Prolapse
Pelvic organ prolapse (POP) is when pelvic organs (uterus/cervix, bladder/urethra, rectum) fall into the vagina. An “anterior” prolapse is the uterus and/or bladder structures falling down/backwards into the vaginal wall. A “posterior” prolapse is the rectum collapsing down/forward into the vaginal wall. You can have just an anterior prolapse, just a posterior prolapse, or a combination of both to varying degrees.
Common symptoms of pelvic organ prolapse (borrowed from Haylen et al., 2010):
vaginal bulging
feeling like there is something “in” your vagina
pelvic pressure/heaviness/aching
low backache
the feeling of needing to manually support vagina to pee/poop
often symptoms are relieved when you get off your feet and get worse as the days goes on
NOTE: A person may have no symptoms but still have a visible prolapse! The grade or severity of prolapse does not always match up with your symptoms!
The hymen (vaginal opening) is what we use as a reference point for describing prolapse. It is also important to note that the position where your prolapse is evaluated should be based on the position where you have symptoms. A women might not demonstrate much of a prolapse when she is laying down but it may become much more obvious when she is standing or vice versa Signs may also increase later in the day (when your muscles are tired!!).
This is how we “grade” POP:
Stage 0= absent/none
Stage 1= >1 cm above vaginal opening
Stage 2= 1 cm above or @ vaginal opening
Stage 3= beyond hymen
Stage 4= the organ is now completely prolapsed through the vaginal wall
POP is due to stresses and demands put on the body that weaken or loosen the pelvic floor. POP can happen rather quickly (a women who has a very hard, long “pushing” during her labor trying to get a baby OUT). It can also happen over a longer period of time (chronic straining to “push” out urine or have bowel movements, chronic coughing, women who do a lot of heavy manual labor daily). As a profession we are starting to consider that prolapse has much less to do with any stresses caused by exercise, but rather poor daily habits can start a prolapse and significantly make it worse.
For acute prolapse symptoms (especially for newly postpartum mamas):
For prolapse, it really comes down to having good strength and managing the pressure in the body. What you do with your internal air pressure is always important, but this especially true postpartum.
Examples of creating excessive downward pressure (potentially worsening prolapse symptoms):
Straining to poop/pee
Holding your breath during daily movements, lifting your baby, exercise
Constantly sucking in your stomach
Aggressive belly binding
Increased pelvic heaviness after too much time walking/on your feet
If you lack the body strength to lift your babe and perform daily tasks, you’re much more likely to strain and create this no-good downward pressure. The guide is designed to help you to regain the strength to do all of your daily mama tasks and more. We advocate that you are mindful as to HOW you do the exercises and progress your walking. Any pelvic heaviness should be gently acknowledged and activities should be modified (temporarily).
Think about it terms of “pressure”. Anything that causes downward pressure on your pelvis is likely going to make your symptoms feel worse. Holding your breath, rigid belly binders/belly bands, sucking your stomach in, coughing, heavy lifting, straining in the bathroom…. try to see in your mind and feel with your body how all of these activities create pressure DOWN. These are all things you want to avoid or minimize as much as possible when you are being bothered by prolapse symptoms. Breathing, doing activities with good posture, getting off your feet when you need to, and engaging a light pelvic floor contraction when needed are all things that can create LIFTING in the pelvic floor. When you feel like your pelvis is quite literally dragging you down… its good to know what can give you a lift!
Slow down. Get off of your feet and rest until symptoms decrease. Don’t lift anything that feels heavy. Take a few really deep breaths, into the sides of your rib cage and gently exhale and blow out symptoms arise. You get bonus points for laying with your butt elevated on a few pillows (if this feels good). Prolapse is your organs falling into the vagina, so you want to take pressure off.
If you can’t complete the walking or exercise components of the postpartum guide guide without pelvic heaviness, then you should temporarily back off. Same goes for anything that reproduces those heavy feelings, that task is not serving you at this moment. Rest assured, the guides are safe but listening to your body is always the most important thing you can do. You’ll be pleasantly surprised at how much better things feel when you take away some of the irritating factors for the “heavy” symptoms
Control any constipation (you don’t want to be straining to poop). Hydrate aggressively. You should never “push” pee out but really check in and make sure you’re not doing it now. Exhale when you are moving from one position to another and with EVERY abdominal contraction (this is the whole “blow before you go” phrase). Up and down from sitting, in and out of bed, etc
You just had a baby, hormones are changing rapidly, and your tissues are still healing and somewhat fragile. Women with prolapses can experience rapid changes for the worse but often for the BETTER if mamas can take some extra care.
Women who start having prolapse symptoms during/after baby often feel discouraged and frankly angry at the lack of education and how alone they feel with having this particular issue. Please know that this is exceedingly common and VERY TREATABLE. POP does not mean your exercising days are over or that you cannot ever safely pick up your toddler ever again. With exercise and lifestyle advice, you can treat the majority of POP symptoms conservatively. Even if a women does end up being recommended for surgery, these are procedures that can have a very high failure rate IF people do nothing to change their habits that negatively contributed to their prolapse. This is not victim-blaming, rather a plea to change the things you can to optimize your body’s functioning!
Prolapse Management:
How to Prevent and/or fix it:
If you have pelvic organ prolapse or are pregnant and trying to prevent it, here are some things you should NOT be doing:
Lifting heavy weights
Holding your breath
Straining on the toilet
Hovering over public toilets to pee (your pelvic floor can’t relax)
Return to activities such as running and jumping too quickly postpartum
The risk of pelvic organ prolapse is higher if you do not know how to work your pelvic floor correctly. Having a stable core and knowing how to use the pelvic floor during pregnancy will help prevent this from happening. It’s harder to fix than it is to prevent so prevention is key!
What Should I do?
If you have bladder/uterine prolapse: Do more of your Kegels (pelvic floor strengthening) in quadruped or lying on stomach. This way gravity can assist by putting the focus toward the front of the pelvic floor.
If you have rectocele: Do more Kegels lying on your back with legs up and bolster under your bottom. This way gravity can assist by putting the focus toward the back of your pelvic floor.
Another important piece of this puzzle is to work on your core strength. Having a strong core places less pressure on the suspensory ligaments of the internal organs. The pelvic floor helps support your internal organs (bladder, uterus, rectum) so if your pelvic floor is also strong it will do its part to keep your insides inside of you!
Tips:
The Right Exercise
Mindful exercise progression postpartum- take your time. Don’t jump back into high intensity exercise right away. Birth is a major trauma on the body and tissues need time to heal
increase overall bodily strength (the guides!!) so daily activities aren’t so effortful
Avoid bearing down while holding breath
Avoid Valsalva
If you are going to do high impact stuff (power-lifting/CrossFit/endurance running)— please go see a physical therapist to help you with the transition back to these activities
Fix Daily Activities
Proper TA contraction with pelvic floor during ADL’s
stack your rib cage over your pelvis, your muscles will have an easier time firing if they are in good posture
Exhale during bending, lifting, pushing, pulling activities (“blow before you go!”)
Proper body mechanics with bed mobility: avoid jackknife sit-ups from supine- Log rolling is very helpful, think about exhaling while using arm to push up to sitting
Try a preventative pelvic floor contraction prior to a cough/sneeze
Bathroom Positions- get a squatty potty (seriously, you won’t regret it).
Exhale during bowel movements
The bottom line: Rehabilitation (on your own with this guidance and/or with the help of a professional) can help prevent worsening of symptoms, improve the “grade” of your POP, improve your symptoms, and improve your quality of life!
Why should I be worried about it now?
Prolapse can get better, but it can also worse. 50% of women who have had a baby have pelvic organ prolapse (Gunter, 2005), 37% have hysterectomy (removal of the uterus) by age 60 (Sheth et al., 2014). The lifetime risk of prolapse surgery is 11% of women (Jia et al., 2009). 30-70% of the women who have prolapse surgery will have prolapse surgery again (Tijdink et al., 2011). These statistics do not even touch the women who suffer with ongoing symptoms who never treat their symptoms with surgery!
Returning to exercise after baby:
You can do too much too soon. Prolapse can get better, but it can also get worse. You can make it out of the birth of your baby without prolapse and then develop it later. If it occurred during birth, than it is something you have to manage in this early period when you’ve got a newborn baby! As we’ve described, the structures that hold everything up in the pelvis are more vulnerable during your pregnancy and postpartum period. Motherhood is a physical job that begins at a time when you are weaker due to decreased activity levels in mid to late pregnancy and your birth recovery. This is often how prolapse occurs in the postpartum period, having (or choosing) to do a bunch of really physical stuff when you are weaker than normal! There is no magic “safe” timeline for people to return to desired activities, it varies for every woman. Breastfeeding extends the timeline because it maintains your body in a pregnancy-like state. These are all the factors that a woman returning to exercise should take into account.
To avoid this from happening, you need to have a strong enough pelvic floor to support your organs, as well as having strength in other areas of the body that help support the pelvic floor. People with weakness have to strain to accomplish tasks, and this stresses the pelvic floor. We would never deny that sometimes women have horribly traumatic births and elements of their prolapse are related to factors outside of their control. Empowering women with the tools they need to heal themselves can change their future. If a woman with prolapse and her medical team decide a procedure is necessary, she’ll be able to go into that procedure stronger and less likely to experience future surgeries. You can also discuss with your provider whether or not you would be a good candidate for a pessary, which is a soft, flexible device that is placed in the vagina to help support the bladder, vagina, uterus, and/or rectum.
Women who start having prolapse symptoms during/after baby often feel discouraged and frankly angry at the lack of education and how alone they feel with having this particular issue. Prolapse is exceedingly common and it is treatable. POP does not mean your exercising days are over or that you cannot ever safely pick up your toddler ever again. With exercise and lifestyle advice, you can treat the majority of POP symptoms conservatively. The guides will help you get there!