As unusual as this question may sound, it is one which I am very commonly asked. The feeling of vaginal, perineal, or rectal pressure all day, or sometimes just at specific times of day or with specific activities (e.g., during workouts) can be stressful and feel embarrassing to talk about, but as with most things stressful and/or embarrassing, it becomes less so when we have a better understanding of what is actually occurring. With that in mind, let’s get into the topic of: prolapse.
There are several types of prolapse:
Cystocele - The back wall of the bladder falls into the vagina
Uterine prolapse - The uterus lowers into the vagina
Rectocele - The front wall of the rectum falls into the vagina
Rectal Prolapse - The rectum lowers within itself toward and out of the anus
Urethrocele - Urethra lowers into the vagina
Enterocele - Small intestine lowers out of the abdominal cavity and into the pelvic cavity
Permission to use copyright image from Pelvic Guru, LLC pelvicguru.com
This list is not comprehensive but does cover the most common types. It is important to note that each of these prolapses can occur together or separately and for differing reasons. Cystocele is extremely common after pregnancy, whereas a rectal prolapse can occur with years of straining and constipation. All prolapses occur when the pelvic floor and the ligaments suspending the organs are unable to provide enough support to hold the organs in an optimal position.
“So… are my organs falling out?”
It may feel that way, but they are attached to the inner walls of the pelvic and/or abdominal cavity, so they won’t completely “fall out.” In the highest stages, however, an organ can begin to protrude from the body either vaginally or rectally.
Let’s talk about the four stages of prolapse. I’m going to use cystocele as the example here because this is the most common type that women experience.
Stage 1: Slight descent of the bladder into the vaginal wall but remains at least 1 cm higher than the hymen. You may or may not experience symptoms.
Stage 2: Greater descent into the vaginal wall but remains at about the level of the hymen (within 1 cm above or below).
Stage 3: The tissue has protruded to greater than 1 cm past the hymen but has not fully protruded.
Stage 4: The tissue has protruded fully with complete eversion of the vagina.
Permission to use copyright image from Pelvic Guru, LLC pelvicguru.com
“Ok, so do I have a prolapse?”
Common symptoms include difficulty urinating or leakage, straining for bowel movements or never feeling completely empty, vaginal, perineal or rectal pressure, or an uncomfortable rubbing sensation on your underwear. If you use a mirror to look at your vulva and vaginal opening you may see something that looks like these pictures.
Permission to use copyright image from Pelvic Guru, LLC pelvicguru.com
Permission to use copyright image from Pelvic Guru, LLC pelvicguru.com
Getting diagnosed
Your doctor will assess for prolapse vaginally and/or rectally depending on the type of prolapse, your symptoms, and the specialty of the provider. Most physicians will assess in a supine position with your feet in stirrups or in the jackknife position with you laying face down bent over a table.
So much fun!!
(Narrator’s voice: “It was not, in fact, much fun at all.”)
Physical therapists may assess for prolapse in either of these positions and they may also assess in a more functional position such as standing. The standing position is usually a great way to assess the organ movement because it is a position in which you spend most of your time. When laying down you could be given a stage 0 (no prolapse) or Stage 1 but moving into a gravity dependent position (standing) can increase that stage and better line up with your symptoms.
Treatment
Now that you have a diagnosis, let’s talk about treatment. The most well-known options include surgery - the installation of a sling or mesh to mechanically support the descended organs within the pelvic floor. If you prefer to avoid the surgical route, another option to support the organs is a pessary. A pessary is a device that is inserted into the vagina in order to block the organ from lowering any further into the vaginal canal. Here is an example of one type of pessary that is used to block the uterus from descending.
Pessaries can be worn either all the time, only during the day, or only during certain activities such as running. Depending on the type of pessary and your medical provider, you may place and remove the pessary on your own or you may go to the clinic periodically for the pessary to be removed, cleaned, and reinserted.
Physical therapy treatment consists of assessing the pelvic floor and abdominal muscles for strength, tension, and laxity, and addressing the deficits. Your program may consist of strengthening the pelvic floor and abdominal muscles. It may also consist of some stretching or relaxation exercises in order to help the pelvic floor be more effective when contracting. Therapists who are trained in visceral mobilization will do hands-on treatment to facilitate the body to heal itself by promoting optimal positioning of the uterus, bladder, or intestines.
“This makes sense and seems like what I’m feeling! What can I start working on now to help reduce my prolapse?”
Here’s a simple exercise you can start with today: pelvic floor strengthening while laying with your hips on a pillow. Bringing the hips up above the shoulders uses gravity to encourage the organs to move up and out of the vaginal canal. In this position it is also easier to contract the pelvic floor and begin a strengthening program.
Lay in this position and perform 5-10 pelvic floor contractions (kegels) before you go to the bathroom. This helps to clear the pathway and allows your bladder and bowels to empty more easily.
Quick contractions: Squeeze and release without holding the squeeze. The goal is to do these squeezes as quickly as possible but still perform a full squeeze and a full release. Quick contractions improve the coordination and strength of the fast-twitch muscle fibers which work when you jump, run, cough, and sneeze. It works for only a brief moment then is able to relax.
Endurance contractions: Squeeze and hold before releasing fully. Your hold may be 3 seconds or 10 seconds but when you feel that you are starting to lose the contraction, go ahead and relax fully. These endurance holds will build up the slow-twitch muscle fibers that work all day long with sitting, standing, and walking without getting much of a rest.
I hope this brief summary of prolapse has given you the knowledge and empowerment to remove some of the potential stress and embarrassment, and to be proactive and begin your path to return to your best.
If you have any questions, please reach out to me, give me a call or email, and I will be more than happy to help you!
Thanks for reading!
Comments