Angela Rake, Pilates teacher, Women’s Wellness Coach, mum of 3 and co-founder of Zing Wellness, talks about pelvic organ prolapse, shares her experience of it and answers some of the questions she is most frequently asked about prolapse.
After finding myself weeing on the kitchen floor when I had a particularly bad cold in the early postnatal days after the birth of my first child , I made it my mission to rehabilitate my pelvic floor and help other women to do the same. As well as educating and supporting clients to rehabilitate their pelvic floor I want to dispel myths and fears around it as it isn’t always as bad as it sounds and there is so much help and support out there.
Although experiencing a prolapse after childbirth is very common it is my view that it is really only of concern if it is causing you symptoms. Many women have a prolapse without even knowing it! What’s the saying? ‘If it ain’t broke, don’t try and fix it’, However, suffering with some of the symptoms associated with a prolapse is definitely not normal, and certainly not something you should live with.
It took me until after the birth of my second baby to get a bladder and rectal prolapse properly diagnosed after I saw a GP in the early days after my first baby who said “what do you expect, you’ve just had a baby’. Luckily this explanation was far from satisfactory to me and my journey into women’s health began . After the birth of my third baby I saw a gynaecologist who said there was absolutely no sign of a prolapse. I had sought support, attended countless women’s health related courses and put in lots of work to achieve this and I still do. My pelvic health remains an integral part of my exercise regime and during holiday periods where I am not in my normal routine I confess I can feel it in my pelvic floor.
I now spend much of my time in my women’s health focused Pilates classes talking about the pelvic floor and pelvic health. There is SO much help out there and I am here to tell you how to find it. With awareness, education and the right support you can take steps to help your body.
Recently I was asked by a client how a new mum would know if she had a prolapse and how to alleviate the symptoms so I thought I would write a blog sharing what I know about prolapse in the simplest of terms. My key message is to tell you, it is okay, there is SO much help out there and I am here to tell you how to find it.
If this sparks your interest I have specifically created a Core Care & Pelvic Floor Repair course which helps you put all of this into practice. It is accessible in a 6 week group class format, 1-2-1 format and online course format, something for absolutely everyone.
What Is Pelvic Organ Prolapse or ‘Prolapse’ or POP?
Prolapse is when, for a variety of reasons, the fascia and pelvic floor muscles which support your pelvic organs become softer, loose or weakened and as a result your pelvic organs (your bladder, bowel, rectum or uterus) move downwards in the pelvic basin. It can present with no symptoms at all, to a little vaginal heaviness, to severe symptoms. A bulge may be felt inside or outside the vagina. You may experience bladder, bowel or sexual symptoms. You can get different types and different levels of a prolapse which I will attempt to explain.
To demonstrate how prevalent prolapse is I thought I would start by sharing these statistics with you.
50% of women who have had children have some degree of symptomatic or asymptomatic pelvic organ prolapse (Hagen & Stark 2011)
50% of women experience pelvic organ prolapse with symptoms of bladder & bowel dysfunction (Hagen et al 2004)
In women with vaginal prolapse, 63% will experience urinary stress incontinence (Bai at al 2002)
Urinary incontinence during pregnancy nearly doubles the likelihood or urinary incontinence at three months post baby (regardless of how baby is born) (Eason et al 2004)
Women who are incontinent before pregnancy are 5 times more likely to leak after birth than women who are continent before pregnancy (Sampselle et al 1998)
Becky Aston, Pelvic Health Physiotherapist says: “Pelvic organ prolapse is the medical terminology for a change in position of the pelvic organs and it’s a very medical term that can evoke fear. We know that at least 50% of women who have had a vaginal delivery will have some sort of anatomical change that will lead to the diagnosis of a prolapse, but maybe we need to re frame our thoughts on prolapse…. Can we expect to deliver a baby vaginally and not have some sort of anatomical change- for those who have been through vaginal childbirth I think you would agree- probably not. Can we expect to feel supported and secure in the vaginal area? Yes, because we have support structures that help us rehabilitate after childbirth and why progressive rehabilitation is so important. Start with connection of the pelvic floor and the breath, see a specialist to check you are engaging well if at all concerned, and start with exercises such as Pilates before moving slowly towards impact exercise”.
How Do You Know If You Have Pelvic Organ Prolapse?
Firstly, you may not know as you may have no symptoms at all. Your symptoms may also be really mild. Conversely symptoms can also be severe and have a huge impact on your quality of life. If you do have symptoms they are likely to be one or many of the following.
Be aware that sometimes symptoms are worse at different times of the day or month or when you are more tired or after times of increased intra-abdominal pressure like when lifting, carrying, baby wearing, coughing, sneezing or straining to go to the toilet:
- A feeling of pressure, heaviness or bearing down in the pelvic floor that gets worse with standing or coughing
- A feeling of discomfort, aching or fullness in the pelvis
- A feeling that there is a bulge or something is ‘out of place’ or protruding in your pelvic area
- You may notice visible changes and see organs or tissue protruding from your vagina that you didn’t before
- A dragging or uncomfortable sensation in the pelvis or lower back pain
- Painful sex
- Hard or sore when trying to insert a tampon or a feeling of the tampon falling out
- Urinary incontinence
- Inability to empty the bowels properly
- A feeling of needing to protect your bowels when going to the toilet (using your fingers to split to reinforce the back wall)
52% of women with lower back pain during pregnancy were found to have pelvic floor dysfunction (Pool-Goudzwaard et al 2005)
A study of 1004 women with pelvic organ prolapse showed that straining on the loo is associated with anterior vaginal all prolapse and perineal descent (Kahn MA 2005)
Prevalence of stress of urge incontinence and intravaginal prolapse was 42% in women with one or more vaginal deliveries as opposed to 35% in women who had a c-section delivery. (Sakala 2006)
What Are The Different Types of Pelvic Organ Prolapse?
There are different types of prolapse and it is very common to have more than one type at the same time for example I was diagnosed with a front vaginal wall prolapse and back vaginal wall prolapse with perineal descent.
Front Vaginal Wall or Bladder Prolapse or Cystocele – this is the most common type of prolapse. This is when the wall supporting the bladder bulges down into the vagina. Symptoms experienced might be difficulty fully emptying the bladder, urinary tract infections, a strong urgency/desire to empty the bladder, needing to go to the toilet more including at night , incontinence when running/jumping/coughing/sneezing and difficulty passing urine.
Back Vaginal Wall Prolapse or Rectocele– where the lower rectum bulges into the back wall of the vagina. Symptoms experienced might be difficulty emptying or fully emptying your bowels, bowel or wind leakage, a sudden need to empty your bowels or needing to use your fingers to ‘splint’ to support the back wall when emptying your bowels.
Uterine or Womb Prolapse – when the uterus moves downwards towards your vagina due to lack of support causing the cervix to sit lower.
Vaginal Vault Prolapse – this is when women have had a hysterectomy where the uterus has been removed causing the top of the vagina to bulge downwards. Symptoms may include a feeling of a bulge inside or outside the vagina. Sometimes you may be able to see the bulge with a mirror. The vagina may feel wider, looser or more lax. It may be difficult to keep a tampon inserted or there may just be a felling of it falling out.
There are also different levels of severity of a prolapse. It can range from a mild organ descent to one where it feels like the organs are hanging down, out of the entrance of the vagina. Women’s Health Physiotherapists and Gynaecologists use different grading systems to measure the severity.
What Causes Pelvic Organ Prolapse?
Pregnancy and childbirth are the most common causes especially if there has been an instrumental delivery, episiotomy, significant tearing or prolonged pushing.
However pregnancy and childbirth aren’t the only contributing factors. High impact and combative sports, weight lifting, family history, obesity, persistent coughs, constipation, the drop in oestrogen during menopause, previous pelvic surgery and neurological conditions that affect cognitive function can weaken the pelvic floor and contribute to a prolapse.
I also find that pre-existing breathing habits and patterns when managing intra-abdominal pressure are big contributors. They may not be the primary cause but certainly contribute. For example, a mother may be symptom free after childbirth but start experiencing symptoms when baby is bigger and heavier and needing to be carried a lot. So although, pregnancy and childbirth may have had an impact, its actually the constant load through the core and how it is being managed that triggers the symptoms.
What Can You To Do To Help A Prolapse?
- See a Women’s Health Physiotherapist via your GP or privately like Becky Aston or Erica Lewis and get a diagnosis and guidance on how well you are engaging your pelvic floor and managing intra-abdominal pressure.
- Give your body time to heal in the early postnatal period. There are reasons why cultures that have a period of confinement in the postnatal period where ‘the mother is mothered’ through nourishment, nutrition, rest, herbs, abdominal massage, abdominal binding and given time to recover and bond with baby have lower rates of pelvic floor dysfunction.
- Breathe……the breath is the pump for your core. It also brings oxygen to all your vital organs and calms your nervous system. It is most important to sync with your breath correctly so always exhale and connect with your pelvic floor and core before you load up your core by lifting something heavy (and be conscious of good lifting technique). This is often referred to as the ‘knack’. If you were to inhale on effort the pressure would push downwards into your pelvic floor exasperating your prolapse.
- Have good bladder and bowel habits. Don’t go to the toilet just in case. Once you have done your wee rock forwards and backwards to ensure you have fully emptied your bladder. Don’t bear down to go and don’t limit your fluid intake.
- Drink enough water and eat enough fibre rich foods. Ensure you are not straining too much when emptying your bowels. Sit properly (upright and with knees open), keep your tummy relaxed and use a squatty potty or stool to sit yourself in a squat position when going for a poo. Also don’t hold your breath when going. A slight bearing down will help the stools move out of you. I used to have to support my back passage with my fingers or support the perineum when going for a poo to help me to empty my bowels fully and not leave behind anything in the ‘pocket’ caused by the prolapse.
- If it is affecting your sex life use lubricant and experiment with different positions.
- Try to manage your weight as much as possible (I know, I know, easier said than done).
- Avoid high impact exercise or any movement that makes your symptoms feel worse and engage with a Specialist Pilates teacher like me or with Fitness professional with thorough training in pelvic health to help you learn how to connect with your pelvic floor effectively and provide a graduated rehabilitation programme.
- Do your pelvic floor exercises (having checked with the Women’s Health Physio that you are engaging effectively) but most importantly integrate engaging this work into your day to day movement patterns so that it becomes second nature.
- Invest in a pelvic floor training device to help you train your pelvic floor muscles.
- You can explore the use of a vaginal pessary that you insert into your vagina and helps support your vaginal walls and uterus. It can be a very effective solution but does require fitting and needs to be checked regularly. Some women only wear a pessary for activities that cause them symptoms, others wear them all day and remove at night. Be aware this isn’t an option for everyone. For example my prolapses were to low for a pessary to be even considered. On the other hand I have a client who was certain she was having surgery until she started my Pilates classes and tried a pessary.
- Vaginal oestrogen can sometimes be prescribed to help with symptoms such as bladder urgency and vaginal dryness. It is often prescribed alongside a pessary.
- Surgery is always an option and I have clients who have had very successful results from surgery but I would encourage you to have explored all other options first and even if it isn’t successful this work will help you recover from your surgery better and increase the chances of a successful outcome,
I’m sorry this blog has ended up being longer than I intended but hopefully if you are worried you might have a prolapse or have a prolapse or even want to prevent a prolapse then it has been super helpful. I am passionate about sharing all the information I have gained over the years through teaching Pilates, all my specialist training, reading and working with amazing inspiring Women’s Health Specialists who do phenomenal work every day.