tennis match. One of my favorite sayings is “Injury occurs when demand exceeds ability”. Finding that muscle balance is one of the main roles of a Physical therapist.
Correcting constipation through dietary changes (increased water intake and slowly raising daily fiber intake) and/or supplements or medication recommended by your doctor.
Proper toilet positioning to optimize the angle of your bowel and urethra (sitting on the toilet with knees above hip level, trunk leaned forward, elbows resting on knees).
After reading this information, it’s normal to have even more questions. That’s quite alright and we’re here to help answer them. Simply reach out to us by pressing the “contact us” button below.