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On Wednesday 26th February, 2014, I presented a talk for health professionals and the general public on the management of prolapse with Dr Hannah Krause and we had a great turn-up and I hope all the ladies really enjoyed the two presentations. When Tracey Sparks, our illustrious CFA Health Promotions Officer asked for a title for my talk I just happened to be flicking through the latest well-known women’s magazine in my waiting room and seriously there was a 5 step plan for weight loss, for getting fit and for even preventing hair loss, so it was logical to put together a 5 Step Plan for Managing Prolapse. I thought it only fair that I blog about it!
Step 1: Know you have a prolapse
Step 2 : Find your prolapse mentor
Step 3.Pelvic floor muscle training, bracing, functional strengthening
Step 4. Managing your bowels well

Step 5. Keep moving and mindfully, learn if you have lifting limits and be aware with repetitive bending AND undertake ‘pelvic-floor friendly’ exercising
To break this into manageable chunks to absorb, I will devote one blog per STEP.
Step 1: Know you have a prolapse

*Over 50% of women complain of some vaginal wall prolapse
*Only 10-20% seek medical attention
*10% undergo surgery for vaginal wall prolapse
*Up to 30% have repeat surgery for failure of surgery and recurrence
*Many women unaware they have mild prolapse
*Worsens with obesity, menopause and aging
*Poor collagen a factor
*Often women present to me for treatment 6 months after joining a gym or going to pilates/boot camp

How to recognize the symptoms of bother of prolapse

A patient’s awareness of an actual bulge has the highest correlation with pelvic organ prolapse severity (Cundiff et al 2007). So if it doesn’t feel right get it checked!
Signs of prolapse

  • Vaginal bulging: complaint of a “bulge” or “something coming down” through the vaginal introitus (opening). The woman may state that she can either feel the bulge by direct palpation or see it aided with a mirror.
  • Pelvic pressure: Complaint of increased heaviness or dragging in the supra-pubic area, perineum and/or pelvis.
  • Bleeding, discharge, infection: Complaint of vaginal bleeding, discharge or infection related to dependent ulceration of the prolapse.
  • Splinting/digitation: Complaint of the need to digitally replace the prolapse (push the prolapse up) or to otherwise apply manual pressure, e.g. to the vagina or perineum (splinting), or rectally (digitation) to assist voiding or defaecation.
  • Low backache: Complaint of low, sacral (or “period-like”) backache associated temporally with pelvic organ prolapse.
  • Other symptoms can include urinary hesitancy, slow urine stream, history of recurrent urinary tract infections, post-defaecation soiling.

Haylen et al 2010

Causes of prolapse:
One of the big culprits: Vaginal Delivery
  • Levator avulsion (see picture below) leads to anterior, posterior wall prolapse
  • Deficient perineal body (between the vagina and the anus) leads to the descending perineum syndrome (DPS) -with ↑difficult defaecation, worsening posterior wall prolapse.

levator avulsion

For a simple explanation of Levator Avulsion: Google Sue Croft Blog ‘Levator Avulsion’.
Other causes of prolapse: What can Physios help with?

Obesity– encourage accountability: ‘Don’t put any more weight on’ – help from a dietitian; encourage ‘pelvic floor friendly exercising’ to burn more fat
Obstructed defaecation, Descending Perineum Syndrome, Straining at stool -Defaecation training
Heavy lifting (children, job, moving house)- Practical hints
Recurrent cough– such as with asthma, flu, chronic respiratory conditions- encourage preventative treatment
Recurrent sneezing – hayfever encourage preventative treatment
Ongoing vomiting such as with morning sickness – encourage active treatment and hand support for the perineum
Lifting heavy weights at the gym; avoid sit-ups, full planks, double leg lifts, leg press- advice re pelvic floor friendly exercising.
SUI- Stress Urinary Incontinence, although significant anterior wall prolapse can mask SUI
OAB- Overactive Bladder Urinary frequency (>5-7 day, 0-1 night for drinking 2 litres of fluid), Urgency, Urge Incontinence- bladder retraining and urge control techniques
Drag and heaviness and exacerbation of low back pain – specific pelvic floor and deep abdominal muscle training
Sexual dysfunction -Difficulty with penetration,, anxiety/disinterest in sex- worried about I/C making prolapse worse, worried about the look of the vagina, dyspareunia. Many women anxious that penetrative sex is going to make the prolapse worse. Reassure intercourse is good for prolapse but no bearing down with orgasm. Many women anxious about the ‘look’ of the prolapse. Local oestrogen if appropriate, use a lubricant, advice re libido issues

Anterior Wall Prolapse: Discovery
Anterior wall prolapse copy
  • Women first feel a bulge or lump in the shower
  • After joining a gym, boot camp, Pilates, Yoga
  • Drag, ache
  • Back pain
  • Difficulty holding in a tampon
  • Difficulty with penetration with I/C
  • At PAP smear
Posterior Wall Prolapse: Discovery
rectocoel 2
  • ¤Lump/bulge
    ¤Drag/ ache/ heaviness
    ¤Increasingly difficult defaecation
    ¤Multiple trips back to the toilet
    ¤Incomplete evacuation
    ¤Requires hand support to defaecate
    ¤Needs to digitate
    ¤Hard to navigate a tampon in
    ¤Intercourse uncomfortable
    ¤At PAP smear

Uterine Prolapse: Discovery
uterine prolapse

•Tampons dislodge
•Discomfort with intercourse- uncomfortable/impossible in certain positions
•Heavy drag
At PAP smear
Vault Prolapse: Just because you’ve had a hysterectomy, doesn’t mean you can’t prolapse anymore- your whole vaginal vault can come down!
vault prolapse

So I am on a mission: along with all my #pelvicmafia friends around the world. Let’s eradicate unnecessary prolapse!! With prevention, prevention, prevention.
Get along to your local Continence and Women’s Health Physio/ Physical Therapist whether they be in Brisbane, Buderim, Dubbo, Chicago, Adelaide or Dublin.