Prolapse: What is it and how to heal.
The definition of a Prolapse is movement of the bladder, bowel, urethra or uterus into the vaginal canal. Our internal system is a pressure system, and if the system is not functioning optimally the pressure will leak somewhere. In this case a prolapse occurs. It's important to remember that these organs are not going to suddenly fall out of your body. Though it may feel like it, they are attached via extremely strong ligaments and connective tissue. Again, prolapse majority of the time is a pressure and support issue, so when we can provide the body with those two things, the body can heal. There are 4 different grades of prolapse: 1-4. Conservative management (ie. physical therapy, pessary support) can improve prolapse by one grade. I have seen prolapse grade improve many times over the last 8 years as a pelvic floor PT, and feel strongly that conservative management should be the first line of treatment once given a prolapse diagnosis.
Four grades of prolapse: image credit Pelvic Global.
Prolapse symptoms can include (but are not limited to):
- Pelvic heaviness and pressure (usually worse after activity or end of the day)
- Falling out sensation
- Pushing out a tampon
- Incomplete bladder or bowel emptying
- Constipation
- Pain/rubbing at vaginal opening
With all the changes that take place after childbirth (like increased ligamentous laxity, possible decrease in pelvic floor support, increased vaginal hiatus width, decreased estrogen) it is very common to experience some degree of prolapse. However, not all women are symptomatic. A symptomatic prolapse can be due for several reasons: birth injury/trauma, pelvic floor weakness or tension, chronic straining, breathing strategies and posture, and increased nervous system response. Another common question I hear is “can I have a prolapse even though I have not had children” and the answer it yes because of some of the above reasons (posture, tension, straining).
Grade does not always equate to severity of prolapse. As PT’s we largely work on managing your prolapse symptoms. Some women can be symptomatic 90% of their day with a grade 1, others may not become symptomatic until a grade 2 or even know they have a prolapse until they see a bulge at the vaginal opening.
It can be overwhelming knowing where to start with a prolapse diagnosis. First, know that you are not alone (hello 90%). Finding a pelvic floor PT to help you take a whole body approach and provide you with an individualized plan is a great place to start. Meeting with a OBGYN or Urogynecologist for possible pessary fitting and/or topical estrogen cream if breastfeeding can also be helpful to provide initial support to the tissues while healing.
So after addressing the above where do you begin? Start with your internal pressure system. 1. Address breathing strategies, restrictions and posture. 2. Provide support 3. Decrease tension.
1. Our diaphragm is the major driver of our pressure system. Having optimal diaphragm positioning (with ribs stacked over our pelvis) as well as diaphragm strength (which helps lift the pelvic floor) is a great place to start. As you can see in the image below on the left is an optimal “stacked” position of our ribs over our pelvis which allows for improved pressure management and diaphragm-pelvic floor coordination. The other postures, though all different, have an “open scissor” position with an excessive anterior tilt and diaphragm stuck in an inhaled state. This is a very common postpartum posture due to the changes that take place during pregnancy.
Left: stacked positions of ribs and pelvis. Image credit: www.ericafriedmanwellness.com
This hip 90/90 exercise is a great position to begin breathing in to help the body sense this “stacked” position as well as engage the hamstrings to provide a more neutral pelvis position.
Hip 90/90 with yoga block support
2. A Pessary is a support device that can be inserted vaginally to provide support to a prolapse. It is not a crutch. Especially if prolapse is extremely symptomatic or if there was a birth injury like a levator ani avulsion. A pessary can provide the necessary support while tissues heal or be the support in place of tissues torn.
3. Pressure does not always come from above - increased pelvic floor tension can pull down on the fascia and surrounding structures and cause increase in prolapse symptoms as well. Especially in cases of symptom reports including: pelvic heaviness and pressure, tampons not fitting right, pain with sex; tension might be a contributing factor. Learning how to diaphragmatically breathe 360 degrees and allow your pelvic floor to go through its full range of motion can be one step that can help decrease the pressure placed on the internal organs.
If you feel you have a prolapse, or pelvic floor tension, here are some positions I like to begin breathing in, especially postpartum to address prolapse symptoms: Prolapse Breathing Positions
If you have further questions about prolapse or would like to find a pelvic floor PT near you I would love to get you connected, so please reach out. This is not a diagnosis to tackle alone. The body heals best when it is supported on all fronts: mental, physical and emotional. Remember, your body is not broken, your body can heal.
In health,
Danielle Khoury, PT, DPT