What Is Pelvic Organ Prolapse And What Can I Do About It?

Ellie is a 63-year-old woman who enjoys playing with her grandkids, walking her dog, and gardening. Over the past year, she has noticed a worsening sensation of fullness in the pelvic area like something is pushing down on her vagina. It has gotten to the point where she can’t go on her daily 4 mile walk with her dog because the heaviness becomes too uncomfortable. She recently went to a physician who diagnosed her with a grade 2 pelvic organ prolapse, or POP. She isn’t quite sure what a grade 2 means and is worried that her pelvic organ prolapse will continue to worsen until surgery is the only option. Ellie isn’t alone, as up to 50% of women who have had children will experience POP.¹ Pelvic examinations typically diagnose 30-50% of POP while self-reporting symptoms diagnose 3-10%.¹

Pelvic organ prolapse occurs when the pelvic organs (bladder, cervix, uterus) descend toward the vaginal or rectal openings. Basically, they aren’t held up in their “normal” positions. Most likely due to a lengthening or weakness of the pelvic muscles and other supportive connective tissue in the pelvis. There are several types of POP: cystocele (bladder), rectocele (rectum), rectal prolapse, uterine prolapse,  vaginal vault prolapse (can occur after a hysterectomy), and enterocele (intestines).²

The 4 stages of pelvic organ prolapse indicate the severity of organ descent and can be found below.¹

• 0 – no prolapse
• 1 – prolapse is greater than 1 cm above the hymen (at opening of vagina)
• 2 – prolapse is less than 1 cm above or below the hymen
• 3 – prolapse is greater than 1 cm from the hymen but no more than 2 cm less than total vaginal length
• 4 – prolapse is descending out of the vaginal opening

Symptoms of pelvic organ prolapse include: pressure, pain, or fullness in the vagina and/or rectum, feeling like something is coming out of your vagina, possible pain with vaginal intercourse, leaking urine or unable to hold urine (incontinence), difficulty emptying your bladder, leaking stool, and difficulty with expelling stool.² Interestingly, symptom severity does not corelate to the stage of a prolapse. Meaning a woman can have significant prolapse symptoms and only a stage 1 or 2 POP, while another woman can have a stage 3 POP and no symptoms that are bothering her. 

A very common “fix” for POP includes surgery where the surgeon will essentially bring the organs back up to their original position. The specific type of surgery can differ and include hysterectomy or use of mesh. There are, of course, risks associated with surgery. In fact, the US Food and Drug Administration (FDA) originally classified mesh as a moderate risk, or class II. However, after noting an increase in adverse effects following vaginal mesh, it was reclassified as high risk, or class III, in 2016.³

Unfortunately, surgery is not a guarantee that the prolapse will be “fixed” long term. A study was performed on 175 postmenopausal women with symptomatic uterovaginal prolapse that underwent surgical intervention - either vaginal mesh hysteropexy or vaginal hysterectomy with uterosacral ligament suspension – to determine if a certain surgical procedure was more successful. Hysteropexy involves lifting the uterus back to its original position with mesh. Hysterectomy involves removal of the uterus. Failure of the surgery was considered as re-treatment for prolapse: such as a pessary fitting, the need for an additional surgery, anatomical changes such as descent of the prolapse following surgery, and symptomatic outcomes such as a feeling of a bulge coming out of the vagina. The results of the study showed that neither surgical intervention was better than the other at reducing failure risk. The even more surprising fact was that after 3 years (36 months), the mesh (hysteropexy) group had a 26% failure and the hysterectomy group had a 38% failure. That means that there was at least 1 in 4 women who did not have successful outcomes following surgery.⁴

If you are apprehensive about surgery, there are alternative options! Studies show that pelvic floor muscle training with a pelvic floor physical therapist can be helpful at reducing symptoms and potentially reducing prolapse severity, although more research is needed to determine the full effect on pelvic floor training and prolapse reduction (elevation of the organs toward their original positions).¹

Women with stage 1-3 prolapse were less likely to develop symptoms and less likely to seek treatment for POP two years following supervised pelvic floor muscle training as compared to those who received lifestyle advice.¹

Additionally, a study conducted on 58 women with stage 2 pelvic organ prolapse showed improved muscle growth (cross sectional area), which typically correlates to improved strength, with women who performed pelvic floor muscle training with hypopressive exercises (using diaphragmatic breathing and abdominal activation) over 12 weeks as compared to those who did not.⁵

Your pelvic floor physical therapist can help with more than just training your pelvic floor muscles. They can assist with ideal and proper breath, core, and pelvic floor muscle coordination which will assist with day-to-day activities. For example, certain toileting positions and movements can be helpful to empty the bladder and bowels more fully and to reduce excessive strain and pressure (pushing) in the pelvic area. PTs can also assist with managing intra-abdominal pressure during daily activities, such as bending and lifting, which are often used when picking up kiddos. This pressure management can be used for other activities, such as gardening or weightlifting, to help reduce excessive pressure on the pelvic muscles and organs.

If you are frustrated by feelings of heaviness or pressure in the pelvic region, difficulty with urination or bowel movements, urine or fecal leakage, or discomfort with daily activities, please reach out to a pelvic floor physical therapist to assist in making your life more comfortable and functional! I always tell my patients that they will never know what their body can do unless they try. Plus, if you do need POP surgery, the techniques your PT will help you with also apply after a surgery to ensure safe healing and success post-surgery! So either way, if you have a pelvic organ prolapse you should absolutely consider seeking care from a qualified pelvic floor physical therapist as the first step in your care!

Written by Jordan Schmidt, PT, DPT

References:

1. Fleischer, K., & Thiagamoorthy, G. (2020). Pelvic organ prolapse management. Post Reproductive Health, 26(2), 79-85.
2. (2020). Pelvic Organ Prolapse. Journal of Midwifery & Women's Health, 65(4), 583-584.
3. Brincat, C. (2019). Pelvic Organ Prolapse. JAMA, 322(11), 1047-1048.
4. Nager, C. W., Visco, A. G., Richter, H. E., Rardin, C. R., Rogers, R. G., Harvie, H. S., Zyczynski, H. M., Paraiso, M., Mazloomdoost, D., Grey, S., Sridhar, A., Wallace, D., & NICHD Pelvic Floor Disorders Network (2019). Effect of Vaginal Mesh Hysteropexy vs Vaginal Hysterectomy With Uterosacral Ligament Suspension on Treatment Failure in Women With Uterovaginal Prolapse: A Randomized Clinical Trial. JAMA, 322(11), 1054–1065. https://doi.org/10.1001/jama.2019.12812
5. Bernardes, B. T., Resende, A. P., Stüpp, L., Oliveira, E., Castro, R. A., Bella, Z. I., Girão, M. J., & Sartori, M. G. (2012). Efficacy of pelvic floor muscle training and hypopressive exercises for treating pelvic organ prolapse in women: randomized controlled trial. Sao Paulo medical journal = Revista paulista de medicina, 130(1), 5–9. https://doi.org/10.1590/s1516-31802012000100002