WHAT IS A PROLAPSE?
The pelvic organs are normally supported and kept in position by muscles and ligaments of the pelvic floor. A prolapse is caused by the stretching of these ligaments and/or muscles supporting the pelvic organs, causing one or more of these organs to rest or descend against the wall of the vagina. A prolapse is a dysfunction of the supporting structures and can affect the function of the organs in some cases.
A study in 2016 found that up to 30-76% of women presenting for routine gynaecological care had a loss of vaginal or uterine support (Barber 2016). It is worth noting that this percentage was not caused wholly from pregnancy.
TYPES OF PROLAPSE
Anterior wall prolapse – is when the bladder is pushing into the anterior vaginal wall, also known as a cystocele.
Posterior wall prolapse – is when the bowels are pushing into the back of the vaginal wall also known as a rectocele.
Uterine prolapse – is where the uterus descends down the vaginal canal, also known as apical prolapse.
Small bowel prolapse – is similar to a rectocele, but instead involves a higher part of the vagina and the organ pushing down is the small bowel and not the rectum, also known as an enterocele.
Vaginal vault prolapse – affects women who have had a hysterectomy and no longer have a uterus. The top of the vagina descends into the vaginal canal, also known as apical prolapse.
For most women diagnosis can be done by a physical exam in conjunction with taking some history of symptoms. When assessing a prolapse it is graded in stages 1-4.
Stage 1 – the organ presses on the wall of the vagina making it bulge a little in to the vaginal canal
Stage 2 – the organ presses on the wall of the vagina making it bulge in to the vaginal canal above the entrance of the vagina
Stage 3 – The wall/organ protrudes around a little out of the vagina
Stage 4 – The wall/organ protrudes out of the vagina
- Instruments such as vacuum or forceps in vaginal birth
- Excess weight
- Chronic Constipation
- Repetitive straining to pass urine or open bowels
- Repetitive lifting of heavy weights
- Chronic lung disease or coughing
- Decrease in oestrogen after menopause
SYMPTOMS OF PROLAPSE
- Vaginal bulging: “feel a bulge at the entrance”
- Pelvic pressure: “heaviness in the pelvis”
- Urinary symptoms such as
- Difficulty starting flow or urine
- Slow stream of urine
- Intermittency with flow
- Straining to void urine
- Needing to lean forward to pass urine
- Feeling of incomplete bladder emptying
- Post micturition leakage
- Anorectal Symptoms
- Faecal urgency
- Sensation of blockage
- Sexual: pain with intercourse, obstructed intercourse
PROLAPSE AND PHYSIOTHERAPY
You do not need to have been pregnant to be at risk of having a prolapse. Physiotherapists with additional training in women’s health can assess and provide a treatment program based on your body and goals.
After you have a baby, at your 1–2-week postnatal assessment your physiotherapist will ask you if you have any symptoms of prolapse as discussed above. In conjunction with an external vaginal exam this can give your therapist a base line of your pelvic floor post birth and if there are any visual signs of prolapse. It is common for that area to be swollen shortly after birth and any sign of prolapse may not be evident at this session.
At your 6-8 week follow up, your physiotherapist will again ask if you have been experiencing any prolapse symptoms. With your consent, an internal vaginal exam may be completed to assess for prolapse. It’s important to know that it can take 6-12 months for your pelvic floor to recover after delivery regardless of the type of delivery. Each woman’s recovery is unique, and we feel strongly that every woman should have access to women’s health physiotherapy during pregnancy and after their birth as part of the standard health care to prevent and treat a range of pregnancy induced conditions such as pelvic organ prolapse.
See our next blog for the treatment of pelvic organ prolapse, coming soon!
- Barber, M. 2016 Pelvic Organ Prolapse. BMJ2016; 354 doi: https://doi.org/10.1136/bmj.i3853 https://www.bmj.com/content/354/bmj.i3853.full
- org [Internet]. Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG); 2006-. Pelvic organ prolapse: Pelvic floor exercises and vaginal pessaries. 2018 Aug 23.Available from: https://www.ncbi.nlm.nih.gov/books/NBK525762/
- Li C, Gong Y, Wang B. The efficacy of pelvic floor muscle training for pelvic organ prolapse: a systematic review and meta-analysis. Int Urogynecol J. 2016 Jul;27(7):981-92. doi: 10.1007/s00192-015-2846-y. Epub 2015 Sep 25. PMID: 26407564.
- Jones, K. A., & Harmanli, O. (2010). Pessary use in pelvic organ prolapse and urinary incontinence. Reviews in obstetrics & gynecology, 3(1), 3–9.