Some thoughts on pelvic organ prolapse (POP), fascia and the pelvic floor muscles
25th March 2021
Pelvic organ prolapse (POP) is, put simply, the descent of one or more organs within the pelvis. POP is hugely prevalent in the general population with 8.4% of women in the UK reporting a bulge or lump to their GP, and 50% of women over 50 having some degree of prolapse. 1 in 10 women will have at least one surgical procedure for POP in their lifetime. People often feel confused about what a prolapse actually is, and this confusion can lead to feelings of anxiety and distress. A prolapse occurs when there is a loss of support from the connective tissues in the pelvis. This can be a lack of muscle bulk and strength (which occurs with childbirth, hormonal changes and the ageing process), or an over-stretching of ligaments or fascia. The most common type of prolapse is a called a cystocele. This is descent of the bladder, which causes a bulge in the anterior (front) wall of the vagina. The urethra can also prolapse too (called a urethrocele). Similarly, rectocele is the term given to describe a bulge that occurs in the posterior (back) wall of the vagina, when the rectum loses some of its support. The uterus can also prolapse - this is simply called a uterine prolapse.
Strong pelvic floor muscles can help to compensate for the lack of support in the vaginal walls, and practical lifestyle advice can make an enormous difference. Pelvic organ prolapse is often associated with childbirth, but sometimes does not become a problem until the peri-menopause when hormone levels begin to change. There is a saying in our speciality, that it is at menopause that we discover the true extent of the problems caused by childbirth. When we are younger, fitter, perhaps lighter, and our tissues have more oestrogen, we can compensate to a degree, for the stretching and weakening of the supporting structures of the pelvis. However, when our oestrogen levels decline, the pelvic floor muscles and connective tissue in the pelvis become thinner – they lose their bounce, thickness, and responsiveness, and this is when the problems can start for some women. Menopause can be a real crunch time.
That’s not to say that postnatal women do not experience or struggle with POP. They do, and according to studies as many as 40-86% of women will have some degree of prolapse at their postnatal check. However, early postnatal prolapse often improves (to the point where it is mild and not particularly troublesome) with a combination of time, a return of normal hormone levels, tissue healing and correct exercise. The prolapse in that case may still be evident on examination, but the woman is no longer aware of it.
POP is not only caused by childbirth and the menopause. It can also be caused by chronic constipation and straining, respiratory problems (chronic cough), obesity, excessive high impact exercise and heavy lifting. Certain connective tissue problems such as hypermobility spectrum disorders and Ehlers Danlos Syndrome in particular increase the chances of developing a prolapse. Many connective tissue disorders are hereditary, and this may be the reason for people saying that prolapse runs in their family.
Prolapse is generally diagnosed by digital vaginal examination by your GP, gynaecologist, or a specialist pelvic health physiotherapist, and will be described as either mild, moderate or severe (1st, 2nd or 3rd degree) depending on how far the organ has descended. It is also described by the affected compartment: anterior (front) vaginal wall = bladder (cystocele), posterior (back) vaginal wall = rectum (rectocele), or uterine (middle) or vault prolapse in women who have had a hysterectomy. It is common to have more than one type of prolapse at once. The good news is that prolapse can be significantly improved with the right advice and pelvic floor muscle training.
See the fantastic infographic from @spring.physio below depicting the different types of prolapse.
Specialist pelvic health physiotherapy can help with all types of pelvic organ prolapse, whether it's the bladder, rectum or uterus that are affected, and is recommended by NICE as the first line of treatment. Surgical options are limited and can have unsatisfactory results, with a high incidence of repeat procedures (11% within 11 years). The current mesh scandal highlights that surgery should only be undertaken when appropriate conservative measures have failed. “Failed” physiotherapy does not just mean that someone has been given a leaflet by their GP and told to do their pelvic floor exercises independently. Appropriate conservative treatment means a minimum of 3 months of physiotherapy treatment with a trained pelvic health specialist for supervised pelvic floor muscle training, advice and treatment.
After an initial examination and confirmation that you do have a prolapse, we would tend to begin pelvic floor muscle strengthening (unless your muscles are hypertonic/overactive – more on that later). Did you know that you need to do two different types of pelvic floor exercises to get the most out of your muscles? When we assess the pelvic floor, we don’t just look at overall muscle strength, we look at the power of the squeeze, and the endurance (how long it can be held and how many times that can be sustained). This is to do with the different types of muscle fibres that make up the pelvic floor. Your pelvic floor needs both power and endurance to work well. In other words it needs to be able to sprint (for example when you cough or sneeze or lift something), and it needs to be able to run a marathon (to provide adequate support for your pelvic organs). We also look at its resting tone, how well it relaxes, and the timing (speed) of the contraction too. If the pelvic floor does not relax fully, this also affects its ability to squeeze strongly. There’s much more to it than you might think...
So, when you exercise this means you not only need to do your slow holds (aiming to hold for at least 10 seconds at a time), but also quick flicks too (where you squeeze hard and fast, but let go immediately). Try to do at least 10 of each type (slow first, followed by quick), three times a day. Your physiotherapist may also advise you to do sub-maximal contractions – these are gentle squeeze at around 30% of your maximum squeeze, that you hold for much longer – 30 seconds plus. You can sit or get up on your feet to do your exercises - mix it up if at all possible. Lying down is ok when you are learning how to do the exercises correctly, are quite weak, or just starting out, but the least challenging. Once you can feel an appropriate contraction in an upright position, then use this to exercise in. Also don’t forget “the knack”, squeeze and hold when you cough, laugh, lift anything or sneeze. We endeavour to make pelvic floor muscle training as functional as possible – incorporating the breath (exhale as you contract your muscles, and on exertion such as lifting), getting you up on your feet using your pelvic floor as you squat or lunge for example. Ensure you let go fully between each repetition too.
If you struggle to “find” your pelvic floor, or are unable to perform the exercises correctly, or your muscles are very weak, there is an array of different devices we can use to help with this. These range from biofeedback devices that connect via Bluetooth to an app on your phone, to electrical muscle stimulation, to real time ultrasound scanning. We have plenty of tricks up our sleeve, and tools in our toolbox to help you to get the hang of the exercises and get the most from your muscles.
Interestingly, Pelvic organ prolapse (POP) and its relationship to weak pelvic floor muscles, might not be quite as straightforward as we once thought. I have recently completed an excellent update on POP from Anna Crowle courtesy of @meps_uk . I highly recommend this course to anyone who hasn’t checked it out. This update discussed fascia and the biotensegrity model as a way of viewing prolapse. The idea that the pelvic floor muscles alone hold up the organs from below is perhaps old fashioned, and we need to also consider the continuous web of fascia that our organs are embedded in.
The biotensegrity theory is that prolapse is caused by tension / scarring in one area of the pelvis, pulling organs out of alignment and causing a bulge in the vagina. This tension / scarring can be caused by childbirth, constipation, surgery or even a fall onto the coccyx amongst other things. Women with POP can sometimes be so fearful of their organs descending (feeling that things are “falling out”, that when they start to experience symptoms, they over recruit and grip with their pelvic floor muscles continuously, leading to shortening and hypertonicity, and potentially more symptoms.
I certainly find more and more in my clinic, that women with prolapse do not present just with straightforward weak pelvic floor muscles. There is often hypertonicity (overactivity) of the pelvic floor evident, with pain and myofascial tension in at least some part of this complex group of muscles. This tension needs releasing through manual therapy, movement, breathing and pelvic floor relaxation, prior to thinking about any strengthening work. This can sometimes be quite difficult for people to comprehend - the idea that we need to release, relax and stretch a group of muscles in order for them to work better for you when needed, can seem strange. Once the overactivity and tension in the muscles is dealt with, strengthening can start, if required. Believe it or not some women with prolapse, never need to do traditional pelvic floor strengthening exercises.
In addition to pelvic floor muscle training or re-education, pelvic health physiotherapists will also give plenty of lifestyle advice regarding how to manage your prolapse. This may be use of “the knack” (the bracing method mentioned earlier), advice regarding lifting and general exercise, and also (and hugely importantly) advice regarding your bowel habit. If you are struggling with constipation or difficult bowel emptying and you have a POP, it is vital that do not strain.... Did you know that most of our toilet seats are too high? By using a foot stool so that your knees are raised higher than your hips, you can make a huge difference to how easy it is to empty. If your knees are raised, and you lean forwards over your knees, this puts your pelvis in a better position and opens up the ano-rectal angle, meaning bowel emptying is much easier. Gravity will be on your side and you won’t be trying to empty uphill!
If you can combine these simple positional changes with not holding your breath (deep breathing can help), and consciously relaxing your pelvic floor muscles (especially as you take a breath in), this can make an enormous difference. Also remember to get 30 mins of cardiovascular exercise daily (walking is fine), and drink plenty of water (aim for 2 litres). Combine this with a diet containing plenty of fibre, fruit and veg, and you’ll notice a change.
It is also sometimes appropriate for a woman with POP to use a pessary. A pessary is typically made of medical grade silicone, and is an object which is inserted into the vagina, and can support the uterus and vaginal walls. It can be a helpful way of managing prolapse. Some pessaries can now even be purchased online, directly by you, and come in sample packs of different sizes for you to try. These are inserted by you, and removed when not required. This means they can just be worn when you exercise, or if you know you will be up on your feet a lot one day for example. Others are designed to be left in situ 24/7 and changed every 4 months or so. These tend to be fitted by your GP or gynaecologist, although some pelvic health physiotherapists are now trained to do this too. A pessary can be useful if you cannot or do not want to have surgery, or as a stop-gap to help you to feel more comfortable whilst you are having your physiotherapy treatment. I am hoping to be able to offer a pessary fitting service myself later in the year – watch this space.
One of my clients told me recently that she felt that her recovery from pelvic organ prolapse and pelvic floor muscle dysfunction, was like a game of Snakes & Ladders. She felt that she was making good progress at times, but that at other times she felt like she had gone backwards (or to use her words, that she had “slipped back down a snake”). Recovery from pelvic health problems doesn’t always follow a neat linear path, particularly recovery from more severe prolapse (as she had) with overactive pelvic floor muscles, or complex pelvic pain. There are often ups and downs along the way. I often tell people to expect to possibly take two steps forward, followed by a step backwards, followed by three steps forward, and another step back and so on. The step backwards might be felt as a temporary increase in prolapse symptoms or leaking for example.
What’s important at those times when you feel like you have gone backwards, is to try to remember how far you’ve come. I would hope that when you are having treatment, that even with a backward step, you would still be able to see the progress you have made - perhaps that you are now having more good days than you were, or that you are leaking less often or smaller amounts, or that you are more comfortable when you have had a busy day on your feet, that your bowel is emptying more easily, or that you have been able to start a walk to run programme for example.
Pelvic health physiotherapy can help you navigate this sometimes bumpy road to recovery, and get you back to doing the things you love as quickly as possible, whether you are struggling with pelvic organ prolapse, pelvic floor issues, pain or all of the above - help is available.
NICE guidelines for pelvic organ prolapse can be viewed here:
Image below purchased and used with the kind permission of Claire Brodie @spring.physio: