Pelvic Organ Prolapse

 

Prolapse literally means “to fall out of place”, from the Latin prolabi meaning “to fall out”.  Pelvic organ prolapse occurs when one or more of the pelvic organs descends downwards, and creates a bulge within or out of the vaginal walls.  


Causes:

The pelvic organs are supported through a passive system of support through fascia and ligaments, as well as by an active system of support through the pelvic floor muscles. Both the active and passive system are very important to prevent pelvic organ descent. Activities which increase abdominal pressure can result in downward pressure which may lengthen/overstretch the passive system (pelvic ligaments and fascia), particular if there is not the muscular support/strength from the active system (pelvic floor) to counteract against this downward pressure. This over stretching of the ligaments/fascia results in decreased support from the passive system, and places extra responsibility on the pelvic floor muscles to help support the pelvic organs. If the pelvic floor muscles are weak, or the downward pressure is strong enough to overpower the muscles, then descent of the pelvic floor muscles or vaginal walls can occur. 


The boat lock analogy is a great visual when describing the relationship between the active and the passive system.  In this picture, the boat is one of the pelvic organs, and the sides of the boat lock are your pelvic bones.  The water is your pelvic strength and function, and the guy wires holding onto the boat represent your fascial attachments.   The boat is supported by the wires water.  If the pelvic floor muscles are weak, or if there is downward pressure that overcomes the strength of the pelvic floor, then there is added strain on the wires/fascia.  In the body this can translate to fascial lengthening, and the organ may sit lower.  What is important to know is that we can always strengthen the pelvic floor muscles, but we can't "strengthen" fascia .   So in pelvic floor physio, we work on activating the pelvic floor, and learning how to protect and preserve the fascial integrity.


There are some factors that can increase the risk of pelvic organ prolapse. Pregnancy, labour, vaginal delivery can certainly cause downward pressure on the ligaments and contribute to pelvic floor weakening.  But other common sources include chronic coughing and constipation.  Sometimes genetics plays a role, as connective tissues may be weaker in some women, perhaps placing them at increased risk.  

 

Most Common Types of Prolapse:

  1. Cystocele - bladder
  2. Urethrocele - urethra (tube that carries urine from bladder out of body)
  3. Uterine - uterus 
  4. Rectocele - rectum

 

Symptoms 

  • Heaviness or feeling of fullness/bulging in the vagina or rectum
  • The feeling of something “falling out”
  • Incomplete bladder or bowel emptying
  • Vaginal air
  • Urgency, frequency or burning associated with urination
  • Urinary incontinence
  • pain/discomfort with intercourse
  • pubic/genital, abdominal or back pain

* It is important to note that these symptoms could also be indicative of another pelvic concern, and do not by themselves mean that a prolapse is present.

*Also, a mild prolapse is often not symptomatic. A mild prolapse is not necessarily a problem, but it is good to know so that you can learn basic conservative measures that can help prevent it from progressing. 


 Can you prevent a prolapse from occurring?  Not completely, but to help reduce your risk you can:  

  • Do kegel exercises as prescribed to maintain good muscle strength and function
  • Maintain a healthy weight
  • Avoid constipation
  • Avoid smoking. Smoking affects the tissues, plus a chronic cough is a major source of downward pressure

 

Pelvic Floor Physiotherapy Treatment

  • Posture, positioning and biomechanics to decrease pressure on the pelvic floor
  • Progressive strengthening exercises for the pelvic floor and transverse abdominus
  • Education for proper bladder/bowel emptying techniques
  • Integration of the core canister with other important muscle groups (ie. gluteal muscles)


*Advanced prolapses with notable connective tissue lengthening may not reduce in their position with conservative management. However, physiotherapy can help prevent things from progressing, as well to improve a successful outcome if surgery is pursued.

Possible adjuncts to discuss with your physician, which may or may not be appropriate to your specific case include hormone replacement therapy, pessaries, and surgery

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