Pelvic Organ Prolapse, What’s it all About?
Before we launch into an all singing all dancing referenced explanation I want to take a minute to speak to any ladies diagnosed with Pelvic Organ Prolapse (POP). If you’ve been diagnosed today or thirty years ago your feelings around your diagnosis are valid. This may sound a little strange but bear with me. Very often in clinic ladies are trying to make sense of something they’ve not the first clue about or something they’ve been catastrophising about and investing heavily in shares of Dr Google*. Giving yourself time to talk about how you’re feeling with your clinician/friends/partner is important. Your emotional wellbeing is an integral part of your recovery and if this isn’t addressed sometimes it can start to affect our ability to heal. Taking practical steps to speak about how you’re feeling can go a long way to helping you on your rehab journey.
So what is POP…
“Pelvic organ prolapse is defined as symptomatic descent of 1 or more of: the anterior vaginal wall, the posterior vaginal wall, the cervix or uterus, or the apex of the vagina (vault or cuff). Symptoms include a vaginal bulge or sensation of something coming down, urinary, bowel and sexual symptoms, as well as pelvic and back pain. These symptoms affect women’s quality of life.”
I like this definition because it references the physical symptoms as well as what you may be subjectively and emotionally feeling. Classically in clinic most ladies I meet with prolapse concerns describe one or several of the following points;
Something Coming Down (SCD) or feeling like there’s a tampon in situ when there isn’t. Sexual issues; dyspareunia (painful sex) ,obstructed intercourse, vaginal laxity, vaginal wind, avoiding sex altogether.
Bladder issues; stress urinary incontinence, urgency, incomplete emptying, nocturia (being woken at night to pee), weak or prolonged stream, position change to start or complete the emptying of your bladder.
Bowel issues; difficulty emptying your bowels (increased straining, incomplete emptying, splinting, digitation, flatal incontinence, faecal incontinence, urgency.
Musculoskeletal pain into the hip, back or abdomen.
Below is a diagram of the four different types of POP. Look at the anterior (front) and posterior (back) walls of the vagina, see how the structures supported by the pelvic floor have moved.
As much as I like the photo above there are a few issues with it. The photo titled “Normal Anatomy”- whatever that is. I have a slight issue with this because every single persons anatomy is different so take that first image as it comes and remember everyone is unique. Note the images include the classic “Cystocele” (aka anterior/front wall, bladder prolapse) and “Rectocele” (posterior/back wall,back passage) terminology. The use of anterior and posterior wall is now more favoured but you will still find textbooks images and clinicians who use Cystocele and Rectocele. I think a step away from the big medical words is a positive mainly because people struggle to pronounce them and medical jargon distances us from our own body. It’s helpful to understand the anatomy post hysterectomy this is sometimes when women can experience a vaginal vault prolapse as the uterus provides support for the top of the vagina.
The list of symptoms above is not exclusive, sometimes ladies will come into clinic and say things just don’t feel right down there. As I always recommend. If you have any concerns at all please speak to your GP or a Womens Health/ Pelvic Health Physio. I promise you it’s nothing they won’t have heard many MANY times before. Sometimes the biggest hurdle is psyching yourself up to go to the GP’s and have that discussion. Please be brave and book an appointment even if you’d prefer to have the discussion with the GP over the phone. Take that first step. You’re not on your own in experiencing POP symptoms…
“Approximately 40-50% of adult women suffer from varying degrees of POP.”
How are Prolapses measured?
A universal measure called the Pelvic Organ Prolapse Quantification (POP-Q) System allows a quantifiable measure to be taken in order to grade a prolapse. This system categorises the prolapse in to the following:
Stage 0: No prolapse is observed
Stage 1: The most proximal portion of prolapse is greater than 1 cm above the level of the hymen.
Stage 2: The most proximal portion of prolapse is found between 1 cm higher than hymen and 1cm beneath hymen.
Stage 3: The most distal part of the prolapse extends more than 1cm beneath the hymen but no further than 2 cm, resulting in no measurement larger than Total Length of the Vagina (TVL).
Stage 4: vaginal eversion has taken place or eversion to with 2cm of TVL.
Image and explanation courtesy of Physiopedia, page listed in references.
Above is a diagram of the sorts of measurements taken when the POPQ grading system is being adopted… It’s quite, shall we say thorough;
Point Aa is at the midline of anterior vaginal wall. Where no prolapse is present this location is 3cm up from the hymen (merely interior to the vaginal opening). Parameters from the hymen can be -3cm indicating no anterior vaginal prolapse or +3cm, which is a full prolapse.
Point Ba refers to the most superior location of the front vaginal wall . This location coexists with Aa (-3cm) in a woman with no anterior prolapse. However, in a woman with full prolapse this location coexists with point C.
Point C is the lowest edge of the cervix or the vaginal cuff (i.e. hysterectomy scar). This location identifies if the cervix is descending.
Point D is the topmost point of the posterior vaginal wall. This location can be contrasted with Point C to assess if the entry to the cervix has been extended.
Point Ap is located midline of posterior vaginal wall 3cm proximal to hymen. The parameters for this point can range from -3cm to +3cm relative to hymen.
Point Bp is the uppermost point of the posterior vaginal wall.
GH is the 'Genital hiatus' that records the length from the urethral opening to the posterior vaginal opening/ hymen. The hiatus refers to the opening in puborectalis muscle, a component of the Levator Anti muscle group. A larger distance here may indicate laxity in this area.
PB is the 'perineal body' and is recorded from the posterior aspect of hymen to the mid-anal opening. This will give an insight to the tonicity of superficial pelvic floor. Through vaginal birth the perineal body can be injuried via tears or by an episiotomy.
TVL refers to 'total vaginal length' measured from hymen to the most distal point. Knowing this allows the depth of prolapse to be assessed and reassessed post surgical repair. (Physiopedia)
I had to make that font a little smaller because it’s quite a read! Please don’t get too hung up on how they measure a prolapse. The important thing to remember is to have an empty bladder and bowel (as much as that’s possible) and to know that the majority of the time a speculum is used to help move parts of the vaginal wall to aid assessment. You can be assessed in any number of positions. Sometimes the clinician completing the assessment may ask you in what position are your symptoms most noticeable and assess you in said position. This can be lying on your back, side lying, standing or with your legs in stirrups. some measurements will be taken at rest and then some will be taken when you are asked to cough or at maximum Valsalva. There doesn’t have to be a formal grading of a POP for a prolapse to be identified. A large portion of the time they can be identified with a vaginal examination that does not use a speculum or by examining in a number of positions and observing.
Why do Prolapses happen?
And now on to one of the most frequent questions I get asked… Why? Why me? What have I done? Was it something I did? The short answer to all of these questions is no, there will not be a specific thing you did that caused the prolapse. More often it’s a combination of factors and some potential predispositions that can cause POP. Identifiable risk factors include;
Pregnancy
Childbirth
Parity (the number of babies you’ve had)
Ageing
Menopause
Congenital or acquired connective tissue abnormalities
Denervation or weakness of the Levator Anti Muscles (LAM)
Smoking
A consistent increase in intra-abdominal pressure (eg. persistent cough)
Prior surgery for POP (Schaffer et al. 2005: Vergeldt et al. 2015)
So you see it can effectively be a combination of factors. Gyhagen et al (2013) identified that there is often a delay in manifestation of symptoms,: in some cases several decades can elapse between childbirth and the clinical presentation of POP and the commencement of treatment. With this in mind we must essentially always be aware of our pelvic health. Just mindfully checking in and practicing good habits can make a big difference.
Treatment options
So you’ve been diagnosed with a prolapse, here’s what we can do about it…
Managing lifestyle factors like your weight can massively help. If we are carrying more weight this can exacerbate the symptoms of prolapse. Pregnancy can do that too, the extra weight of baby and everything that comes with them can mean symptoms temporarily worsen. Any extra weight being supported by the pelvic floor is going to increase its workload. The NICE Guidelines (2019) state weight loss if a woman has a BMI greater than 30 kg/m2.
Diet, are you constipated or are you inclined to suffer bouts of constipation? All that straining and pushing on the toilet can put extra strain through our pelvic floor. We are literally pushing against our pelvic floor and weakening it when we push to have our bowels opened. Increasing your daily fibre intake can help constipation. The NHS (2019) has recommended that we consume around 25-30 grammes of fibre a day. That’s a lot more than you think! There are 2.6 grammes of fibre in a banana. Try to find ways of adding extra bits of fibre where you can. I’m the ground flax seed queen in our house. I put them on everything. There’s a good example of how to up your fibre intake on the NHS website in the reference list. The how to increase fibre at breakfast, lunch and dinner is particularly helpful.
Topical Oestrogen may also help with the symptoms of prolapse especially if there are signs of vaginal atrophy, this isn’t always associated with the menopause and can be present after having a baby and if you’re breastfeeding.
Seeking the advice of a Pelvic Health or Womens Health Physio!! The NICE guidelines state pelvic floor muscle training for at least 16 weeks for a symptomatic pelvic organ prolapse. The time factor is really important to remember, especially when we’re looking at actually influencing the muscles for the pelvic floor. I always compare this to going to the gym, muscles are muscles. You don’t go to the gym for two weeks and give up because you look no different. It’s a long term commitment to see results aka in this case a reduction in symptoms. The same goes with the pelvic floor, these things take time. Ideally you should be issued with an outcome measure to track your progress regarding symptoms of a prolapse as this can guide your physio as to whether or not over time there has been an improvement in symptoms.
Vaginal Pessary, this can be fitted to physically splint/ lift the laxity of the vaginal wall back into place. These can be fitted by specialist physios, nurses or Drs. Oxford University Hospitals, NHS Foundation Trust have written a helpful booklet, Vaginal pessary for prolapse, information for women. I’m going to embed the PDF below, a big thank you to Beverly White, Urogynaecology Specialist Practitioner for putting together the information. Just to be clear there may only be one or two pessaries you’re shown but there are literally (sort of) about 20 out there, some can be in situ when having sex others can’t. Some can be self managed others can’t. Pessaries are most certainly not a one size fits all and your clinician should work with you to see what’s right for you. FYI, if you have a pessary you still have to do your pelvic floor exercises. Nothing is going to do that for you or replace the need for them to be done I’m afraid!
Surgical management is the last thing on the list of recommendations from NICE. And so it should be. Every lady is anatomically totally different but one factor remains the same. Surgery is the last resort if all the treatments above haven’t worked or have not agreed with the individual. It really saddens me sometimes that Physiotherapy and ‘supervised pelvic floor exercises for 16 weeks’ are sometimes bypassed. Of course there are going to be instances where it may not be appropriate for higher grades of prolapse BUT for the majority so much can be gained. Even if surgery is the only route or preferred option you will need to see a physio post surgery. Wouldn’t it be better to learn all those good habits around toileting, posture, diet, exercise, pelvic floor exercises and breath work prior to going for surgery?! Click the link in the references under “National Institute for Health and Care Excellence. 2019,” for more information on the surgical management of prolapse. There’s a reason NICE’s recommendations for management are done in an order and that’s because surgery should never be taken lightly… The Royal College of Obstetricians and Gynaecologists have a good explanation of surgical procedures on their website under; Pelvic Organ Prolapse- Surgical Procedures, I’ll put the link in the references. One last thing on surgical management, you still have to do your pelvic floor exercises post surgery. Sorry!
Final Thoughts…
Prolapse comes from the latin prōlābi meaning to slide along. I think slide along sounds nicer. A prolapse does not define what you do or who you are. It’s basically a medicalised word a lot of ladies find really daunting and I understand that. Especially when women have been experiencing prolapse since the dawn of time and the old wives tales seem to have been passed down the generations.
“Don’t lift anything heavier than the kettle.”
“Just rest with your legs up.”
“It’s just what happens when you have a baby and that’s it now.”
These phrases are some of my pet peeves. I don’t know about anybody else but my baby weighed 8lbs11 when she was born. Add to that a car seat and you most certainly have more than a kettle. Not lifting isn’t really a valid option for women trying to manage their prolapse symptoms. Assessing posture, strength, breathing patterns and how the pelvic floor is responding to fluctuating intra abdominal pressure is going to be more helpful.
Life is busy, just because Great Aunt Sally would have a lie down in the afternoon with her feet elevated (in the 1940’s,) does not mean that’s still the answer. Smoking was thought to be a good idea back then and look how that panned out. Telling a woman to lie down isn’t going to happen when she has three children, a dog, a husband who works away and is self employed. We need to be realistic.
It’s never okay to say “you’ve had a baby, that’s just what happens,”- EVER. Do we say “You’ve had a stroke that’s just what happens,” shrug our shoulders and walk away. No we establish baseline measurements set goals and begin rehab. POP is no different.
We as physiotherapists have always had a holistic approach to our practice and want to work with our patients and other health care professionals involved in their care to achieve their goals. Remember those percentages, 40%-50% of women suffer varying degrees of prolapse. Even Becky with the good hair at baby group. She’s always pristine not a speck of baby sick in sight, her two month old sleeps through the night and she levitates instead of walking… Chances are she may well have a prolapse and is desperate to talk to someone about it. That’s the thing about POP because it involves the vagina it’s deemed as taboo, private or just not something we talk about. In reality it’s no different to any other injury. We MUST for the sake of our future generations start talking about POP, raising the bar with education and treatment, empowering women and finding ways to achieve their goals. Big love V x
*Dr Google is great for finding a local Lebanese restaurant and that’s about it. Try not to unnecessarily worry yourself with unsolicited advice. Try to stick to trusted sources like things published by RCOG, NICE, POGP and of course your friendly local pelvic health physiotherapist, we’re really nice honest.
References
Bump R. C. & Norton P. A. (1998) Epidemiology and natural history of pelvic floor dysfunction. Obstetrics and Gynaecology Clinics of North America. 25 (4), 723-746
Gyhagen M., Bullarbo M., Nielsen T. F. & Milsom I. (2013) Prevalence and risk factors for pelvic organ pro- lapse 20 years after childbirth: a national cohort study in singleton primiparae after vaginal or caesarean deliv- ery. BJOG: An International Journal of Obstetrics and Gynaecology 120 (2), 152–160.
National Health Service. 2018. How to get more fibre into your diet. Accessed online at; https://www.nhs.uk/live-well/eat-well/how-to-get-more-fibre-into-your-diet/ Accessed on 24th August 2021.
National Institute for Health and Care Excellence. 2019. Urinary Incontinence and pelvic organ prolapse in women: Management. Accessed online at:https://www.nice.org.uk/guidance/ng123/ chapter/Recommendations#non-surgical-management-of-pelvic-organ-prolapse Accessed on 24th August 2021.
Oxford University Hospitals, NHS Foundation Trust. 2020. Vaginal pessary for prolapse, information for women. Accessed at https://www.ouh.nhs.uk/patient-guide/leaflets/files/65609Ppessary.pdf Accessed on 24th August 2021.
Physiopedia. Pelvic Organ Prolapse Quantification System. Accessed on 27/09/2021 found at; https://www.physio-pedia.com/Pelvic_Organ_Prolapse_Quantification_(POP-Q)_System
Schaffer J. I., Wai C. Y. & Boreham M. K. (2005) Etiology of pelvic organ prolapse. Clinical Obstetrics and Gynecology 48 (3), 639–647.
Vergeldt T. F. M., Weemhoff M., IntHout J. & Kluivers K. B. (2015) Risk factors for pelvic organ prolapse and its recurrence: a systematic review. International Urogynecology Journal 26 (11), 1559–1573.