What is prolapse?

Prolapse is a common condition where the pelvic organs (such as the bladder, uterus and sometimes bowel) drop down into the vaginal space.  There are different grades of prolapse — mild, moderate and severe.  A mild prolapse will often be unnoticeable with very few symptoms indicating its occurrence, while moderate prolapse is when the pelvic floor organs can be palpated halfway into the vagina, and severe prolapse is when the organs are seen or felt at the entrance of the vagina.

There are four main types of prolapse:

Cystocoele (bladder prolapse): the bladder drops down and bulges into the vaginal space

Rectocoele (prolapse of the rectum): the rectum drops down and bulges into the back wall of the vaginal space

Enterocoele (prolapse of the small intestine): the small intestine prolapses into the vaginal space from above)

Uterine prolapse: the uterus and cervix descends down into the vaginal space

What are the symptoms of prolapse?

Prolapse often causes a heaviness, ‘dragging’ and pressure type of feeling in the vagina which is often worse at the end of the day, than at the beginning of the day or after lying down.

Bladder symptoms such as stress, urge or overflow incontinence.

Bowel incontinence

Difficult bowel movements and incomplete emptying

Lower back or pelvic pain

Pain or discomfort with sexual intercourse

What causes a prolapse?

The pelvic organs are suspended in the pelvis with supporting ligaments above, and muscle and fascia below.  If any of the structures begin to weaken, or become loose, the pelvic organs will descend into the vaginal space.

There are a number of factors that contribute to the weakening and loosening of the ligaments, muscles and fascia:

Pregnancy is one of the most common reasons that women experience prolapse.  The main reason is because of the hormone relaxin, which is released during pregnancy in order to prepare the pelvis for birth.  Its job is to relax the ligaments so that the pelvis can accommodate the baby’s head, open and soften the cervix and vagina to aid birth, and for rupture of the membranes. Secondly, the weight of the baby pushes down on the pelvic organs, additionally stretching the supporting structures and putting the pelvic organs at risk of prolapse.  Most women experience prolapse postpartum that often dissipates if exercises are done to strengthen the pelvic floor.

Natural childbirth causes further stretching of the pelvic floor structures, which is complicated if the pushing phase lasts unusually long, or if it is a big baby.  The muscles need to be strengthened and toned after birth to prevent prolapse from occurring.

Following birth, the effect of gravity can have a negative effect on the pelvic floor. Too much walking and upright activity puts pressure on the pelvic floor, stretching and weakening the pelvic floor muscles, ligaments and fascia.

Chronic straining during bowel or bladder movements puts a downward pressure on the pelvic floor which can relate in stretching of the supporting ligaments. Straining during a bowel movement also causes stretching of the rectum, which could complicate the let down reflex and emptying of the rectum.

Injury to the pelvic floor through an impact or rough sexual contact can damage the supporting ligaments, muscles and fascia.

Genetics also play a role in determining whether or not the supporting ligaments, muscles and fascia will hold the pelvic organs in place.

Surgery such as hysterectomy can cause complications in the pelvic floor, as when the uterus is removed, sometimes the support structures are weakened and a prolapse occurs.  Furthermore, surgery in the pelvic floor region can cause damage to the pudendal nerve which innervates the urethral and anal sphincters.

What can be done about prolapse?

Treatment is based on the severity and type of prolapse.  Most women first consult a general practitioner about the problem, and usually only when it poses a limitation on her activities of daily living.  The doctor will either refer the woman to an obstetrician or gynaecologist who may recommend the insertion of a device called a pessary.  Pessaries are made from silicone and come in many shapes and sizes.  The pessary is inserted into the vagina to support the prolapsed organs, and are often very effective.  It is custom fitted to the pelvic floor, and it can be removed.

The doctor may also recommend physiotherapy which is an extremely effective way of dealing with prolapse.  Physiotherapy will not be able to return the organs to their original position, but it will prevent further prolapse and help with the management of the symptoms of prolapse.

Physiotherapy for prolapse includes a comprehensive assessment of the history of the prolapse, questions about bladder and bowel control, medical history and a physical examination of the pelvic floor.  The examination and treatment will be carried out in a private setting, with the same physiotherapist every time who will provide a sensitive, supportive and professional environment.

Physiotherapy will involve a lot of education, teaching women methods to improve bladder and bowel control and instructions on how to pass bowel movements without straining, and how to retrain the bladder.  Physiotherapists will also educate women on what activities to avoid in order to reduce a prolapse.

Physiotherapy often involves training of the pelvic floor muscles — the support system of the pelvic floor that helps maintain the position of the pelvic floor organs.  The physiotherapist may employ a biofeedback unit that electrically stimulates the pelvic floor to retrain contraction and relaxation of the muscles and make one aware of their position and function.  Treatment also includes re-education of the posture and breathing, and core muscle strengthening.

If the prolapse does not respond to conservative treatment, and is really negatively impacting the quality of life, surgery may be indicated.   There are several different types of surgery that one can consider.  Sometimes a hysterectomy is indicated if there is a severe uterine prolapse, and other times one may need to undergo a procedure known as a sacrocolpopexy in order to reposition the pelvic organs.

Conclusion

Prolapse is a common condition that can cause significant discomfort and even warrant major lifestyle changes.  Women need to be educated on the condition, as well as what can be done about it.  Physiotherapists are experienced in dealing with prolapse and will refer patients to the relevant medical professionals for help.

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