Pelvic organ prolapse is where one (or more) of the pelvic organs drop down into, and sometimes outside, of your vagina. Your pelvic organs are your bladder, uterus and bowel. So your bladder can drop and this will cause it to push on the front wall of the vagina. This is also known as a cystocele. Your uterus can drop down, this is known as a uterine prolapse. And your bowel can drop down, pushing on the back wall of the vagina, and is also known as a rectocele.
Prolapse can be measured in different ways (different doctors use different measuring systems) but one of the most common measuring system’s is the POP-Q. Using a POP-Q system the extent of a prolapse is graded is stages as described below:
Stage 0: No prolapse
Stage 1: The organ is in the upper half of the vagina (so the organ has moved from its normal position but is still inside the vagina and it is in the upper half of the vagina – it is at least 1cm above the hymen (opening of the vagina).
Stage 2: The organ has dropped (or descended) to either within 1cm inside or 1cm outside of the hymen (the opening of the vagina). So at this stage, the organ could be outside of the body (but it could also still be inside). It is within 1cm of the hymen (inside or outside).
Stage 3: The organ has gone past the opening of the vagina and is outside the body by more than 1cm.
Stage 4: The organ is fully outside the body – it has descended as far as it can.
It is now accepted that prolapse is one of the most common health problems in Australia with 75% of women developing at least some degree of pelvic organ prolapse during their lifetime.
Many women with a grade 1 prolapse may not even be aware that they have it. Some may have symptoms such as not being able to wear a tampon (feeling uncomfortable of the tampon falling out) or pain with sexual intercourse. However, they may not realise these symptoms are in fact due to prolapse and therefore may not have been diagnosed and be aware what is causing their symptoms.
Why does prolapse happen?
Prolapse occurs when the support network in our pelvis no longer does its job effectively, then the organs start to drop. But why does the support stop working? Let me explain in a bit more detail how the pelvic organs are actually held in place, this will help you understand how prolapse occurs.
Our pelvic organs are held up in our pelvic cavity by a complex mesh of fascia (imagine cling wrap or a sticky spiders web wrapped around the organs), ligaments and our pelvic floor muscles. Our pelvic floor muscles are below these organs and act as a trampoline and offer support from below.
Now most people focus on your pelvic muscles and blame these for not offering support and hence why we get a prolapse. But, the most important support system for our pelvic organs is in fact the fascia. That sticky web of cling wrap holds our pelvic organs where they are supposed to be. And unfortunately, once the fascia gets stretched or even torn, it can’t be repaired. So, if your fascia becomes stretched or worst case scenario, torn, then that’s a big problem. But how does the fascia get torn or stretched?
To explain this you’ll need to imagine your pelvic organs are a huge gym ball, and we’re going to hang this gym ball from the ceiling. We’ll hang it up from the ceiling with stretchy resistance band (you know the stuff, that elastic exercise band that physio’s love to give out! If you don’t know what I’m talking about just imagine a huge rubber/elastic band) so we’ll tie a couple of resistance/elastic bands around the gym ball to hold it to the ceiling. Now if we left this gym ball hanging from the ceiling all day, for a few weeks, the resistance/elastic bands are eventually going to stretch and the gym ball is going to start to get closer to the floor.
So here’s where the pelvic floor comes in. Our pelvic floor muscles sit underneath the gym ball (our pelvic organs) and their job is to contract and lift the gym ball (organs) up. By lifting the organs up and providing support from below, the pelvic floor muscles are offloading the strain that is being put on the resistance bands (the fascia). So the pelvic floor muscles offload the fascia and support the organs.
But our pelvic floor muscles can’t be switched on all the time to hold our organs up.
So this explains the mechanism of what’s going on inside but how does the fascia get stretched or torn?
Well over time (we’re talking years) if your pelvic floor is non-existent and not working to support the pelvic organs then eventually the fascia (those elastic bands) will get stretched and the organs (the gym ball) will start to drop down and prolapse.
There are other factors that will also stretch the fascia and can increase your chances of a prolapse. These include:
Pregnancy – this causes increased weight on the pelvic floor for a whole 9 months, and the more pregnancies you have the more strain on the fascia.
Giving birth – the process of a vaginal delivery and pushing the baby out puts a lot of stress on the fascia and in the worst cases scenario it can even cause tearing of the fascia and pelvic floor muscles (so less support for the organs as the pelvic floor muscles now can’t hold the organs up).
Respiratory disease – increased coughing puts increased strain on the pelvic floor and organs.
Bulimia or a history of vomitting – vomiting increases abdominal pressure which in turn increases the strain on the pelvic organs (pushes them down every time you vomit).
A history of heavy lifting – again the continued abdominal bracing and strain that recurrent heavy lifting places on your pelvic organs and your pelvic floor puts you at risk of a prolapse.
Impact sports (running, jumping, trampolining) – the recurrent force that is transferred through your pelvis, to your pelvic organs and your pelvic floor, with sports that include running and jumping, puts strain on your fascia and pelvic floor which increases your risk of pelvic organ prolapse.
Menopause – once you’ve been through the menopause your levels of oestrogen drop. Oestrogen is a hormone which helps to keep your pelvic floor muscles working well (it helps keep them toned). So with less oestrogen and less muscle tone the pelvic floor doesn’t support the pelvic organs which in turn puts a strain on the fascia.
How do I know if I have a prolapse?
Symptoms of a prolapse include a feeling of heaviness or dragging in the vagina, feeling a bulge or lump protruding from the vagina, low back pain is also often associated with prolapse. Other symptoms can also include; hesitancy in initiating your flow of urine, slow urinary flow and a feeling of incomplete emptying of the bladder, nocturia (passing urine at night) this is due to not being able to fully empty your bladder during the day due to the prolapse. If the bowel/rectum is involved you could have symptoms of constipation, feeling you haven’t completely emptied your bowel. Uterine prolapse symptoms can include pain with intercourse.
If you are experiencing any of the above symptoms or think that you may have a pelvic organ prolapse then it is best to see your GP who can refer you to a specialist women’s health physiotherapist to assess you and discuss your treatment options.
For more info on prolapse, exercises to help strengthen the pelvic floor, what to do to help avoid prolapse and more, they keep your eyes on the blog for more info.