Pelvic Organ Prolapse

By Gail O’Neill

Our pelvic organs (bladder, vagina, uterus and rectum), are supported by our pelvic floor muscles (PFM) and endopelvic fascia which is a sheet of connective tissue that covers the internal organs. When there is a loss of support within this system one or more of our pelvic organs can descend or prolapse into, and in some cases, out of the vagina. This usually occurs with older women.  However, it can happen with women of any age.  Some causes may include: childbirth, aging, decrease in estrogen, prior surgery, regular heavy lifting, exercise overload, connective tissue injury, obesity, injury to Levator Ani muscle (PFM) and chronic straining which occurs with constipation.

There are certain types of prolapse.  The most common is bladder prolapse or Cystocele.  This is a result of the bladder moving to the front of the wall of the vagina (anterior).  If severe, the front wall of the vagina may bulge out of the opening of the vagina and may actually be visible at the vaginal opening.

A Rectocele is when the lower part of the bowel or rectum moves forward into the back wall of the vagina.  This is known as a posterior vaginal wall prolapse. This may be more evident during and after straining when having a bowel movement.

Uterine prolapse occurs when the uterus and the cervix drop into the vagina from their normal position. If a woman has undergone a hysterectomy, the upper part of the vagina can move downward.  This is referred to as a vaginal vault.

A Rectal prolapse is a condition that is confused with a pelvic organ prolapse (rectocele).  This involves only the rectum- not the vagina.  This prolapse affects the lower part of the bowel or rectum moving down or out of the anus.  A rectal prolapse is most often cause by weakening of the supportive tissues holding the rectum in position.  This weakness may be in the Pelvic Floor muscles which includes the external anal sphincter.

Some symptoms associated with POP may vary and do not always correlate with the severity of the prolapse. They generally are worse with prolonged upright postures such as standing and relieved when lying down.  Some common complaints may include: vaginal bulging, heaviness or pressure within the pelvis, lower back pain, lower abdominal pain and/or pressure, difficulty emptying bladder, difficulty evacuating bowels, manually repositioning the prolapse in order to effectively void.

If left untreated, a POP will not heal or disappear on its own.  Given that a prolapse occurs due to tissue being stretched beyond its limits, once over stretched, the tissues are not able to return to their former length.  Some mild to moderate grades of prolapse can improve with pelvic floor rehabilitation.

A Gynecologist, Uro-Gynecologist or pelvic floor physical therapist are trained to assess the severity of a prolapse. It is measured in stages using a calculation referred to as the POP-Q.  This system measures the amount of downward displacement of the affected organ in relation to distinct landmarks within the vagina.  The prolapse is graded from Stage 0 (no prolapse) to Stage IV (complete protrusion through the opening of the vagina).

Addressing pelvic organ prolapse may include strengthening of the pelvic floor muscles, pessary inserts and behavioral modification in order to educate patients how to avoid worsening their prolapse.  These may include avoiding activities which increase intra-abdominal pressure which can occur with both heavy lifting as well as straining with constipation. Pessaries (supportive devices that are custom fitted and inserted into the vagina) act as a sling to help support and keep the organ elevated.

If you feel that you have an organ prolapse, you should be evaluated by an appropriate health care provider.  Our experienced and well trained pelvic health physical therapists here at Pelvic Health Solutions are available to treat any issues with pelvic organ prolapse.