New Blog: Pelvic Organ Prolapse

Written By Dr. Jane Allen, PT, DPT

Introduction

Expectant and postpartum mothers now have unprecedented access to information on women’s health conditions. While much of this information serves as a valuable resource for women to advocate for their health and well-being, oftentimes this information is presented in a way that can be unnecessarily frightening. ‘Pelvic organ prolapse’ (or POP for short) is one of the many women’s health conditions that when seen in a quick scroll through a mom’s blog or on a social media outlet, can be especially alarming. In this review, my goal is to present helpful information that (1) defines POP, (2) discusses how POP is diagnosed and managed, and (3) discusses conservative treatment options for symptomatic POP.

Definitions

The term prolapse is used to describe a tissue or organ that has been displaced from its normal position. POP is defined by the International Urogynecological Association and International Continence Society as “the descent of one or more of the anterior vaginal wall, posterior vaginal wall, or apex of the vagina.” During a physical exam, a prolapse will appear as a bulging of the vaginal wall. While this may sound very serious, it is important to point out that POP is very common, and often has no symptoms. During pregnancy, and up to one year after birth, up to 50% of women will present with a POP. Of that 50%, only 3% will have any symptoms. This information suggests that POP is usually asymptomatic (Barber & Maher, 2013). According to the 2019 clinical practice guidelines put forth by the American College of Obstetricians and Gynecologists (ACOG), POP should not be considered pathological, and should only be treated when symptomatic. The most commonly reported symptom of POP is a ‘bulge’ or ‘pressure’ in the vagina which is affected by gravity (Collins et al. 2022) Other possible symptoms or comorbidities include pelvic pressure or discomfort during intercourse or vaginal insertion, urinary leakage, difficulty emptying the bladder, and difficulty emptying the bowel. Symptoms of POP can vary significantly based on daily activity levels, body position, and fullness of the bladder or rectum. Risk factors for POP include the number of pregnancies, number of vaginal deliveries, increased age, obesity, connective tissue disorders, menopausal status, and chronic constipation.

Diagnosis

POP is often described as a ‘benign’ condition (Raju & Linder, 2021). The physical finding of POP correlates very poorly with associated symptoms. The symptoms that a woman experiences should be validated regardless of physical exam findings. Treatment should also be based on a woman's experience. Poor correlation of exam findings with pelvic symptoms has led to several other theories on what might cause a woman to experience the sensation of bulging or heaviness in the pelvis. It has been suggested that other structures in the pelvis, such as muscles and ligaments of the pelvic floor, could also be responsible for pelvic symptoms.

Conservative Treatment

The first line of recommended treatment for POP (as well as many other conditions) is education. A woman should be assured that POP is common, and most often unharmful, diagnosis. Without treatment, POP is normally stable (Swift et al., 2005). Progression of POP is usually very slow and associated with weight gain and increased age. The second line of treatment for POP is to recommend lifestyle modifications that can improve pelvic symptoms. These recommendations may include maintaining a healthy weight, being physically active, toileting modifications, and avoiding straining for bowel movements by managing symptoms of constipation with water, fiber, and (when needed) osmotic laxatives (ACOG Practice Bulletin 2019). Pelvic floor muscle training (PFMT), which is often performed by a pelvic health physical therapist, is also recommended as a treatment for symptoms associated with POP. PFMT has been shown to improve pelvic muscle strength as well as symptoms of POP. In some studies, PFMT has also been shown to decrease the physical findings of POP (Brækken, Majida, Engh, & Bø, 2010). The final line of conservative intervention for symptomatic POP is a pessary. A pessary is a removable device that is placed into the vaginal canal to support the pelvic organs. Pessaries are a safe and effective management strategy for POP (Sansone et al., 2022). Pessaries are usually prescribed and fitted by a gynecologist.

Conclusion

If you’ve found yourself with symptoms consistent with POP and wonder if you need treatment, our team is here to help you build a healthy lifestyle and musculoskeletal support for your pelvic floor to help you get back to enjoying all of your activities without fear of pain or increased concerns for your future family planning. We will help you understand your symptoms, develop a safe and effective plan, and communicate with your care providers and partners to advocate for your needs. Reach out to us today!

References

Barber, M. D., & Maher, C. (2013). Epidemiology and outcome assessment of pelvic organ prolapse. International Urogynecology Journal, 24(11), 1783-1790. doi:10.1007/s00192-013-2169-9

Brækken, I. H., Majida, M., Engh, M. E., & Bø, K. (2010). Can pelvic floor muscle training reverse pelvic organ prolapse and reduce prolapse symptoms? an assessor-blinded, randomized, controlled trial. American Journal of Obstetrics and Gynecology, 203(2). doi:10.1016/j.ajog.2010.02.037

Bø, K., & Nygaard, I. E. (2019). Is physical activity good or bad for the female pelvic floor? A narrative review. Sports Medicine, 50(3), 471-484. doi:10.1007/s40279-019-01243-1

Collins, S., & Lewicky-Gaupp, C. (2022). Pelvic organ prolapse. Gastroenterology Clinics of North America, 51(1), 177-193. doi:10.1016/j.gtc.2021.10.011

DeLancey, J. O., Morgan, D. M., Fenner, D. E., Kearney, R., Guire, K., Miller, J. M., . . . Ashton-Miller, J. A. (2007). Comparison of levator ani muscle defects and function in women with and without pelvic organ prolapse. Obstetrics & Gynecology, 109(2, Part 1), 295-302. doi:10.1097/01.aog.0000250901.57095.ba

Iglesia, C. B., & Smithling, K. R. (2017). Pelvic Organ Prolapse. American Family Physician, 96(3), 179–185.

Li, C., Gong, Y., & Wang, B. (2015). The efficacy of pelvic floor muscle training for pelvic organ prolapse: A systematic review and meta-analysis. International Urogynecology Journal, 27(7), 981-992. doi:10.1007/s00192-015-2846-y

Pelvic Organ Prolapse: ACOG Practice Bulletin, Number 214. (2019). Obstetrics & Gynecology, 134(5). doi:10.1097/aog.0000000000003519

Raju, R., & Linder, B. J. (2021). Evaluation and management of Pelvic Organ prolapse. Mayo Clinic Proceedings, 96(12), 3122-3129. doi:10.1016/j.mayocp.2021.09.005

Reimers, C., Stær-Jensen, J. E., Siafarikas, F., Bø, K., & Engh, M. E. (2017). Association between vaginal bulge and anatomical pelvic organ prolapse during pregnancy and postpartum: An observational study. International Urogynecology Journal, 29(3), 441-448. doi:10.1007/s00192-017-3407-3

Sansone, S., Sze, C., Eidelberg, A., Stoddard, M., Cho, A., Asdjodi, S., . . . Chughtai, B. (2022). Role of pessaries in the treatment of pelvic organ prolapse. Obstetrics & Gynecology, 140(4), 613-622. doi:10.1097/aog.0000000000004931

Swift, S., Woodman, P., O'Boyle, A., Kahn, M., Valley, M., Bland, D., . . . Schaffer, J. (2005). Pelvic Organ Support Study (POSST): The Distribution, clinical definition, and epidemiologic condition of pelvic organ support defects. American Journal of Obstetrics and Gynecology, 192(3), 795-806. doi:10.1016/j.ajog.2004.10.602

Tennfjord, M. K., Engh, M. E., & Bø, K. (2020). The influence of early exercise postpartum on pelvic floor muscle function and prevalence of pelvic floor dysfunction 12 months postpartum. Physical Therapy, 100(9), 1681-1689. doi:10.1093/ptj/pzaa084

Wiegersma, M., Panman, C. M., Kollen, B. J., Berger, M. Y., Lisman-Van Leeuwen, Y., & Dekker, J. H. (2014). Effect of pelvic floor muscle training compared with watchful waiting in older women with symptomatic mild pelvic organ prolapse: Randomised controlled trial in primary care. BMJ, 349(Dec22 1). doi:10.1136/bmj.g7378