Being diagnosed with pelvic organ prolapse (POP) can feel extremely overwhelming. You may feel like you can’t even get out of bed or complete daily tasks without feeling vaginal pressure, and there is little guidance on what can be done to help a prolapse. Many people are not even aware of what a prolapse is. And looking up pelvic organ prolapse on Google can be far from encouraging. But the good news is, being diagnosed with a prolapse does not mean you are guaranteed to have long term prolapse symptoms or require surgery. In many cases, relief from POP is completely achievable without surgery and may even be able to be improved.
What is Pelvic Organ Prolapse?
Pelvic organ prolapse happens when the muscles, fascia, and connective tissues supporting the pelvic organs (the uterus, bladder, or rectum) become weakened or lax. This allows one or more of the pelvic organs to descend or press into or out of the vagina. With POP, the pelvic organs themselves are not actually damaged, it is simply the supporting structures like fascia and connective tissue that are stretched and/or injured.
Symptoms of prolapse The symptoms often experienced with POP include:
vaginal pressure or bulging
feeling of the vagina falling out
low back pain
pelvic heaviness/dragging that is worse at the end of the day
Depending on the type of prolapse, some people may also note:
urinary leakage
difficulty emptying with peeing or pooping
need to splint or reposition during bowel movements
Stages of Prolapse The stages of prolapse range from grade 0 (no prolapse) to grade 4 (full eversion of the organ). Grades 1 through 3 can often be managed with a combination of pelvic floor physical therapy and support devices such as a pessary, however grade 4 POP typically does require surgical intervention.
Causes of Prolapse Pregnancy, labor, and childbirth are the most common causes of POP, but there are other factors to consider. Other contributors of POP include chronic pelvic floor muscle dysfunction, hormonal changes due to menopause, chronic constipation, chronic respiratory diseases with long-term cough, obesity, hypermobility disorders, repeated heavy lifting with improper breathing, and pelvic surgery.
What is normal to feel "down there"?
Early postpartum healing. It is normal to have a sensation of a bulge or pressure in the perineum within the first 6 weeks after having a baby from increased blood flow to the pelvis during pregnancy and tissue laxity due to pregnancy and the birthing process, but some of that laxity can improve on its own during the body’s natural healing process.
Positioning of pelvic organs. It is also normal to have some descent and movement of the pelvic organs with or without having a baby. Your pelvic organs are not rigidly held in the exact same position at all times. The bladder and rectum are changing shape and size based on their contents (urine and poop), and the uterus is changing size during the course of the monthly menstrual cycle.
Some people are freaked out to hear they have a prolapse from their provider, but may not have experienced ANY of the sensations like heaviness, bulging or pressure in the vagina.
A true clinical diagnosis of prolapse is when there is a descent of the pelvic organs WITH symptoms and sensations related to a prolapse, such as bulging or pressure, leakage, and/or difficulty emptying. Stage of prolapse and symptoms are NOT correlated - just because you see it, does not mean you absolutely will feel it!
Pregnancy. Yes, pressure or heaviness in the perineum might increase with each pregnancy, especially with a history of prolapse or inability to move due to pelvic rest. The increase in pregnancy hormones that help to relax the ligaments in the pelvis can cause the sensation of pressure to worsen as the weight of the growing baby changes along with increased blood flow to the pelvis.
Hormone changes. Hormonal changes during pregnancy, breastfeeding, menstrual cycles, and menopause can also affect whether or not you might experience symptomatic prolapse. Estrogen plays an important role in how we might experience prolapse symptoms. Estrogen is what helps maintain the healthy tissues of the vagina. When estrogen levels are decreased, such as during breastfeeding or from menopause, the lack of estrogen can cause a thinning of the vaginal mucosa and is thought to reduce the strength of the connecting tissues supporting it. This can contribute to vaginal dryness and increased sensitivity of the tissues, meaning they become more aware of movement or descent of the pelvic organs that they otherwise would not feel with normal levels of estrogen.
Using a vaginal estrogen cream may help to restore the natural health of the vaginal mucosa to improve dryness and sensitivity – talk to your doctor if you think you would benefit!
Menstrual cycles. If you feel like your prolapse symptoms change during your menstrual cycle, you are not crazy! There are a few different reasons for this. First, as mentioned earlier, the uterus changes size during the course of the monthly menstrual cycle and is heaviest just before your period starts. Even the position of the cervix changes during your cycle, and it sits the lowest during menstruation.
Estrogen levels are also lowest during menstruation. Estrogen gradually rises throughout the first half of your cycle and then drops steeply again after ovulation. There is continual movement that goes with the ebb and flow of your body’s natural rhythms and cycles!
MenstrualCycle.webp image from The Flower Empowered https://theflowerempowered.com/
Be your best advocate. Make an appointment with a urogynecologist and pelvic floor physical therapist if you have not already. A urogynecologist is a gynecological specialist, not an OBGYN, who specializes in pelvic floor conditions such as perineal injury, prolapse, bladder health, and pessary management. Pelvic floor physical therapists can educate you on proper breathing and pressure management with day to day activities and exercise, advise on return to exercise and modifications for activities, and screen for potential pelvic floor muscle dysfunction to optimize your pelvic health!
Images used with permission from Pelvic Guru®, LLC www.pelvicglobal.com
In the South Jersey area and want one on one care with the Breathe Life Team? Schedule an appointment for your complimentary 15 min phone call to see how pelvic therapy can help you!
Dr. Becca Jones, PT, DPT, CSCS, is a 2016 graduate of New York University with her Doctorate of Physical Therapy. Her passion for supporting people through their pregnancy and/or post partum journey inspired her to specialize in pelvic health. Dr. Becca believes in providing holistic, individualized care in order to restore comfort and build confidence to get people back to what they love.