Pelvic Organ Prolapse - Part 1
The risk of Pelvic Organ Prolapse can increase with pregnancy and vaginal delivery, however may occur even without any pregnancies and can even happen to men!
What is it?
'Prolapse' comes from the latin word prolabi which means "to fall out". Pelvic Organ Prolapse (POP) involves the descent of the pelvic organs; the bladder, bowel or uterus, into the vaginal space. The degree of prolapse is measured on a scale of 0-4, determined by how much the organs have moved toward the opening of the vagina or if they are protruding outside the body. This may be observed by your family doctor, OB/GYN, birth professional or pelvic health physiotherapist by asking you to cough or hold your breath and bear down for 8 seconds to determine the extent of the prolapse.
The female pelvic anatomy (larger pelvic outlet and open space of the vagina) combined with our upright posture makes women particularly vulnerable to this condition. However, men can also experience similar descent of their pelvic organs but instead of falling out, falls down to create a significant amount of pressure on the prostate.
I drew you some more pictures that may not be entirely anatomically accurate but should give you an idea of what happens!
Normal Pelvic Anatomy
What are the signs and symptoms?
As the organs lower toward the pelvic floor muscles, this can create uncomfortable pressure on the pelvic floor muscles with pain, heaviness, or the feeling of 'sitting on a golf ball'.
Women often report a sensation of 'things falling out' and can sometimes feel a protrusion or bump. Penetrative intercourse can be uncomfortable and some women find it difficult to insert a tampon and keep it in.
Bladder Prolapse (Cystocele)
Prolapse of the bladder, cystocele, is the most common type of prolapse that I see and can also contribute to overactive bladder syndrome which is an increased frequency of urination, or feeling like you need to go. As you can see, there is a 'pocket' that sits below the level of the urethra (where the urine exits). It is often difficult to completely empty this part of the bladder as the liquid needs to essentially go against gravity to exit. The remaining urine can becomes very concentrated and stimulates the bladder to empty even when it is not full leading to OAB. A cystocele can also cause sudden leaking of urine with changes of position, as well as increased waking during sleeping hours to empty the bladder (Nocturia).
Bowel Prolapse (Rectocele)
Prolapse of the bowel, rectocele, can also contribute to difficult elimination of stool and constipation as some of the faeces can get stuck in a similar 'pocket' and become very solid.
Uterine Prolapse (Uterocele)
The uterus is a suspensory organ that is attached by a strong ligament to the sacrum (not shown in the picture). Poor alignment and the habit for us to constantly tuck our tailbones under or sit on our sacrum has the effect of lowering the uterus into the pelvis like a puppeteer lowering a string.
Prolapse of the uterus, uterocele, involves the uterus falling down within the vagina, however it also tends to bring down vaginal walls as well and can contribute to both a cystocele or rectocele. Contact with the cervix with penetration can be quite uncomfortable and can often be felt as a deep pain during intercourse.
What causes it?
Prolapse is rarely the result of a single incident, but rather the result of insufficient support by the pelvic floor and core abdominal musculature over several to many years. Poor alignment, positive-heel wearing and our limited repertoire of daily movement are all contributing factors. Chronic constipation or habits of constantly sucking in the stomach create ongoing unnatural loads on the ligaments and pelvic floor muscles.
During pregnancy, ligaments throughout the body but especially within the pelvis are subjected to hormonal changes that allow extra movement in preparation for childbirth. Combining these lax ligaments with a long pushing phase of delivery or extreme pressures created by Valsalva manoeuvres (breath holding and bearing down) can significantly exacerbate a prolapse that was not noticeable beforehand.
High impact activities such as running and exercising with heavy weights (without adequate pelvic floor and core strength) can also increase your risk, in the absence of pregnancy but especially early post-natally. So can carrying heavy loads, such as your baby (plus the car seat, pram and the bag of baby clothes/diapers/food/toys) when your pelvic floor is particularly vulnerable in the months soon after delivery.