What you need to know about pelvic organ prolapse.

Pelvic organ prolapse affects approximately 25 per cent of women according to Dr. Scott Farrell, professor in the department of obstetrics and gynaecology at Dalhousie University. Prevalence increases in postmenopausal women.

What is pelvic organ prolapse?

Pelvic organ prolapse refers to a loss of support of the pelvic organs. The area is divided into three different compartments: the anterior, where the bladder sits on the front wall of the vagina; the central, either the uterus or, if it has been removed, the top of the vagina; and the posterior, where the rectum lies below the vagina.

A cystocele is a bulge out of the vagina, under the bladder; a uterine prolapse is where the uterus comes down into the vagina; and a rectocele is a bulge of the rectum into the back wall of the vagina.

What are the causes?

Pelvic organ prolapse is caused by a loss of support provided by the thickness and the strength of the vaginal walls, which support the bladder in front and the bowel in the back; also a loss of support from a number of ligaments in the pelvis, which support the uterus and the top of the vagina.

Childbirth is one cause. Hormones produced during pregnancy soften collagen to allow the cervix to open for delivery; however, they also affect all the tissues in the pelvis, thus putting pelvic support structures at risk.

Vaginal deliveries using forceps can considerably increase the risk of damage to pelvic support structures.

Decline in estrogen hormone production that comes with menopause causes pelvic structures to shrink and become thinner and weaker and more prone to prolapse.

What are some symptoms?

If the prolapse is mild there are usually no symptoms at all. Even women with advanced degrees of prolapse may be aware of it, but asymptomatic. Others can experience the following:

• A sense of pelvic pressure and discomfort
• Tissue protruding from the vagina
• Problems emptying the bladder
• Difficulty evacuating the bowel
• Discomfort with intercourse

What are the treatment options?

Doing nothing but observing things is always an option for milder prolapses. Active treatment options include the use of a pessary, a rubber or plastic ring-shaped device inserted into the vagina to hold up whatever it is that is slipping down. Pessaries have been shown to work in all degrees of prolapse.

Local hormone replacement in the form of an estrogen tablet or cream inserted into the vagina is used to keep vaginal tissues healthier. Estrogen tablets are not absorbed into your system so they don’t offer the potential complications that women have experienced when taking estrogen orally.

Surgical procedures are also possible. Approximately 25 to 30 per cent of women who have surgery for prolapse will experience another prolapse. There was a lot of controversy in the United States about vaginal mesh used in surgery and some of those products have been removed from the market.

“We tend not to use mesh, except in very selective cases and for incontinence procedures because that is the safe thing to do. We tend to use the natural tissues of the patients themselves during the surgery. The goal of surgery is to get things back as close to normal as possible,” Dr. Farrell says.

What can help?

Avoid heavy lifting, straining, or standing for long periods.

Do pelvic floor exercises, including the Kegel exercise, regularly.

Francesca Ambrocichuk, pelvic floor physiotherapist at Synergy Physiotherapy and Pilates in Halifax, says pelvic floor physiotherapy is a conservative approach to pelvic organ prolapse (POP) which should be considered in mild to moderate prolapse as it can address the condition, strength and functional issues of the pelvic floor by specifically utilizing manual techniques and exercises, as well as addressing other issues.

“Pelvic floor physiotherapists take a global approach to address the relationship of the supporting core muscles, posture and lifestyle habits to help you manage the prolapse. We provide education and advice to help make your exercise routine or leisure activities pelvic floor safe. You don’t have to stop what you enjoy; you may have to modify it,” Ambrocichuck says.

The big message is prevention.

See a pelvic floor physiotherapist to help you modify your activities and take charge of your pelvic floor muscular health (and to teach you the proper way to do a Kegel exercise) before you suspect you have a problem.

Talk to the women in your life—your mother, sisters and friends, no matter their age. You should not be embarrassed to discuss this issue.