Prolapse 101

What is Prolapse?

Have you ever felt like your lady parts might be falling out? It’s a scary, not to mention unpleasant, feeling of pelvic pressure, heaviness or even bulging. This is one of the big signs we see in patients with Pelvic Organ Prolapse! In case you don’t know the answer to the question: What is prolapse? We’re going to dive into what it is, why it happens, and what your next step should be if you suspect you have one!

Prolapse is when one or more of the pelvic organs drop or press into or out of the vagina. There are 3 different types of prolapse, depending on the pelvic organ that's affected. The organs that can be involved are:

  • Bladder (also called a cystocele)
  • Uterine (pictured below)
  • Rectal (also called a rectocele)
prolapse diagram

Symptoms

  • Vaginal bulging typically noticed when wiping
  • Pelvic pressure or the feeling of a “lump” in the pelvic area
  • Low back discomfort
  • Incomplete emptying (bowel or bladder)
    • Increased urgency or frequency as a result of incomplete emptying
  • Position changes required to finish emptying (bowel or bladder)
  • Pain or discomfort with intercourse

Understanding Your Prolapse

To understand prolapse, let’s talk about the anatomy involved. The pelvic floor muscles support the bladder, uterus, and rectum from underneath. Ligaments and fascia provide support to these structures from above. With any change in the strength of the pelvic floor muscles or integrity of the ligaments and fascia, it can result in that ‘drop’ of a pelvic organ.

To help diagnose how far the prolapse has dropped within the pelvis, there is a 4-point grading system:

  • Zero - Grade 0: normal, no descent of the pelvic organs
  • One - Grade 1: mild, prolapse is 1 cm or more above the vaginal opening
  • Two - Grade 2: moderate, prolapse is at or within 1 cm of the vaginal opening
  • Three - Grade 3: major, prolapse is more than 1 cm outside the vaginal opening
  • Four - Grade 4: prolapse is entirely outside of the body.

While we use this grading system to determine the severity, it’s not a perfect system.  It's common to have variability throughout the day based on where you are in your cycle, what activities you did, and how fatigued you are.  We commonly hear women report that symptoms are worse later in the day due to the effect of gravity in upright positions. 

Regardless of the "grade" of prolapse, your symptoms and severity of symptoms can vary greatly from other people. Because of this, it’s always important for your medical professional to know how it’s limiting you throughout the day.

Causes of Prolapse

The biggest cause of prolapse is too much intra-abdominal pressure over a prolonged amount of time. Simply put, it’s poor pressure management within your trunk. Certain activities are notorious for increasing our abdominal pressure such as coughing, holding our breath while lifting, straining to have bowel movements, and poor posture. 

There are also other factors that can increase your risk including:

Hormone Levels. One factor that increases risk for prolapse is decreased estrogen during postpartum and menopause. This decreases the strength of the pelvic floor and the integrity of the ligaments that hold the organs up. During periods of increased intra-abdominal pressure (i.e. lifting, coughing, or standing) there isn't adequate support for the pelvic organs.

Ligamentous Laxity.  The fascia and ligaments above the pelvic organs can also be compromised in individuals with poor connective tissue strength such as during pregnancy or those with general hypermobility. As these tissues loosen, there is less force holding the organs up against gravity or times of increased intra-abdominal pressure.

Pregnancy & Childbirth.  This is commonly associated with increased risk for prolapse. The first reason is that there is displacement of abdominal and pelvic organs as the baby gets bigger, causing the organs to shift and fit into a less than ideal position leading up to delivery.

The second reason is the extra pressure on the organs and the pelvic floor from the weight of your baby. The last reason is if you have prolonged pushing times during childbirth, which causes extra pressure and stress on the pelvic floor.

Constipation. Increased risk for prolapse can happen when your are constipated because of the straining and pushing associated with difficult bowel movements. Over time, the repeated strain on the pelvic floor and pelvic organs can lead to prolapse especially when combined with other risk factors (i.e pregnancy, menopause).

How Do I Fix It?

You should make an appointment to get evaluated by a Pelvic Floor Physical Therapist, if you think you might have a prolapse. A pelvic floor physical therapist can determine what is causing the symptoms of your prolapse and the proper way of treating it.

In the meantime, pay attention to any activities that make your symptoms worse. It will help you know which activities to avoid temporarily in order to prevent worsening your prolapse. Once you’ve been assessed by a pelvic floor physical therapist, you'll be able to get to the root of your symptoms and work to increase the support of the organs in this area.

With conservative treatment, it's likely it will not improve greatly in terms of the grade, but the symptoms can be resolved. This will allow you to perform everyday activities without that pelvic heaviness! Prolapse can sound scary, but the good news is that with a mild prolapse the symptoms can greatly improve.

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