Sue, Katie, Sophie and Micheal (in utero),January 1991
I remember the day I was standing outside my children’s school and a friend told me she had a prolapse and I said to her “How do you know?” -which was pretty funny/weird because I was a physiotherapist taking antenatal classes and heavily pregnant with my third child!
She said: “I can feel it every night in the shower when I am washing and some days I can feel it when I am just walking – it feels like a tampon is dislodged”.
A few months later, after I had my third child, I unfortunately knew exactly what she was talking about.
They call it ‘Livin’ the dream’.
Soon after that realisation, an unexpected job came my way. My baby was only a few months old but they needed someone at QE2 to do a 4 hour a week locum to replace the Head of Department, so she could attend a meeting. What soon followed was my introduction to Women’s Health ‘proper’. The girl who was doing women’s health was leaving and they asked me would I like to take it on. I jumped at the chance and started with the courses and conferences that would become a ritual for me for the next 30 years. I became passionate about Pelvic Health and the passion has never diminished over the years.
I have always said that my own pelvic floor dysfunction has made me a better pelvic health physiotherapist, but there have been times when I have wished that wasn’t the case and that I didn’t understand so much of the physical and emotional burden that comes with having problems ‘down below’.
But what that insider knowledge has given me is a bird’s eye view to the treatments and strategies that make a difference to pain, heaviness, fear and all the ‘joyful’ sensations that do accompany the diagnosis of prolapse.
So I have decided to write this blog with some Top Tips to most effectively managing prolapse and how to stay sane if you feel your prolapse is restricting your ability to exercise through your post-baby life.
Know the stats!
50% of women who have a vaginal delivery will have some degree of prolapse, but only 15% will be symptomatic!
So it is a very common occurence, but not everyone is going to be symptomatic – so if you get told by your obstetrician, GP or Pelvic Health physiotherapist that you have a prolapse – try hard not to freak out. Facebook and the Internet have turned Prolapse into Superstar Celebrity Status, whereas for many years, prolapse just couldn’t get a gig (article) in the papers. Fortunately, prolapse is well managed by conservative strategies such as pelvic floor muscle training, bracing or the knack, defaecation dynamics (an easy position and coordination for emptying your bowels) and other lifestyle changes.
The Australian Commission on Safety and Quality in Health Care have a number of documents that help women understand what the course of treatment should be when considering any pelvic health treatment progression and they have one for prolapse making it easy for you to read and consider the best approach. Interestingly, the first one is Do Nothing! As a natural interventionist (ask my husband and children) I struggle with this, because if we Do Something (Physiotherapy) then we may not need the third one which is Surgery.
I have written many blogs on managing prolapse and have brought many of them together in this one blog.
Top Tip 2
Stop feeling with your fingers/looking with a mirror
Women are often encouraged to look at their perineum and vulva to learn about all their anatomy ‘down below’, but when you have just had a baby, the ‘look’ of the area can change and look quite distorted, scary even. Things may still not be drastically symptomatic of prolapse (bulge, heaviness, drag)- but if you keep looking, and keep feeling and keep checking Facebook and Instagram (yes there is a site which has comparative pictures for women to look at and assess whether they have a Grade1,2 or 3 prolapse – all of which can magnify the representation of the prolapse on your sensori-motor cortex- the sensory brain map), then your anxiety levels will go through the roof and it will feel worse than it may actually be. This blog talks about how your anxiety can make the prolapse feel worse than it actually is.
Get an assessment from your pelvic health physio at 6 weeks and let them reassure you that it is early days and that there is often considerable improvement once you start a physio home programme. If you are unsure who to see, the Continence Foundation of Australia have a register of pelvic health physiotherapists in each state and the Australian Physiotherapy Association also have a Find a Physio register on their site.
Top Tip 3
Don’t let your fear of exercising with a prolapse ruin your life
Exercise is the elixir of life!
Our knowledge about prolapse and exercise prescription is a work in progress. The evidence is evolving constantly and like Coronavirus has taught us – it’s important to follow the evidence. Dr Jenny Kruger from Auckland is working on a device to check the effect of intra-abdominal pressure rises in women undertaking certain exercises or manouvers. Other researchers around the world such as Dr Ingrid Nygaard are asking questions about what truly constitutes necessitating the banning of a certain exercises. Exercise is important for so many reasons – bone density, maintaining good cardiovascular function, sustaining excellent mental health, maintaining muscle mass, keeping joints well lubricated and working well and finally helping to manage weight.
So suddenly stopping exercise because you have a prolapse is a serious thing to contemplate and needs to be justified and well thought out. Top Tip 4 will assist you in understanding how you can still exercise – even with a significant prolapse and levator avulsion injury. There are many ways to exercise and get around the new normal after a difficult birth that has changed your anatomy. Your treatment needs to be individualised for your pelvic floor and progressed carefully as you get stronger and fitter. What women go through when having a baby, needs to be respected! Just because for centuries women have been basically popping babies out and then getting back to their chores around the house or out in the fields, doesn’t mean we have to keep doing the same old thing now that we know more. Get your pelvic floor assessed early at 6 weeks by a pelvic health physiotherapist and keep in touch with her for the 12 months after your baby is born and prior to and following subsequent pregnancies.
Remember the benefits you reap from exercising throughout your life far outweigh the risks with prolapse – but respect your pelvic floor and tailor your programme to what you can manage.
Hiking in the Swiss or Italian Alps is my elixir of life
Top Tip 4
Pessaries can be a game changer!
Probably one of the most satisfying things I have ever learnt about is fitting pessaries for women with prolapse. They literally can free up a women to resume exercise and allow them to do so with gay abandon. A pessary works like a splint to help support the structures to stay in a better position – sometimes they aren’t perfect, but they are better than exercising with nothing.
The evidence is not there yet to prove categorically that a pessary prevents prolapse from occuring if a woman has a levator avulsion injury, but it seems logical that a mechanical support of some type is going to help oppose downward forces. If there is an avulsion injury, pessaries are much harder to fit and of course with the joy of changing a women’s life with a pessary, also comes the disappointment when the physio can’t make one work in someone with avulsion. Physios have all seen the women who come with 6-8 pessaries (and sometimes more) in a plastic bag that they have purchased but they have failed, hoping like crazy we will find something that will stay in.
Levator Avulsion illustration
Pessaries have to be treated with respect. There is nothing worse than the forgotten pessary or getting an infection (bacterial vaginosis) which is a serious infection in the vagina from not removing and washing the pessary as it’s supposed to or getting a fistula from a pessary that may have migrated into the wrong position and caused a communication into the rectal wall. Following the rules with pessaries will help prevent any of these unfortunate complications.
Top Tip 5
Do your pelvic floor exercises!
The evidence is clear. Doing pelvic floor exercises strengthens muscles, thickens them to improve support for the vaginal structures and helps prevent a prolapse from getting worse.
I put it to you: Nobody ever says…Sue I’ve cleaned my teeth twice a day religiously for 6 months…but you know I am very busy with the kids. I drive them to sport, I am working fulltime and cooking, shopping and cleaning. I have no time for teeth cleaning.
And yet… we have this thing called pelvic floor muscle training which is proven to help with prolapse prevention (and urinary incontinence improvement) and women often say – I am very busy with the kids. I drive them to sport, I am working fulltime and cooking, shopping and cleaning. I have no time for pelvic floor exercises.
Try and make it a routine, remember them, add them into your general exercise programme and don’t forget to relax your pelvic floor muscles plenty of times and keep breathing as you do them, holding for 10 seconds. If you are looking for a new product to help you make pelvic floor exercises more fun, a Perifit is a new pelvic floor exercise device which we are selling now at the rooms and I do like it as it rewards relaxation as well as tightening. It has a number of games that you ‘play’ as you are exercising through an app on your phone.
I hope you find some of these tips useful and don’t forget to see a Pelvic Health Physiotherapist if you have any embarrassing problems that are limiting your enjoyment of life. Embarrassing problems are our core business.
(It’s been a while since my last blog. Probably the longest break I have had from writing since I started my blog 9 years ago. It was because the Continence Foundation of Australia’s 29th National Conference, which I was Co-Chairing with Dr Peta Higgs, was happening at the end of October and in the lead up and afterwards it was insanely busy. It feels good to have that big responsibilty successfully completed, but I just want to say a big thank you to everyone who virtually attended and especially to all those who presented. It was a wonderful collection of presentations and because it was a webinar rather than a face-to-face conference, those recordings will be up on the Conference App until mid January. As wonderful as it was, I do hope that 2021 allows us some mercy and we can attend in real life in Melbourne for the combination ICS and CFA Conference 12-15th October, 2021. We need to be able to dance at the Conference Dinner!)