Pelvic Organ Prolapse

Pelvic Organ Prolapse

This information is provided as a general information and a guide only and clients are advised to consult with their own caregiver for further advice.

Pelvic organ prolapse (POP) is known under many guises and names, mostly reflecting the feelings women have when they have a prolapse such as;
hanging down, descent, lump in vagina, bulging vagina, loose vagina. Basically the uterus, bladder, intestine and/or rectum come down from their normal position and bulge into the vagina or out from the vaginal opening. The pelvic organs are normally supported and kept in their original position by muscles and ligaments/fascia of the pelvic floor. When there is damage (tearing or stretching) or weakening of these supporting structures, these organs are pushed or drawn down towards the vaginal opening.

 

The things you may feel with a prolapse are a lump, bulge, heaviness in the pelvic region, back pain, something falling out, discomfort/inability with using tampons or during sex, and urinary or bowel symptoms amongst others. Everyone is different.

We also know that the symptoms felt with your prolapse do not correlate well with the degree or severity of your prolapse as assessed by your physio or gynaecologist. That is, your prolapse may be minor on examination, but you may feel it is very bothersome to you.

These symptoms may vary over time. They tend to be more noticeable after standing or at the end of the day, after intercourse, after or during a bowel movement, having a bad cold or hayfever, or exercising intensely may also worsen the symptoms you feel.

In the past most women were recommended to treat prolapse with "watch and wait” with no further investigations or assistance to modify lifestyle or perform pelvic floor exercises or they were sent onto surgery. The good news is that in the last few years we have seen more research for the evidence that Pelvic Floor Physiotherapy can offer women with POP. So let’s talk more about POP and why some women develop it and how to manage it.

Prolapse is generally more common or reported by older women. This is because pregnancy, childbirth, and menopause are risk factors for prolapse. There is no one single cause usually attributable for your POP. 

It is estimated that maybe 50% women have some form of prolapse often without any symptoms. What we do know for certain that in your lifetime you have a 15.2% of having surgery for prolapse and a 30.5% risk of seeking surgery for either/or stress incontinence or prolapse so that’s 1/5 of all women seeking surgical management for prolapse. 

Surgery does have a failure rate of 10-70% depending on all considered factors and in itself, gynae surgery is a risk factor so it is more likely you will need to repeat surgery than not. We believe that surgery has high failure rates because it is fixing the anatomical or structural defects but it does nothing to strengthen the underlying pelvic floor muscles or change other modifiable risk factors such as overweight, exercise regimes, bowel habits, lung and respiratory dysfunction and disease, lifting and diet factors.

It is therefore important to understand the impact of POP and how to prevent, treat and /or manage it from a conservative management point of view. 

"Pelvic Floor Muscle training should be first line treatment for symptomatic POP"(ICI 2013, Level 1 evidence)
The management for grade 1-3 POP is assessment, treatment and monitoring by a Pelvic Floor Physio and an experienced urogynaecologist. For more bothersome symptoms, of a grade 2-3 POP sometimes a pessary (a vaginal splint) is used to support the tissues. Surgery is reserved for women who have had no relief from Physio or other conservative measures. The below text explains these treatments in more detail.

PHYSIO for POP

In 2010, a study in Norway found that with intensive Physio, not only did the POP severity and symptoms reduce, but the actual anatomic position of the bladder and rectum reduced. Great news!! However, the women in this study had 19 individual Physiotherapy treatments. whew! That's alot and we normally see women less than 5 times for POP. So maybe we are undertreating women.....

In most other studies the treatment regime is about 5 treatments and the results are usually good and symptoms improve but the anatomic position of the pelvic organs did not change. Also women need to continue to perform Pelvic floor exercises for life to maintain the relief. So it’s effective but you need to find a way of continuing your exercises.  We are now recommending more treatments however for POP (perhaps 10 with a bit more ongoing follow up) based on this study in Norway and recommend you don't give up your Physio too early :) The other great thing about Physio is it is risk free with no complications. It is also more cost effective than surgery or pessary management.

We at seasons of life are also really good at listening to your experience and trying to help you find suitable strategies for yourself and your family of adhering to exercises and the other lifestyle changes we make in conjunction with you.

ALSO if you are having surgery, (either for POP or incontinence) there is evidence that Physio will improve the likelihood of success (Jarvis 2005). Most gynaes refer to pelvic Floor Physio pre surgery for Pelvic floor exercises or if they are not, the evidence points to that they should! Tell your surgeon and/or GP about the evidence and insist on best current guidelines and practice. 

Perioperative Physio may improve quality of life and urinary symptoms in women going to surgery for POP, ie it’s likely to help. Moore 2013 (Recommendation Grade B)

It is better to see us before the operation so you can learn the exercises correctly so from the first minute you are not incorrectly trying to do pelvic floor exercises. It is also easier to learn when you are not in hospital, in pain or recovering from major surgery. Muscles have memory and it is easier to regain that process after surgery having already got the contractions correct. We like to see you at least once prior to surgery but if you are not able to elicit a proper contraction of your pelvic floor muscles, we may need to see you more.


SURGERY

Surgery is used for most bothersome or persistent symptoms that have failed to respond to Physio or Physio plus pessary if it was suitable. Newer surgical techniques are more effective, require less hospitalisation time, require less revision, are less invasive and have less side effects. These decisions about appropriate treatments are made in conjunction with your specialist and the Physio treating you at the time. Sometimes the treatment is not clear cut and trials of conservative therapy or pessaries are made. Surgical decisions are made in conjunction with you and your surgeon. The type of surgery will depend on a lot of different factors.

 

We see you at 2-6 weeks after your surgery depending on whether you have seen a Physio before your operation. We will instruct you on exercises, and lifestyle things such as diet and bowel habits, discussing weight issues and looking at access to weight loss programs, return to sexual function if appropriate, lifting techniques and occupational risks and modifying those. With return to general exercise, we know that increased pressure through the body can weaken the surgical repair. This includes high impact exercise, sit ups, double leg Pilates exercise, to name a few. Generally unless otherwise advised, beginning with gentle walking and cycling at a low intensity for 6-12 weeks then increasing to a moderate intensity over 3-6 months is recommended. Swimming and general moderate water activities can be resumed at 6 weeks usually. Pilates can be resumed under the supervision of a pelvic floor Physio at 3-6 weeks; the intensity would be increased slowly depending on your pelvic floor strength over 3-6 months. Avoid 'gym' or studio Pilates or even moderate ‘core’ abdominal work outs. We see a lot of women here for clinical Pilates who have POP and can help you develop a challenging fun workout that keeps your Pelvic Floor safe.

Topical Oestrogen

The vaginal area needs adequate levels of oestrogen to maintain healthy tissue.  The vagina's epithelium, or lining, contains oestrogen receptors which when stimulated by the hormone, keep the walls thick and elastic. When circulating oestrogen decreases, the vaginal lining becomes thinner and drier. Oestrogen levels drop when breast feeding and at menopause. Ovestin (brand name) cream is recommended to replenish the walls and tissues of the vagina to keep them thick and elastic and help prevent worsening or improve symptoms of POP. After an initial course you may find you can have a break or maintain the level of comfort with intermittent use of the cream. Some women who are breastfeeding may experience milk supply dropping, in this case you just stop the oestrogen.

No one has conducted a long-term study of vagifem. All of the studies that have been evaluated this drug's benefits and risks have followed women for 12 months, or less. 

There is no data on the use of topical oestrogen in women who have had breast cancer. But because of the very low systemic absorption and because of quality-of-life issues, even oncologists have become more comfortable having women who have had breast cancer use topical oestrogen to relieve for example, vaginal dryness. 

Pessaries are small rings or silicone vaginal inserts that support the bulging area and the evidence is positive to improving the symptoms of POP and quality of life.(ICI 2013,Dumulin NAU 2014) We see alot of postnatal women who do well with a pessary while their body is recovering from carrying a baby in utero and from delivery. We do not fit pessaries here at seasons of life but refer you to a gynaecologist who can do this for you. 

Well sorry this was sooo long but hopefully it has given you some food for thought about your symptoms and POP and whether we can help you here at seasons of life:)