Whilst many scoff at this image, it is an excellent way to find out what women are complaining about (prolapse wise) when they stand up
I am writing this long blog in response to an increased level of anxiety over the past couple of years in patients about their pelvic organ prolapse (POP).
Over the years much has changed in the way prolapse has been measured, reported and thought of by gynaecologists and other health professionals who see patients with prolapse. Women are now asking about their grade of prolapse and are constantly worrying about where their prolapse is sitting. Sometimes they are overly informed.
The POP-Q scoring system is a standardized method of assessing site-specific pelvic floor defects through nine measurements of the vagina and perineum obtained during a routine pelvic exam.(1)
The small wooden measuring stick called a POP-STIX which is a way to objectively measure prolapse and GH+PB. The small machine is a Peritron which allows us to benchmark the squeeze pressure for the woman from appointment to appointment
Another way is via 3D/ 4D (tomographic) ultrasound which allows an assessment of pelvic floor trauma such as levator avulsion injuries and hiatal ballooning. (The width and depth of defects are able to be measured or estimated, and the number of abnormal slices correlating with the likelihood of prolapse and symptoms of prolapse are assessed). (2)
Taken from Professor Peter Dietz site
One of the positives and the negatives about prolapse diagnosis in 2019, is so much has changed about the level of knowledge that patients have about prolapse. Because of the internet, women can readily research information, but when they read the symptoms, they sometimes then panic that they have prolapse when they actually don’t or the degree of prolapse is not at a significant stage or their symptoms may be due to something else. The other isssue is that whilst they don’t actually have any prolapse yet, they may have a significant muscle trauma which may lead them to develop prolapse in the future and when they read about levator avulsion, it does lead to a lot of panic, anxiety and sometimes serious depression.
One of the critical things to acknowledge and respect is that it is inconceivable that the vagina is going to stay completely unchanged after a vaginal birth. You can see in the image below the tremendous stretch that happens when the baby’s head is crowning.
The 1939 Dickinson-Belskie Birth Series Sculptures: Baby’s head crowning
But we know many women come through relatively unscathed. What is available to try and predict who is more likely to have issues with a vaginal birth and who isn’t?
There are many factors that affect the degree of change that occurs post-vaginal birth such as: your collagen make-up (do you have a collagen disorder such as Marfan’s or Ehlers-Danlos Syndrome (EDS)? – Although specific genetic predisposition has not been identified, a systematic review of genetic studies found that collagen type 3 alpha 1 was associated with POP (OR 4.79)(1)); the size of the baby’s head; the overall weight of the baby; your age with the first pregnancy (over 35 has an increased risk of pelvic floor dysfunction); any instrumentation that may be required to assist the baby out (with a forceps delivery there is a 40% chance of an avulsion injury). These factors are now able to be discussed with the obstetrician or midwife and the mother (and her partner) via a risk prediction model called UR-CHOICE. Collaborators from a number of centres around the world, led by Eric Jelovsek, have developed UR-CHOICE, a scoring system to predict the risk of future pelvic floor dysfunction based on research looking at the many major risk factors. This research has followed up women at 12 years and 20 years after delivery and this scoring system together with the mother’s own preference, may help with counselling women regarding pelvic floor dysfunction prevention.(4, 5)
UR-CHOICE stands for:
U – Urinary incontinence before pregnancy.
R – Race (ethnicity).
C – Child. Bearing first child started at what age?
H – Height. Mother’s height (if < 160cm).
O – Overweight. Weight of mother, Body Mass Index.
I – Inheritance. Family history of PFD (mother and sister).
C – Children. Number of children desired.*
E – Estimated foetal weight (baby weighing greater than 4kg).
*If caesarean deliveries are indicated this is important due to an increased risk of placenta praevia and accreta with increased number of caesarean deliveries.(5)
Discuss any factors you have on this list with your obstetrician to completely understand the implications.
I have also included a part of the conclusion from the Hallock study (2016) as this reinforces one of the issues with the vagina – the fact that it moves and responds to increased intra-abdominal pressure – the vagina is dynamic not static and rigid. It is also likely to change through the day depending on your activity levels (increased intra-abdominal pressure) and the degree of upright vs sitting/lying you undertake and it changes and adapts through pregnancy:
“Recent studies have shown that the pelvic floor is a dynamic structure that adapts during pregnancy and delivery by expanding the levator hiatus, increasing elastase activity, and lengthening pelvic floor muscle fibers. Future studies with animal or imaging models will provide even more insight into these mechanics.” (3)
Regarding your risk of prolapse if you look at the stats – up to 50% of women over the age of 50 who have had a vaginal birth will have some degree of prolapse in their lifetime. However many prolapses are asymptomatic for many years with only 15% of women being symptomatic at 20 years.(5) This is an important statement. Only 15% of women are symptomatic at 20 years after they had their babies.
Hallock also states that mild POP, defined as any degree of prolapse on examination is practically universal in older women, but women may not have symptoms unless prolapse is more severe. Thus, estimates of the prevalence of POP will be impacted by the threshold used to define the condition.
So my point in this article is having a prolapse need not be considered a devastating diagnosis. The degree of prolapse in any one woman can vary from day to day and from hour to hour within any given day depending on what they are doing. The significance health practitioners place on the degree of prolapse can vary depending on their experience and their deference to current research, which is that conservative management of prolapse should be the first line of treatment offered to a woman and that ‘watchful waiting’ is an important concept to consider for every patient. And some health professionals may fail to relay to the women that if you aren’t bothered by the prolapse, then you don’t necessarily have to rush into surgery to just correct the anatomy.
Over the years I have written many blogs about the preventative strategies available to treat prolapse. One of the most crititcal, is effective education. While it’s useful to know the state of your pelvic floor post-delivery, if you become paralysed by the fear of moving because of the state of your pelvic floor, it may have worse impact on your mental health, as well as your over-all physical health, if you are too scared to exercise and simply stop altogether. This can even lead to cardio-vascular problems in later life, bone density issues plus a risk of diabetes or obesity developing amongst others.
Therefore I believe it is important not to catastrophize about your prolapse as this will change your life if you become fearful about moving and exercising.
Many times women know that something has changed quite soon after a vaginal birth because they may have an episode of urinary incontinence or faecal incontinence. They may find out they have a small prolapse at their 6 week post-partum O&G check up or they don’t, because the doctor may not to want to worry them, because it is so mild. And so they then may discover it at their PAP smear two years down the track or not because the doctor thinks she may not cope with the news. And then, unfortunately much later still, the patient suddenly finds out when she can feel a lump after an intensive weights session when attempting to ‘get fit’ in a rush 10 years later.
This is where I think it should be manditory to see a pelvic health physio at 6-8 weeks post-partum regardless of the mode of delivery and any dysfunction that the patient may or not have. (The range of weeks is mainly due to a couple of things. When my daughter had her first baby, while I was visiting her in melbourne and I was attempting to do something like going for a shop with the baby, I was reminded that even at 6 weeks (and me not having had the baby) – it can be a big ask getting out to appointments – I had, not surprisingly, blocked out from my memory that first 12 weeks with your first baby. It takes effort to get ready and get all the paraphernalia associated with taking a baby out if they are a bit finicky and you are operating on zero sleep. Every time I see a girl at 6 weeks post-natal I congratulate them (in my head) on their achievement of getting it together and coming to see me. The second reason is if you’ve had a traumatic delivery you may be still be feeling sore/ weak/ wet/ heavy/ draggy from the vagina and having soiling etc.)
But it is also important for health professionals to keep the patient calm about the prolapse. When you see that research shows that after one vaginal delivery, a quarter to half of the women demonstrate a mild prolapse during the first postpartum year,(7) then maybe we health professionals need to be relaying a message to our patients that this laxity may never progress, especially if you are consistent with your exercises and the knack and we all be more accepting of mild prolapse (that is asymptomatic unless a lot of attention is drawn to it).
The Bio-psychosocial model by Butler and Moseley 2015- usually applied to pain management but can equally be applied to the emotional burden of prolapse
And this is where the Biopsychosocial approach may be applicable to treating patients with prolapse- to take the fear-provoking language, thoughts and behaviours out of the conversation with women with prolapse. This model takes into consideration more than just the biology (the anatomy of the vagina and pelvic floor – Where does the prolapse sit? What are the muscles like? What are the suspensory ligaments like?); it takes into consideration the psychology (How traumatised is the patient? and her partner? from the birth process? How supportive and understanding are the staff, the O&G of her feelings, her thoughts? after the birth of her baby. Is she showing signs of depression or PTSD?; and taking into account the social aspect – her family support, her work colleagues, her friends (who may be having absolutely no problems and is entertaining daily with cupcakes and lattes)?
The woman is more than her prolapse and every woman is an individual and her individual needs have to be respected, her narrative has to be heard, and if it’s a traumatic birth – just because 30 years ago women knew no better and seemed to ‘suck it up’ – doesn’t mean this denial of what the woman has gone through has to be perpetuated. The saying ‘but at least you have a baby‘ and completely disengaging with the process the woman went through to get the baby, causes a lot of grief for patients and that needs to be respected and validated.
This mandatory pelvic health assessment by a physio would allow the woman:
- to have an accurate assessment of the muscle damage that may or may not have happened;
- to be encouraged to work on the muscles that remain;
- to learn about ‘the knack’;
- to learn the correct defaecation dynamics and position (constipation and straining at stool can be asociated with prolapse);
- to see if a pessary may be indicated to prevent worsening prolapse particularly in those early months and years when lots of heavy lifting is undertaken with babies, toddlers and their miriad of equipment;
- to recover well from even a caesarean birth (learn good bladder habits, positioning for bladder and bowel emptying and address any other concerns)
- to debrief about the birth with an understanding health professional.
With regard to this increasing anxiety and distress that many working with women with prolapse are seeing, increasingly research is now being undertaken looking at the emotional burden of women with prolapse. Chiara Ghetti (2016) reports that they wanted to look at the emotional burden experienced by women with prolapse as “POP affects many areas of the woman’s life including social, psychological, occupational, domestic, physical and sexual.” They developed a condition-specific health-related quality of life (HRQOL) instrument, but acknowledged that the tool did not capture the complexity of women’s experience or to discern the impact of these conditions on her emotions and emotional well-being(8). Prolific researcher Ingrid Nygaard has undertaken some interesting research not only looking at the influences of intra-abdominal pressure and other influences on POP, but also the cultural context in which women experience changes and symptoms of POP.
Ghetti’s qualitative research I believe will be so validating for many women who have had a traumatic birth and I have directly taken the following from the article for this reason. These are things we hear every day in our clinic and it is so important to recognise the commonality of themes as described in the transcript.
Transcript analysis revealed three main themes related to women’s emotional experiences:
- emotions associated with the condition of prolapse,
- communicating emotions related to prolapse
- emotions relating to treatment.
Emotions Women Experience Associated with the Condition of Prolapse
Little to no emotions related to prolapse were described by some subjects. Their experiences were mainly limited to physical bother. In this group there were subjects whose prolapse had developed so quickly there experienced no emotion, while for others the prolapse had been such a longstanding problem it had just become normal part of life. Overall, the remainder of subjects collectively described a spectrum of feelings related to prolapse. Annoyance, frustration, and irritation were common themes, with one woman stating she was frustrated with having new worries. Others described unhappiness associated with the uncertainty of what was occurring and anger that this was happening to them.
Stronger emotions of depression, anxiety and sadness were described by some. Feelings of anxiety were often associated with a feeling of uncertainty of ‘something being wrong’. Several subjects also described concern and anxiety for the fear of having cancer. Others described anxiety about the change in their day to day routine because of the condition. This was often related to the incontinence symptoms they experienced.
Feelings of sadness were often associated with the thought of getting older. For others the sense of sadness was linked to a feeling of falling apart. Some women further elaborated on the feeling of falling apart, as a sense of brokenness or defectiveness, but did not directly associate it with a specific emotion. The feeling of brokenness and incompleteness surfaced also in a discussion of how prolapse affected the participant’s intimate relationships and how this made her feel. In a similar fashion, some described feelings of not being a whole woman.
Communicating Emotions Related to Prolapse
Overall women described a general difficulty in discussing their pelvic floor symptoms and their effects on daily life. Alongside identifying pelvic floor disorders as taboo, some women identified a sense of shame that made talking about their symptoms even more challenging. Women described secrecy surrounding pelvic floor disorders even amongst other women.
When asked specifically about talking to their gynaecologist or surgeon about their emotions, several subjects stated they had indeed spoken to their physician about their feelings. Of the subjects who had already addressed their emotions, one stated that her surgeon brought up the discussion; the other stated she started crying during her visit and her surgeon helped address her emotions. Other subjects were divided about whether to speak to their specialist about their emotions or not.
Others felt it was not a good idea to speak about emotions or mental health issues with a surgeon or physician. Some themes emerged about the responsibility of both patient and physician in discussing topics related to emotional well-being, with some having no expectation that a surgeon would discuss her well-being. In contraposition, others felt that physicians somehow just know how their patients feel.(8)
This qualitative research is so helpful for health professionals who may have become blasie about births and the ‘less than satisfactory state’ of the pelvic floor after the birth. Sometimes I think the more health professionals see, the more commonality is assigned to the cohort and the individual’s experience is somewhat diminished. This may lead to dismissing of the feelings the woman may be experiencing and this will add to their distress.
The good news is Nygaard’s qualitative research “will examine the cultural aspects of perceptions, explanations of pelvic floor support changes and actions taken by Mexican-American and Euro-American primiparas, emphasising early changes after childbirth. Summarising the projects’ results in a resource toolkit will enhance opportunities for dialogue between women, their families and providers, and across lay and medical discourses, with a view towards workable prevention strategies.”(7)
I hope this long blog is useful in allaying some fears, explaining some thoughts you may have had and explains some things that may have been said to you after your baby was born. Remember women have been having babies for millenia, but the research is relatively new and still evolving.
Me with Paddy 15/2/2017
(1) Bump RC, Mattiasson A, Bo K, Brubaker LP, DeLancey JOL, Klarskov P, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol. 1996;175:10–17. [PubMed] [Google Scholar]
(2) Dietz 2007
(3) Hallock, J. L., & Handa, V. L. (2016). The Epidemiology of Pelvic Floor Disorders and Childbirth: An Update. Obstetrics and gynecology clinics of North America, 43(1), 1–13. doi:10.1016/j.ogc.2015.10.008
(4) Sue Croft Pelvic Floor Essentials, Edition 3
(5) 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.
(6) 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.
(8) Ghetti, C., Skoczylas, L. C., Oliphant, S. S., Nikolajski, C., & Lowder, J. L. (2015). The Emotional Burden of Pelvic Organ Prolapse in Women Seeking Treatment: A Qualitative Study. Female pelvic medicine & reconstructive surgery, 21(6), 332–338. doi:10.1097/SPV.0000000000000190