Understanding Prolapse - can a prolapse come and go? And if so, why?

What is pelvic organ prolapse?

Pelvic organ prolapse (POP) occurs when one or more of the pelvic organs slip from their normal position and bulge into the vaginal canal. This can occur with the bladder, uterus, rectum, small intestine, or a combination of the organs. Pelvic organ prolapse is staged 1-4 with 1 being classified as minimal descent of the pelvic organs and stage 4 visibly descended externally. 

What can cause pelvic organ prolapse? 

Pelvic organ prolapse can occur after child birth, hysterectomy, menopause, and/or a lifetime of chronic straining with bowel movements or heavy lifting. 

Types of pelvic organ prolapse? 

The most common classifications of prolapse we see and treat in the clinic include cystoceles, rectoceles, and uterine prolapse, with enterocele and uterocele being less common. A cystocele is the descent of the bladder into the vaginal canal, while a rectocele is the descent of the rectum into the vaginal canal. A uterine prolapse is the descent of the uterus. Though less common, a urethrocele is a type of prolapse that occurs when the urethra moves from its normal position and presses against the front wall of the vaginal, and an enterocele occurs when the small intestine prolapses into the back of the vaginal canal. 

Early signs and symptoms of prolapse? 

Common signs and symptoms of prolapse include a heaviness sensation (patients often report it feels like a dumbbell sitting on their pelvic floor) or the feeling that something is about to fall out of the vagina. If it occurs after a specific event (such as birth or lifting something heavy) there might be a visible bulge of an organ coming out of the vaginal canal. 

Fluctuation in Symptoms

Can a prolapse come and go?

The short answer is yes, prolapse can come and go, and often does. Prolapse can come and go with different activities, based on time of the day, constipation, and hormonal fluctuations throughout the cycle. Most of our patients that we see for prolapse are very in tune with their bodies and have picked up on some patterns, however, not all of them. 

Factors that affect prolapse symptoms

Factors that affect prolapse include gravity which is typically why patience with prolapse say their symptoms are worse in the evenings than the mornings. Constipation is another big one that can worsen prolapse; the rectum sits right on top of the pelvic floor, and if it is full of stool it’s way more challenging for the pelvic floor to do its job. Managing constipation is key for prolapse! Chronic straining is another major factor in prolapse fluctuation. Constantly bearing down or holding your breath will put added pressure on the pelvic floor and ligaments that support the pelvic organs thus increasing prolapse.

How physical activity impacts prolapse symptoms

Exercise is great for managing prolapse. The latest and greatest research shows that glute strength supports the pelvic floor and is an excellent treatment strategy for prolapse. Exercise can however exacerbate prolapse if correct breathing patterns aren’t performed with exercise. Most of our patients are either using incorrect breathing strategies or holding breath while exercising which puts added pressure on the pelvic floor and pelvic organs. 

The role of posture and daily habits in prolapse severity

Posture can play a major role in prolapse. A common example I like to give is for the postpartum population during pregnancy. Most women stand with their feet a little wider and their toes pointed out more than when they’re not pregnant. However, if this is not retrained postpartum (typically by strengthening the core and glutes) this will continue for quite some time. When you stand with your toes pointed out more than parallel, this is called external rotation one of the primary pelvic floor muscles is an external rotator. It can become shortened and symptomatic if contracted for long periods of time, thus, not able to support the demand of the pelvic organs. When you point your toes in more than out, this is called internal rotation. When you internally rotate at your hip joint, the pelvic floor muscles lift and support the pelvic organs. This is what we want! The way we stand (posture) impacts pelvic organ prolapse greatly. 

Management and Treatment Options

Non-surgical treatment for prolapse 

Nonsurgical options for managing pelvic organ prolapse include pessary fittings and pelvic floor physical therapy. 

A pessary is a support device that is similar to a sports bra for the pelvic organs. There are different sizes and shapes and each person should be individually fitted for their own pessary. Read more about pessaries here. 

Pelvic floor physical therapy is an individualized treatment option for pelvic organ prolapse and uses both exercises and lifestyle modifications with the goal of non-invasive treatment to get you back to living your best life with confidence. Treatment will look different for each person based on severity, goals, and other symptoms present.

Pelvic floor exercises to manage prolapse

Unfortunately, there’s not a one size fits all algorithm to treating pelvic organ prolapse with exercise, otherwise I wouldn’t have a job. 

Conservative treatment options, such as pessaries and pelvic floor PT are usually prescribed prior to surgery for prolapse staged 1 to 3, while stage 4 prolapse typically requires surgery. Pelvic floor physical therapy before and after surgery yields the best outcome, similar to PT before and after a knee replacement.

Exercise prescription should be just that— a prescription. It should be specific to the individuals goals, symptoms and lifestyle.

Surgical options for prolapse

Surgical options for prolapse depend on the type of prolapse and severity of prolapse. The most common type of surgery I’ve seen for prolapse is a sacrocolpopexy, which is where surgical mesh is used to lift the pelvic organs back into place.

Lifestyle changes to manage prolapse

Hands down the two most important lifestyle changes that are key to managing prolapse include changing the way that you breathe and managing constipation. Which is usually shocking to most patients as they’re expecting a kegel prescription for managing pelvic organ prolapse. Incorporating the right exercises for strengthening is also a game changer!

Preventing Prolapse

Tips to prevent prolapse from worsening

Similar to treatment, the best recommendation for preventing prolapse is: 

• Correct breathing mechanics

• Core strengthening and proper core activation

• Avoiding chronic straining

• Glute strengthening

• Postural awareness

• Managing any constipation 

How childbirth affect prolapse

Push duration during childbirth can affect prolapse as well as pushing technique. Generally longer push times are harder on your pelvic organs. There’s a great amount of fascia and ligamentous support in the pelvis to hold the organs and their place. A great amount of stretching to these ligaments will slacken the vaginal canal and allow for the pelvic organs to fall into the vaginal canal - creating a prolapse situation.

Postpartum care to prevent prolapse

Graded return to exercise or activity during the postpartum period is key for preventing prolapse. Doing too much too soon can be damaging to your pelvic organs and/or their support structures. Additionally, training the pelvic floor and core to fire together to support the pelvic organs helps tremendously. 

If breast-feeding or postmenopausal, it’s important to remember estrogen is lower during this time, which affects the pelvic floor muscles and how they function. Talking to your provider about estrogen cream or putting more emphasis on pelvic floor muscle training helps with this.

Long-term management strategies for prolapse

If your prolapse is greatly impacting your quality of life and daily function, and you’ve tried conservative treatment, surgery might be the best option for you. But if you’re looking to conservatively manage your prolapse, pelvic floor PT with or without a pessary support is the best option for treating and learning how to prevent progression of your prolapse. 

We are currently taking new patients with prolapse in Rockwall, Canton, and Sulphur Springs. If you are interested in scheduling an appointment, please request an appointment here and someone from our team will reach out to you to get you scheduled.