The 5 P’s of Prolapse: a less overwhelming & accurate resource.
As a pelvic floor therapist, the most phone calls that I get from people looking for immediate support is without a doubt individuals who have pelvic organ prolapse (POP). On visit one with these patients, we often focus on education based of each individual’s needs. By the end of the visit, they always feel much more at ease and with actionable steps to help versus the usual doom & gloom information that you’d find online about prolapse. This blog post is going to be packed FULL with some of the information & education that I go over with my patients on day one. It will also include additional resources, so go at whatever pace feels good for you. Please know, if you are suffering from POP symptoms, you are not alone. They are scary, but I promise you will feel empowered after reading this resource.
Let’s just start with some basics like what is it and how does it occur.
Pelvic organ prolapse occurs when the muscles or supporting tissues in the pelvic region aren’t function optimally. One may feel pressure/heaviness and/or see tissue changes or a “bulge”.
The most prevalent risk factors include:
Childbirth and Muscle Weakening: Vaginal childbirth can lead to the stretching and weakening of the pelvic floor muscles. The risk of pelvic organ prolapse later in life is heightened among those who have experienced multiple vaginal childbirths. It's important to note that prolapse can also occur in women who haven't given birth or have undergone a cesarean (C-section) delivery.
Straining & Excessive Abdominal Pressure: Giving birth to a baby weighing over 8½ pounds can place increased strain on the pelvic structures, potentially increasing the risk of prolapse. Individuals with a history of chronic constipation and/or chronic coughing are also at an increased risk due to the added strain on the pelvic floor.
Aging and Pelvic Floor Disorders: Pelvic floor disorders become more prevalent among older women. Notably, around 37% of women with pelvic floor disorders are between the ages of 60 and 79, and approximately half are 80 years or older.
Menopause and Hormonal Shifts: Hormonal shifts during and after menopause, including the decline in estrogen levels, are associated with an increased risk of pelvic organ prolapse. The exact reasons behind this connection are subjects of ongoing research.
Genetic Influence: Family history is being investigated by researchers for its potential role in the development of pelvic organ prolapse. Genetic factors may play a part in predisposing individuals to this condition.
Now let’s look at some of the research, you may be surprised at how come it actually is!
A study from the Gambia found that 46% of women had some degree of prolapse on examination, but only 12.5% of the women reported symptoms related to POP. Advocacy groups like The Association for Pelvic Organ Prolapse Support (APOPS) reports between research, the rate at which women are inaccurately assessed, and at frequency that women are not searching out treatment for POP, it is likely that about 50% of women >50 have a prolapse. So please know that if you are having signs and symptoms of prolapse, you are not alone. And maybe more importantly - there is help just by influencing the mind and body (more on this below!)
Several studies have provided optimistic insights into the relationship between physical activity and POP. For instance, a study conducted in 2016 by researchers such as Almeida focused on women who actively engaged in weight lifting. Surprisingly, the findings indicated that only a mere 2.3% of these women exhibited signs of pelvic organ prolapse.
Similarly, a study in 2020 led by High and their team explored the experiences of 314 women who participated in CrossFit. The study revealed that only 3.2% of these individuals exhibited symptoms related to pelvic organ prolapse.
Adding to this body of research, an impactful study carried out in 2020 by Lori Forner, an esteemed Australian expert in pelvic floor health, provided even more comprehensive insights. This study encompassed nearly 4000 women, spanning various activity levels. The participants were grouped into distinct categories which were: Light Lifters (lifting up to 33 lbs max), Moderate Lifters (lifting up to 110 lbs max), Heavy Lifters (lifting more than 110 lbs max and Non-Lifters
Contrary to the alarmist assertions often encountered, this particular study did not identify any significant correlation between weight lifting and heightened issues with prolapse. Quite the opposite, in fact. Which is why getting someone with prolapse symptoms feel empowered to lift and lift properly is hugely important in pelvic floor therapy.
Across all participants included in the survey, approximately 14.4% reported experiencing symptomatic prolapse.
What can get confusing is this concept of ANATOMICAL prolapse versus SYMPTOMATIC prolapse:
Anatomical Prolapse: This entails observing a bulge within the vagina, where tissue moves downward and occasionally even beyond the vaginal opening. This visual manifestation may or may not correspond with symptomatic sensations like heaviness/pressure and/or a sensation akin to "bubbles" in the vagina. Anatomical prolapses are classified on a GRADE scale from 1 to 4, reflecting the extent of descent of vaginal walls, ranging from minimal to more pronounced movement outside the vaginal opening.
Symptomatic Prolapse: This involves a feeling of pressure/heaviness and/or an unsettling sensation of something descending within the vagina. Additional symptoms could encompass experiencing difficulty in fully emptying the bladder (requiring standing up, shifting, and then sitting down again to expel more urine), encountering obstruction during penetrative intercourse or the insertion of a cup/tampon, and occasionally sensing shifts or bubbling within the vaginal region. These symptoms may or may not correlate with observable changes in tissue (referred to as a visual bulge).
Frequently, patients inform me that their OB has assessed them and found no signs of prolapse. This scenario often contributes to patient confusion, as they are told that their experiences don't align with what medical professionals are observing. Such persistent confusion can inadvertently foster fear. Here are three potential reasons why your OB might not have detected your prolapse:
Position of Assessment: OBs often evaluate patients while lying down, a stance that fails to replicate the conditions under which most patients experience prolapse symptoms - standing or when influenced by gravity. Understandably, patients often resort to lying down to temporarily alleviate symptoms, given the limited impact of gravity. Consequently, pelvic floor therapists frequently evaluate prolapse in functional positions like standing and squatting, which resonate more with the postures where symptoms typically manifest.
Timing of Assessment: Assessments conducted earlier in the day might miss the presence of prolapse or bulging, as many patients may only notice symptoms later in the day after being on their feet for a while.
Type of Prolapse: It's important to recognize that an OB's primary focus is on anatomical prolapse - the observable bulge. However, it's entirely plausible to experience symptomatic prolapse without a corresponding visible bulge. This nuanced distinction is more common than one might think.
If you find yourself grappling with either the "sign" of anatomical prolapse, characterized by a visual bulge or descent of vaginal wall tissue, or with "symptoms" like intermittent pressure and heaviness that may manifest only part of the day (or even constantly), you're not alone in your experience. The intricate interplay between anatomical and symptomatic aspects warrants a comprehensive understanding for both patients and healthcare providers.
Now, let’s delve into the core strategies that you can begin implementing TODAY to alleviate your prolapse symptoms and promote the well-being of your body, ultimately working towards reducing or even eliminating your prolapse.
Introducing the 5-P’s:
1. Posture:
During pregnancy, our posture undergoes significant changes to accommodate the growing belly. Often, these postural shifts persist postpartum without our conscious awareness. A common observation is that the hips and pelvis tend to shift forward in relation to the chest and ribcage, while the knees lock out. This altered posture becomes a daily norm, from holding and soothing the baby to tasks like cooking and doing dishes. Unfortunately, this posture subjects the pelvic floor to increased downward pressure, particularly the front/anterior pelvic floor (near the bladder), and also leads to heightened tension in the glutes. Sitting and feeding/living/working in a slumped position (think C-shape) can also create unnecessary downward pressure onto the pelvic floor.
Our approach involves deliberate mindfulness towards the body's alignment, aiming to align the rib cage directly over the pelvis. This alignment can be achieved through various techniques, often involving gentle knee unlocking, relaxing the glutes, and subtly shifting the hips and pelvis back. Need personalized guidance on finding effective cues? Let’s have a conversation!
For more insights on maintaining proper posture during pregnancy and motherhood, explore this informative video.
2. Pressure Management:
I acknowledge that explaining this facet (the "P" for Pressure Management) can be somewhat intricate, so I recommend referring to this video that demonstrates how pressure influences the pelvic floor. Among its roles, the pelvic floor absorbs and disperses pressure. While this is beneficial, scenarios arise when the pelvic floor can be overwhelmed such as:
Intense Pressure from Pregnancy: It's essential to acknowledge the 10 months of pressure experienced during pregnancy.
Stretching Post-Childbirth: Childbirth results in the pelvic floor undergoing a 33% increase in length (and it doesn’t simply revert to its original state within 6 weeks postpartum).
Excessive Pressure from Various Sources: This includes straining, constant sucking in the belly, breath holding, inadequate core activation, and other factors.
When these situations converge, they can exacerbate prolapse symptoms. A quick technique to manage intra-abdominal pressure is to exhale during exertion movements, such as lifting a baby or handling bulky items like water bottles at Costco. Check out this video on lifting mechanics with breathing to help decrease downward pressure.
3. Pelvic Floor Preparation & Core Connection:
In my experience, individuals with prolapse often encounter aggravated symptoms due to their pelvic floor being overly tight, weak, or uncoordinated. Postpartum, the pelvic floor muscles might appear dormant, leading to surprising tightness. Therefore, seeking assessment from a pelvic floor therapist is crucial to understand your unique circumstances. It's important to clarify that pelvic floor preparation isn't limited to Kegels (repetitive pelvic floor contractions). Instead, it entails creating a proactive routine before embarking on walks or workouts to connect with both your pelvic floor and core muscles through breathing. This component is pivotal and usually marks the first exercise I introduce postpartum. Sadly, over 40% of women execute pelvic floor contractions incorrectly – some even push down instead of contracting upward. Considering our aim of reducing pressure on pelvic organs, I stress the significance of consulting a pelvic floor therapist to receive tailored advice.
Explore this video to grasp the principles of pelvic floor and core connection.
4. Pooping Properly:
Maintaining optimal bowel habits is pivotal for supporting pelvic floor health and managing prolapse. An excess of bowel movements can strain and tense the pelvic floor, while too few can result in pressure and straining. Many prolapse patients notice a direct link between heightened symptoms and bowel movements, indicating an interplay with pelvic floor function.
Gain insights from this video that delves into the dynamics of defecation, encompassing proper techniques for healthy bowel movements.
5. Positive Perspective:
Possibly the simplest yet most challenging of the "P's." Many patients grappling with prolapse symptoms reach out to me with concerns and tears. This experience often evokes feelings of isolation, despite being a common occurrence. Moreover, for some, movement and exercise – typically natural mood enhancers – can exacerbate symptoms. Instances arise when the safest haven seems to be lying down in bed. It's important to recognize that heightened stress consistently amplifies POP symptoms. Amidst such circumstances, turning away from extensive internet searches and engaging with a movement-positive pelvic floor therapist is recommended. Embracing gratitude practices, stress management strategies, seeking supportive social circles, and even consulting a mental health professional can be immensely beneficial. These symptoms are indeed complex, and apprehension and unease around them can inadvertently intensify symptoms. This intricate connection between the pelvic floor, the pelvis, and the mind underscores the significance of adopting a positive mindset. Simply put, when the mind is at ease, it resonates positively within the body.
I’m lastly going to talk about one bonus “P’s” and that is:
PESSARY!
I can’t end this blog article without mentioning pessaries since I am usually the first person to mention these magical devices to patients. Sometimes people need/want immediate symptom relief. Some have their symptoms ONLY with lifting heavy weight in the gym, or during specific days of their menstrual cycle. And for some, just knowing their is an option other than surgery if they are having some reoccurring symptoms after pelvic floor therapy… enter the fabulous pessary device. Pessaries are medical devices that are placed by a medical provider into the vaginal canal to help support the pelvic organs. I love to have patients use pessaries as a tool to help essentially “reset” the pelvic tissue, significantly decrease symptoms (woohoo now less pelvic floor clinching) and we can still work in physical therapy to retrain all the things listed above in the 5 P’s. For a large amount of patients, overtime they can get rid of their pessary (only if they want to!) or wear them only when they feel like they want to. One study found that pessary use helped to decrease the grade of the anatomical prolapse.
If you are feeling like you want some additional support or have questions about if pelvic floor therapy will help you with you prolapse (the answer will be absolutely yes!), then book a discovery call with me! During these 15 minute calls, I will learn a bit more about you and your goals, and during our first appointment we will come up with an evidence based and individual game plan for you.
References:
Almeida MBA, Barra AA, Saltiel F, Silva-Filho AL, Fonseca AMRM, Figueiredo EM. Urinary incontinence and other pelvic floor dysfunctions in female athletes in Brazil: A cross-sectional study. Scandinavian journal of medicine & science in sports. 2016;26(9):1109-1116. doi:10.1111/sms.12546
Forner LB, Beckman EM, Smith MD. Symptoms of pelvic organ prolapse in women who lift heavy weights for exercise: a cross-sectional survey. International Urogynecology Journal. 2019;31(8):1551-1558. doi:10.1007/s00192-019-04163-w
High R, Thai K, Virani H, Kuehl T, Danford J. Prevalence of Pelvic Floor Disorders in Female CrossFit Athletes. Female Pelvic Medicine & Reconstructive Surgery. 2020; 26 (8): 498-502. doi: 10.1097/SPV.0000000000000776
