Do you feel pressure or heaviness between your legs? Have you ever had the strange sensation that something is falling out of your vagina? Does your vagina look or feel different since having a baby? Have you changed the way you urinate or have bowel movements to complete one?
If you have ever asked yourself any or all of these questions, you may have a pelvic organ prolapse (POP). POPs occur when the muscles and ligaments in your pelvic floor can no longer support your organs. The organs that slip out of place include your bladder, urethra, uterus, vagina, small bowel, or rectum. Pelvic organ prolapses are not uncommon at all; in fact, as many as 50% of women* who have given birth one or more times have some degree of genital prolapse. Of these women*, only 10 to 20% experience symptoms. Another study reports that one in five women* will undergo surgery for pelvic organ prolapse in their lifetime secondary to these symptoms.
There are different types of prolapses. Once we find out where the protrusion is, from there we can decipher what is at the root of the issue. So, for example, a protrusion in the front of the vagina is the bladder (cystocele) or urethra. A protrusion in the center is the uterus. A protrusion in the back of the vagina is either the rectum (rectocele) or bowel. The following is a story of a patient of mine, and through this, we can see an example of a bladder prolapse caused by labor and delivery.
How do I know if I have one?
One patient described their son’s birth as the following: their baby descended through the birth canal so forcefully and quickly that they didn’t have time for an epidural. With their muscles damaged by the abrupt delivery, they were never really able to fully recover. They now have difficulty holding their urine and leaks throughout the day, requiring frequent changes of panty liners. They don’t feel much while having sex with their partner and they get upset when their partner frequently slips out. Their bladder is no longer supported properly and falls back into the vagina, making it physically difficult to urinate. They need to stick their finger up their vagina so they can move their bladder into place before urinating. At only 33 years old, they were told they wouldn’t be able to deliver any more babies vaginally and would need to plan C-sections in the future and that they would need pelvic floor surgery after their childbearing years
Other patients have told us they see “something hanging out” of their pelvis while shaving their legs in the shower. More often than not, their OBs used suction during a difficult delivery and their organs were pulled down, along with the baby. These patients feel they need to sit after standing for several hours due to uncomfortable pelvic pressure. They developed uterine heaviness after multiple vaginal deliveries, making it difficult to walk or exercise and develop pain in their backs and/or vaginal muscles. They have difficulty urinating or having bowel movements. On the other hand, some are pain-free but do feel or see a bulge protruding out of their vaginas and this concerns them.
How does this happen?
The most common cause of a pelvic floor prolapse is pregnancy. During these nine months, many changes occur in the abdominal and pelvic connective tissue. The increased uterine weight puts pressure on the pelvic floor muscles and the mother gains a significant amount of weight. Also, trauma may occur during vaginal delivery and abdominal straining may occur during labor. Lastly, possible nerve damage may result during labor and delivery.
Besides pregnancy, other common causes for protruding organs are
- Advancing age
- History of pelvic surgery
- Chronic coughing
- Increased intra-abdominal pressure (from heavy lifting, and using incorrect exercise form)
How do you know if your condition is bad?
Pelvic Organ Prolapses (POPs) are measured in 4 categories:
- First degree: descent halfway to the hymen
- Second degree: descent to the hymen
- Third degree: descent )halfway past the hymen
- Fourth degree: maximum possible descent for each site
A severe (third or fourth degree) pelvic organ prolapse can be seen with the use of a mirror between the legs while lying down and bearing down (as if you are having a bowel movement). A first or second-degree prolapse is diagnosed via intravaginal assessment so you won’t see the protrusion.
What can I do to fix it?
Now that you’ve established your organs are drooping, what can you do? Fear not! There absolutely are some lifestyle changes that will help and prevent your condition from worsening.
- Strengthen your pelvic floor muscles to support the organs above them and decrease that ‘heavy’ feeling.
- Engage in a weight loss program
- Commit to a smoking cessation plan
- Learn how to properly engage the core versus straining it during daily activities and exercise
- Modify your diet to decrease constipation
- Adopt proper evacuation techniques during bowel movements to avoid straining.
So what are your other options?
Besides seeing a physical therapist, pessaries are a good option. Pessaries (PES-uh-res) are removable medical devices that can be inserted into the vagina to support the descending organs. The most commonly used pessary is the ring with support, which treats grades I and II uterine and bladder prolapses.
There is also an underwear/ external splint that can be worn to support the hanging organs, called Fembrace.
A physical therapist can use biofeedback to help you understand how to properly work your pelvic floor muscles. This involves using pain-free electrodes to monitor your pelvic floor muscle activity. The electrodes are connected to a computer that reads the muscle activity. Many people don’t know how to correctly strengthen their pelvic floor muscles. Seeing muscle activity on a computer screen is often helpful.
A physical therapist can also teach you how to minimize strain in the area by showing you how to effectively use your core as a ‘splint’ when exercising or exerting effort. By teaching a patient how to self support your prolapsed organs, you may be able to stop incontinence, decrease vaginal/pelvic/lower back pain, and most importantly decrease the chances of it becoming worse.
* Language used in the study referenced.