Continence Awareness Week for 2024 has just finished and I thought it important to re-post this blog on The Biopsychosocial Management of Prolapse. Every week we see lots of women who have been recently told that they have prolapse and they are very distressed with this diagnosis. This blog outlines the importance of addressing these concerns and helping women cope with this new awareness of their prolapse diagnosis and reassure them that a fulfilling active life can continue into old age.
I also thought I would re-post it because last week I attended a Reformer Pilates class at my local gym to consider whether I could do a class on a regular basis to get stronger now I have some more time. You may well remember that we set up a ‘pelvic floor friendly’ exercise studio in 2015 called Studio 194 where all the classes took into account the reality that many women have prolapse and other pelvic floor dysfunction that need to be considered when prescribing exercise. My message to everyone from my attendance last week is you need to look carefully into where you are doing Reformer Pilates classes for their screening of your pelvic health state prior to commencing – otherwise you may well develop prolapse that IS bothersome from the class.
I wasn’t asked any questions at all about my health -medical or pelvic health; there were prolonged periods of time in table-top (both legs up) on the reformer with no regard to the individual’s personal strength and because there were maybe 15 ladies in the class, there was obviously no supervision possible of their form/technique. As it turned out I had to stop because I do get very dizzy if I lie down too flat or change sides quickly as we did in this class (a residual issue from over 30 years ago when I developed severe labyrinthitis from a nasty virus that went on for 3 weeks). So no reformer pilates for me, but there are plenty of other great exercise possibilities for me at the gym, I do monitor closely what is going on for me (and I do wear a pessary!).
For the majority of women attending who have not had children this will be fine, but if you have had children – particularly vaginal births – you should be screened, personal questions needs to be asked (both your medical and pelvic health history) and an individualised programme prescribed. I would also recommend looking for classes with smaller numbers in the class so your form can be supervised.
Here is the reposted blog:
The Biopsychosocial Management of Prolapse
What is Prolapse?
Vaginal prolapse (Pelvic Organ Prolapse or POP) occurs when there is a relaxation of the fascia and other ligamentous supports of the vagina and pelvic organs and/or muscle damage causing the organs of the pelvis (the bladder, uterus and bowel) to descend to or beyond the opening of the vagina (the hymen). Rectal prolapse occurs when a mucosal or full-thickness layer of rectal tissue descends in the rectum and may eventually protrude through the anus.
Since 2002, vaginal prolapse has been classified by doctors and pelvic health physiotherapists using the POP-Q system grading prolapse from Grade 0 to 4. In recent years there has been a definite change in the clinical relevance of these prolapse gradings, although they are still important for researchers.
The change is guiding health professionals towards assessing the bother of symptoms for the woman rather than the anatomical positioning of the anterior and posterior walls or cervix/vault. This is because many women can have significant prolapse but are completely unaware of any bothersome symptoms and other women with minimal laxity or bulge can be highly anxious and in a world of distress exacerbated by a diagnosis of Grade 1 or 2 prolapse.
Women in clinic are often devastated on learning that they have a prolapse regardless of the grading they have and how symptomatic they actually are. Like everything in life, the language around prolapse has increasingly had a powerful effect on the psyche of many women who have been given a diagnosis of prolapse. Due to the plethora of Facebook groups and internet blogs from non-scientific sources, women are widely read on prolapse and this can have a devastating effect on their mental health and well-being. Yet again it is obvious that a biopsychosocial approach to managing prolapse is an important holistic progression in prolapse management.
Biopsychosocial approach
Addressing the psychological impact of a prolapse diagnosis on a woman who has just had a baby is as critical as talking about pelvic floor exercises, defaecation training and fitting a pessary. It is incumbent on all health professionals to take into account the impact of their words on a woman as well as their expert opinion and diagnosis.
Interesting research (O’Boyle et al 2002, Larsen and Yavorek 2006, Buschbaum et al 2006) has shown a surprising number of young nulliparous women (never had a baby) had Stage 1 prolapse as measured by the POP-Q system and yet they were completely asymptomatic. So there are variations in what is actually normal and this is what needs amplifying with conversations around prolapse in the clinical setting.
POP following vaginal birth is a very common condition with up to 50% of women who have had a baby demonstrating vaginal prolapse throughout their lifetime. (1) Many prolapses are asymptomatic for years with only 15% of women being symptomatic at 20 years. (2)
With increasing awareness about prolapse, many women are also worried they have prolapse when in fact they don’t. This causes tremendous anxiety, perhaps completely unnecessarily. Get an accurate diagnosis confirmed by your doctor or pelvic health physiotherapist who understands about prolapse stages.
So how helpful is the grading system and the old definitions of POP?
The International Urogynaecological Consultation for Pelvic Organ Prolapse believes there is a need for improvement and is running a 3 year project with a committee of expert urogynaecologists looking at best practice documents and consensus papers on the management of POP with final conclusions being produced in 2023. They have released a new definition with Clinical POP being defined as anatomical prolapse with descent of at least one of the vaginal walls to or beyond the hymen with maximal Valsalva effort, with the presence either of vaginal bulge or of functional or medical compromise due to prolapse without symptoms bother. What this means is to be clinically defined as having POP requires descent of at least one wall to or beyond the hymen with either bothersome vaginal bulge or functional or medical compromise due to the prolapse (such as obstructed voiding or renal impairment). (3)
Why is this important? The thinking is to try and normalise this variation in positioning of points of assessment and bring the relevance back to how is function compromised for the woman.
Prolapse is strongly associated with levator avulsion
Research has shown that prolapse is strongly associated with levator avulsion and while it is important that women know if they have any muscle injury so they can implement the preventative strategies in my book Pelvic Floor Essentials (Edition 4) to stop a prolapse from occurring or worsening any diagnosed prolapse, it is also important to emphasize what a woman can do with her pelvic floor muscles, not what she can’t do.
Prolapse symptoms that women commonly complain about :
- the feeling of a lump or bulge in the vagina or dropping below the entrance of the vagina (feeling like a dislodged tampon), discomfort or pressure on the pelvic floor or rubbing of the tissue against underwear causing ulceration of the vaginal tissue.
- a sense of vaginal drag, heaviness, ache and/or unresolving low back pain.
- changes with sexual intercourse (bulky or loose-lax feeling during intercourse, the ‘look’ of the vagina changes making the woman anxious).
- the inability to hold in a tampon.
- a loose feeling when exercising.
- bowel dysfunction including difficulty with complete evacuation of the bowels, some rectal tissue coming out of the rectum during or after defaecation, difficulty getting clean after defaecation.
Don’t let the diagnosis of prolapse define who you are or what you can do with your life in the future. It need not be considered a devastating diagnosis.
You have read many preventative strategies in previous blogs or my books – this knowledge is empowering. It is important not to catastrophize about your prolapse as this will change your life if you become fearful about moving and exercising.
Decreasing your exercise can also affect your mood making you feel depressed and have a significant impact on your quality of life and that of your family.
Seek help early and find yourself a prolapse mentor – a health professional who will calmly give you evidence-based advice and treatment as well as supporting you emotionally should you need it and help you achieve your exercise desires.
I hope this blog puts prolapse into perspective and gives you an insight into the importance of using what you have; to continue to exercise – seeking help from health professionals who will facilitate this in a way that suits your pelvic floor; and to understand that your brain can play an important role in how you perceive your prolapse.
Seek help from a pelvic health physio near you. Sue is still working at Active Womens Health with the team at 7/47 Hampstead Rd, Highgate Hill (PH 0407659357). You can also access names of pelvic health physiotherapists from the APA Find A Physio website. Just enter your postcode in the search bar.
References:
- Hagen S, Stark D, Maher C, & Adams E (2006). Conservative management of pelvic organ prolapse in women. Cochrane Database of Systematic Reviews (Online), (4), CD003882. 10.1002/14651858.CD003882.pub3.
- Jelovsek E, Chagin K, Gyhagen M, Hagen S, Wilson D et al (2018) Predicting risk of pelvic floor disorders 12 and 20 years after delivery Am J of O & G Vol 218, Issue 2 Feb: 222.e1-222.e19.
- Women’s Health Training Associates 2021 Research Update Taryn Hallum
