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The Truth about Pelvic Organ Prolapse: What your GYN is not telling you

Many women are concerned of the risks of developing or continual progression of POP after being diagnosed. When speaking with your provider about concerns of prolapse, it is important to remember a few truths! Just because someone can “see” a prolapse does not mean you have a POP (pelvic organ prolapse). True POP is diagnosed by experiencing symptoms like perineal pressure, leakage, fullness in the rectum and having visual diagnosis of at least a stage 2 POP. The sensation of a “bulge" is the most predictive symptom of a POP. A bulge sensation in the pelvis should not be overlooked, as many times it can be the root cause of leakage, constipation and lower back pain.

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.

What your doctor may NOT be telling you...

True or False: The bigger the bulge…

FALSE! The severity of bulging symptoms is NOT found to be correlated with worsened degree of POP. For example, if you feel a bulge at the perineum that gets heavier throughout the day, it does not mean your daily activities are worsening POP. POP grading does not change from a grade 2-4 in one day. Two women with the same POP symptoms, like a bulge or pressure, can have different grades of prolapse. The physical perception of prolapse symptoms is different for each body due to nervous system sensitivity, your emotional relation to the pelvis and atrophic changes of the vagina due to hormonal shifts.

For example, two women may each be diagnosed with a grade 2 uterine prolapse. However, one who also has anxiety and has gone through menopause may feel more frequent or more symptomatic sensations compared to another woman who does not have anxiety or is premenopausal.

True or False: Not all POP are created equal.

When seeing a gynecologist or urogynecologist, the assess the amount of tissue movement in the vaginal canal, but grading the movement from 1-4. We can assess the grade of a prolapse with a visual and digital examination of the vaginal opening. The symptoms you experience are not correlated with the grade of POP, rather the size of the genital hiatus.

What is the genital hiatus (GH) you ask? It is a measurable space between the urethra and the bottom opening of the vagina. By measuring this space in centimeters, we can predict the risk of developing POP over the next 5-10 years.

For example, women with a GH larger than 3 cm are at a higher risk of developing POP over 5-10 years. The larger than GH at start of care > 3 cm had a faster rate of descent in soft tissue over the years.

True or False: Does pelvic muscle strength count?

Research notes women with POP do have weaker PFM strength than women without. It is questionable if weaker PFM causes a POP or prolonged periods of unsupported POP cause weaker PFM. Its a chicken or the egg scenario.

For example, think of an elephant (a prolapse) sitting on a trampoline (your pelvic floor muscles) for 7 days. You remove the elephant from the trampoline and the trampoline netting is stretched and sagging downward. But over the next week, the netting and springs start to return to an elevated level. Now maybe the trampoline does not have the same bounce, but it has the ability to improve its elasticity. This is what we expect with PF muscle training and minimizing downward pressure from coughing, daily activities like lifting and breath holding.

True or False: My long labor caused my POP

This can be true, but it depends on other factors! One out of 5 women will have some degree of a pelvic avulsion. Avulsions can occur anywhere on the body where muscle connects to a bone. Pelvic muscle avulsions occur when the stress of the pelvic muscles are stressed after prolonged pushing more than 4-5 hours, birth assisted procedures like use of forceps or vacuum. This is a soap box topic for me. I cannot tell you how many women have some degree of an avulsion post birth/obstetrical injury and they are never assessed at or after the 6 week postpartum visit.

Most avulsions of the pelvic floor occur at the pubococcygeus/puborectalis insertion near the pubic bone, an area of fascial support for your bladder and uterus. Women with avulsions, even a slight degree of avulsion are 2x more likely to have POP. There is an increased risk of bladder prolapse and 4x likely to develop uterine POP.

True or False: The pelvic pressure I feel after birth is going to remain for ever.

False. Time is on your side during your first 6 weeks to 6 months postpartum journey. There is a significant change in the opening of the pelvis in the first 6 weeks (about a 2 cm difference) thanks to hormones and elasticity of tissue returning to its new normal.

However after 6 weeks, there is no additional change to this area. This is why it is so important to be assessed properly by a pelvic therapist after a vaginal delivery to know what your new baseline is at 6 weeks. Women who birthed via cesarean section have no difference in space between 6 weeks and 6 months. The key difference here is that the baby did not pass through the vaginal opening, therefore a stretch did not occur to the tissue.

True or False: I am going through menopause. It’s all part of aging.

True! Estrogen levels change during menopause and during pregnancy. Estrogen is high during pregnancy and is lower after pregnancy. During pregnancy, high estrogen increases tissue laxity and the mobility of our joints, making it easier to give birth vaginally. A downswing in estrogen postpartum allows for tissue tightening and less mobility. This is necessary to help close the bones and allow tissue to return to its natural tone.

As the estrogen levels slowly return throughout the first postpartum year, there is usually an improvement in frequency and intensity of bulging symptoms. The balance of too little or too much estrogen is a fine line that makes the difference!

Same can be said for menopause, the less estrogen we have the more likely you are to experience symptoms for developing a POP. The lack of estrogen in the postpartum period and post-menopause causes an increase in atrophic change that causes increased sensitivity to POP symptoms. But does not change the actual shape or tissue laxity. This is why some women with a grade 1 POP have terrible pressure symptoms with none to minimal mobility. Estrogen is key here!

True or False: If I just lose weight my prolapse will heal

Maintaining a healthy weight for your height and body type is important. However weight loss or gain does not change the stage of POP. Weight loss is encouraged to not worsen the downward pressure over time as well as pelvic muscle training.

Maintaining a healthy weight can minimize pressure on the organs in the pelvis, but so can pelvic floor physical therapy. Training your pelvic floor muscles with a stage 1 or 2 POP is beneficial! Pelvic floor muscle training reduces the descent of pressure on the organs and can provide strategies to support your body throughout the day. Most women with mild POP will notice the most change in symptoms after PFMT. Training the PFM changes the symptoms but not the actual descent or visual look of the organs at the opening of the vagina.

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


Dr. Amanda Heritage, PT, DPT is the owner of Breathe Life Physical Therapy & Wellness, LLC located in Collingswood, NJ. She has been practicing physical therapy with a strong focus on pelvic health for over 12 years. She enjoys encouraging women about pelvic therapy as a treatment option for those suffering with pelvic pain, incontinence or constipation.

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