Pondering Pelvic Prolapse

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Ever wonder about pelvic organ prolapse and what it means? Well, here is everything you need to know!


Q: Where are my Pelvic Floor muscles?
A: The muscles create a hammock that go from your pubic bone (in front)  to your coccyx (in back) as well as side to side. The pelvic floor muscles consist of three layers; the superficial layer can be found externally and internally while the two deeper layers can only be found internally.

Q: What is the job of the pelvic floor muscles?
A: These muscles support your organs, provide sphincteric control to help maintain bladder and bowel contents, and contribute to sexual function.


Q: Ok but what exactly do these muscles do?
A: In order to urinate, pass a bowel movement, or achieve orgasm the Pelvic Floor muscles need to relax and expand. In order to prevent urinary or fecal leakage the pelvic floor muscles need to be strong and remain active. For a variety of reasons the pelvic floor muscles can become weak, spastic, or restricted leading to difficulty with bowel movements, urination, or sexual function.

Q: What is Pelvic Floor Physical Therapy (PF PT)?
A: Physical therapists are musculoskeletal experts, this applies to the pelvic floor muscles as well. A physical therapist works with the client on re-training the Pelvic Floor muscles to work properly. An underactive Pelvic Floor (example: prolapse, weakness, urinary incontinence, postpartum issues) requires a strengthening/up-training program, whereas an overactive pelvic floor (example: constipation, chronic pelvic pain, sexual dysfunction) requires relaxation/down-training program.

Q: How do my Pelvic Floor muscles relate to my prolapse?
A: The job of the pelvic floor muscles is to support your organs. If the pelvic floor muscles are weak they will be unable to support your organs. This lack of muscular support will cause the organs (often times the bladder or rectum) to descend which is known as a prolapse.

Q: How can Pelvic Floor Physical Therapy help my prolapse?
A: PF PT works on re-training and strengthening the muscles through an up-training program to better support your organs. Once the muscles that support your organs are strengthened the organs will have a better support system and not descend.

Q: Should I just do kegels all day every day and hope the prolapse resolves? If I don’t have a prolapse should I be doing kegels to prevent a prolapse?
A: Kegels are great WHEN they are done correctly. Unfortunately most people do not know how to properly engage their pelvic floor muscles and perform the kegels. People tend to substitute with their inner thigh muscles or gluteal muscles instead. This is why in certain countries, such as France, women are sent to PF PT after giving birth to learn how to properly perform kegels and strengthen their pelvic floor muscles. In order to prevent substitutions it is beneficial to see a PF PT to ensure proper pelvic floor muscle activation.

 

Q: If I haven’t yet seen a PF PT but was diagnosed with a prolapse is there anything I can do in the meantime?

A: Yes! There are certain positions that will alleviate the pressure placed on your organs providing you with some much needed relief. Gravity is working against you and your prolapse putting pressure on the organs, when you take the pressure off the organs you allow gravity to work in your favor. One of the positions is to lay on your back on the floor with your feet up on the couch alternatively you can lay on your back with your hips elevated upon pillows or a wedge. Finally downward dog is a yoga position that helps temporarily pull the organs back into alignment.

From Class to Clinic

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As a graduate student, one of my least favorite classes was my research class (said with all due respect, Dr. Lipovac. As the famous adage goes, it wasn’t you, it was me). I was more interested in anatomy, physiology, neurological rehabilitation, kinesiology, and, of course, my musculoskeletal classes.

Ironically enough, the topic of research moved to the top of my priority list as soon as I left the classroom and entered the clinic. Suddenly, I was faced with many clinical questions, and my ever-curious mind began seeking answers. For example, is sexual dysfunction more prevalent in societies where premarital intercourse is discouraged? Is there a connection between patients who have had eating disorders and pelvic floor dysfunction? Is pelvic organ prolapse (POP) more prevalent among women who have had vaginal deliveries as opposed to cesarean section (c-section) deliveries?

Before I knew it, I was perusing PubMed and the NIH websites for fun, during my free time, to explore evidenced based research for these and other answers. I found myself offering to help doctors with clinical trials that they were conducting. Research is now an integral focus of my time and energy, and it is one of the reasons that I write this blog- to encourage myself to remain abreast of the latest research as well as share it with you.

Considering this background about the history of my relationship with research, you can imagine how excited I was when a colleague of mine, Chayala Englard, shared an article with me from BJOG: An International Journal of Obstetrics & Gynaecology (January 2013) which answered one of the aforementioned questions.

The article explores the prevalence of symptomatic POP in women twenty years after either one vaginal delivery or one c-section delivery. Women who delivered vaginally were twice as likely to experience POP compared to women who delivered via c-section (14.6% vs. 6.3%). Furthermore, infant birth-weight and mother’s current BMI were found to be risk factors associated with POP after vaginal delivery. Mothers shorter than 160 cm (approximately 5’3”) whose infants weighed more than 4,000 grams (approximately 8 lb. 13 oz.) were twice as likely to develop prolapse compared to mothers of the same height who delivered infants weighing less than 4,000 grams. In addition, POP prevalence increased 3% with each unit increase of the mother’s BMI as well as 3% for every 100 gram (approximately 3.5 oz) increase of the infant’s birth-weight.

In addition, urinary incontinence was more prevalent among women who demonstrated prolapse compared to women who did not. However, episiotomy, vacuum extraction, and second-degree laceration (or greater) were not correlated with increased POP prevalence compared to women who delivered spontaneously.

Does this mean that all women should request elective c-section deliveries? Absolutely not! C-section delivery is a surgery and is accompanied by the same risks and complications of any surgery. However, this evidenced based research indicates that it may be worth discussing with your doctor if you have a personal history or family history of prolapse. It is valuable information that can help you and your doctor make an informed decision together.

And so, another clinical question gets answered thanks to research! Onto the many others that are continuously developing day by day.

Gyhagen, M., Bullarbo, M., Nielsen, T. and Milsom, I. (2013), Prevalence and risk factors for pelvic organ prolapse 20 years after childbirth: a national cohort study in singleton primiparae after vaginal or caesarean delivery. BJOG: An International Journal of Obstetrics & Gynaecology, 120: 152–160. doi:10.1111/1471-0528.12020