Pelvic Floor Advice & Management

Pelvic Organ Prolapse

What is Prolapse?

Prolapse refers to either of the following:

  • A uterine prolapse where there is descent of the uterus into or through the vagina.
  • An anterior vaginal wall prolapse where the bladder bulges into the vagina wall.
  • A posterior vaginal wall prolapse where the bowel or rectum bulges into the vagina wall.
  • A vault prolapse. If a woman has had a hysterectomy and the uterus is no longer present, the top of the vagina can still descend down into the vagina.

 

Prolapse

Prevalence of Prolapse

Prolapse is more common in women than incontinence. Estimates are that 50 to 80% of women who have had a child will have some form of prolapse but may not have any symptoms. By the age of 70 years, 50% of women will have some form of prolapse.

Contributory Factors to the Development of Prolapse

Pelvic floor muscles together with fascia and some ligaments hold the bladder, bowel and uterus in place. When these structures become stretched or weakened, they may become insufficient to hold the organs in place.

The “boat in the dock” analogy below demonstrates this:

 

Prolapse

The picture represents the following:

  • The boat is the pelvic organs (bladder, uterus or bowel)
  • The water level is the pelvic floor muscles
  • The ropes attached to the boat is the fascia

When the pelvic floor muscles (water level) are firm and high, the fascia (ropes attached to the boat) is not under stress. Therefore, the boat (organs) sits in its rightful position. If the pelvic floor muscles are weak, stretched and sagging, the organs lower and begin stretching the fascia. If there is stretching or breaking of the fascia then there is further lowering of the pelvic organs.

 

The following can weaken structures;

  • Pregnancy and childbirth

    The physical trauma of labour and birth results in overstretched muscles and damage to the fascia (particularly if the baby is over 4kg). Studies also suggest that women who experience multiple pregnancies that are close in succession are at greater risk. This is due to muscles and ligaments being under constant strain.

  • Post-partum

    Insufficient rest and recovery after birth slows the healing.

  • Age

    Post-menopausal women are at greater risk due to decreased oestrogen levels. Oestrogen makes the tissue more elastic and hold better.

  • Heavy lifting

  • Genetic conditions

    Women with a genetic collagen laxity (hypermobility) have very mobile joints.

  • Obesity, large fibroids or pelvic tumours

    These women are at greater risk due to the increased intra-abdominal pressure.

  • Chronic constipation

    Straining to empty the bowel causes the same damage as having a baby.

  • Smoking or lung disease

    Constant coughing weakens the pelvic support structures.

Handy Hints to Improve your Prolapse

  • Avoid heavy lifting. The maximum weight you should lift is 1/3 of your body weight. If you have to lift, gently contract your pelvic floor muscles. Breathe out as you lift.
  • Do not strain to empty your bladder or bowel. Instead concentrate on using your waist muscles and bulge your stomach outwards.
  • If you experience a heavy feeling, lie down with your feet higher than your head and pillows under your buttocks.
  • Lift your pelvic floor muscles before you cough and sneeze.
  • Reduce your weight down to a Body Max Index (BMI) of 23.
  • Rest in the middle of the day, lying down with pillows under your buttocks.
  • Keep your pelvic floor muscles strong and concentrate on the lift upwards.
  • Do low impact exercise (e.g. fit ball) which strengthens your lower abdominal muscles.
  • Try intercourse in the morning rather than at night when prolapses are often further down.
  • Expect to be slightly worse before your period and allow for doing less heavy work.
  • Avoid squatting, kneel with legs together instead.

Conservative Measures

Many women (24% to 74%) with a uterine prolapse may gain relief from a vaginal pessary which is fitted by a Gynaecolologist.

If you require surgery

Ensure that you have done the following:

  • You have strengthened your pelvic floor muscles and abdominals.
  • You have resolved your constipation (your surgery will not last if you strain to empty your bowels).
  • You have learned good voiding habits so that you do not push to empty your bladder.
  • You have reached your BMI of 23 and maintained this.
  • Your lifestyle means that you will not have to lift heavy weights e.g. how old are your children? Would you lift them if they were sick?