I often don’t tell my patients they have prolapse unless they ask… and news flash: Every. Single. Postpartum. Individual… that I have assessed has some sort of prolapse.
Why do I withhold this information? Because the diagnosis of prolapse is devastating for most and the attachment to it can be a barrier to recovery. Sure, the symptoms associated with prolapse aren’t fun and are scary by nature. The rehabilitation of prolapse is also complex, complicated, and long. But the fact is that most prolapses can be conservatively treated to where the individual has no symptoms and is doing everything they want to be, including but not limited to, running, jumping, and even lifting heavyweights. Yes, you can lift heavy weights again EVEN WITH A PROLAPSE!
How do I know this? Because I have a prolapse. I also run, lift and play soccer. In addition to my own experience, I have treated at least 100 people with prolapse as well. At this point, I understand the ups and downs of it as well as the ins and outs (pun intended).
I think the first way of making prolapse less scary is by explaining what it actually is. First, a bit of an anatomy lesson…
Pelvic Floor Breakdown
There are three holes in the pelvic floor that we see from the outside. Each of these holes leads to a pelvic organ: urethra to the bladder; vagina to the uterus; and anus to the rectum.
The front one is very small and often hidden but trust me, it’s there. That is the urethral opening. The urethra is the passageway for the bladder to release its contents. The bladder sits on the front side of the vaginal wall. When the bladder increases in volume, it can press into other pelvic organs and the next passage…
The middle hole is the vaginal opening, the one we usually know best after having a kiddo. If we took a tour into the vaginal opening, we would find ourselves in the vaginal canal. Gosh, I’m starting to sound a lot like Ms. Frizzle from the magic school bus here (a reference for anyone born in the 80s). The vaginal canal is a passageway or tunnel that leads up to the cervix aka the opening to your uterus. The vagina has a wall of muscle and tissue that helps it maintain its structure, but after pregnancy and birth, the wall of the vagina may be thinner and weaker as it heals.
And the back hole is your butt hole or more anatomically correct, your anus. The anus is the passageway from the rectum. The rectum sits on the backside of the vaginal wall. When the rectum increases in volume, it can also press into other pelvic organs and the vaginal wall.
What about prolapse??
Simply: the vaginal wall is usually strong enough to prevent other pelvic organs from pushing into the vaginal canal.
More in-depth: This wall of the vaginal canal usually provides a wall of support to prevent the bladder or rectum from pushing into the vaginal opening when there is an increase in pressure from filling of the bowel or bladder or pressure of the abdomen. That same wall makes up the canal that babies come through so when you’ve had a kid, this tissue is stretched. This is especially true with a vaginal delivery but also true for cesarean too due to the pressure of a growing fetus in utero, or if you had a prolonged pushing phase before you had a cesarean birth.
When the wall of the vagina no longer provides that strong wall of support, the bladder and/or rectum can push into the wall pressing it into the vaginal opening. This is prolapse. If it’s the front wall, it’s called cystocele. If it’s the back wall, it’s called rectocele. Prolapse of the uterus is also common in postpartum. This is because the ligaments holding the uterus up are stretched out during pregnancy making the uterus hang lower in postpartum. Less common but not unheard of, is rectal prolapse. This is when the rectum starts coming out of the butthole. Given the extreme amount of pressure generated in pregnancy and labor, it can and does occur.
Am I making prolapse sound scarier than you thought at this point? I hope not. I do hope that at this point, it has become obvious why every single postpartum individual I have assessed, has a stage of prolapse. It’s unavoidable given the nature of growing a baby in utero and getting a baby out.
Stages of Prolapse
The stage you might ask? What does that mean? Stages are how the severity of prolapse is measured. There are five stages, each are described below:
Stage 1 – the prolapse is more than 1 cm above the level of the opening
Stage 2 – the prolapse is between 1 cm above and 1 cm below the opening
Stage 3 – the prolapse is more than 1 cm beyond the opening but not completely everted
Stage 4 – the prolapse is completely everted or beyond 2 cm everted
The stage correlates with the severity of prolapse but it’s important to note that not all people with prolapse have symptoms or limitations. In fact, only 3% of everyone with prolapse actually experiences a symptom. This means that most people with prolapse have no idea. It also means that those with symptoms are capable of getting to the point of being symptom-free!!
First, I want to talk about what prolapse feels like. If you do have symptoms, you likely already know you have prolapse but just in case, here are the symptoms of prolapse. It could be any one of these or a combo. Everybody presents just a little different, so everyone’s experience is different as well. It is also important to note that prolapse symptoms could actually be pelvic floor tension rather than prolapse! Different breathing drills can be helpful to find release from pelvic floor tension.
Symptoms of Prolapse
Pelvic heaviness (can sometimes be related to pelvic floor tension as opposed to prolapse!)
Pelvic pressure
Feeling like something is falling out
Seeing or feeling something coming out
Difficulty emptying bowel and/or bladder
Incontinence especially the post-void dribble
Pain with sex
Prolapse Healing
So let’s say you have prolapse, the next thing is what to do about it. There are many different aspects of prolapse rehabilitation, the first of which is to regain the integrity of the vaginal wall followed by improving the strength of the pelvic floor (which is not all about Kegels) and managing the pressure generated in day-to-day activities. Aka there is A LOT to do about it!
This includes:
Pelvic Floor Coordination: learning how to eccentrically lengthen, contract, and release the pelvic floor in coordination with other core muscles. Strengthening with kegels is not the only answer! Having a strong pelvic floor does not mean that this muscle knows how to coordinate with the rest of the system, and often times we need the lengthening to support overall function!
Postural tendencies: how we tend to sit, stand, the leg we favor when we get up, can all influence the pelvic floor tension. We may find that the pelvic floor is more restricted in certain spots due to postural tendencies, or overlengthened in other spots. This could affect the support of the vaginal wall with prolapse.
Pressure management techniques: prolapse is a pressure management issue; if there is too much downward pressure, it could push the pelvic organs down further. After birth, the pelvic organs sit lower, so without managing pressure they may not have the opportunity to move upwards.
Conclusion
Prolapse is so common!! And it does not mean that your life of activity and freedom of exploration of this world is over. You can still run, jump, lift heavy weights, even with a prolapse. The pelvic organs sit lower after birth (vaginal or cesarean birth), and the vaginal wall that supports the integrity of the vaginal canal is weakened from birth. If we can support healing postpartum, and then work on pelvic floor coordination, postural tendencies, and pressure management techniques, we will likely find that we can live symptom free or even resolve a pelvic organ prolapse!