It’s Time To Feel Uplifted

Pelvic organ prolapse can be a real drag can’t it? It is a bothersome – often burdensome – thing that keeps you from doing all the things you need to do – from taking care of your kids, to exercising, to just being upright and walking… Is simply standing up at the day’s end too much to ask?!

We know that a prolapse diagnosis can be devastating for so many reasons. But please believe us when we say that your body CAN get back to the point where daily activities feel normal again.

Your amazing system DOES have the capacity to learn, heal, and be re-trained. And you have untapped potential to change how your system works, even with a prolapse. With clear guidance from us and a good dose of dedication from you, your list of “don’ts” will get shorter, while your list of “dos” will increase.

Girl, it’s time to rise and shine. We’ll do this together.

Raise Me Up

Pelvic organ prolapse (POP) occurs when there is a shift in the optimal position of the pelvic organs (in women those are the uterus, rectum, and bladder).

Symptoms may include a feeling of pressure or heaviness in the perineum, altered flow of urine, a feeling of falling out, constipation or straining, and discomfort during intercourse. Physical signs may include a bulge or protrusion at the vaginal entrance.

Positions where gravity is acting on the body (such as standing, walking, lifting) tend to aggravate signs and symptoms. And positions where gravity is not a factor (such as lying down) tend to be relieving.

POP is interesting in that it is a completely subjective experience; some women with a mild prolapse may have severe symptoms. Other women with more significant prolapses may have minimal or no symptoms.

Your doctor, specialist, or nurse practitioner may diagnose the type of prolapse you have as well as grade the degree of the prolapse. Traditionally:
  • A prolapsed bladder is called a cystocele
  • A prolapsed rectum is called a rectocele
  • A prolapsed uterus is called a uterine prolapse
  • A prolapsed urethera is called a urethrocele
  • A prolapsed intestine is called an enterocele
  • A vaginal vault prolapse occurs only after a hysterectomy where the top of the vagina itself prolapses down

In our practice, we may refer to these traditional terms. However, best practice is moving towards a more anatomically based classification.

You may hear your prolapse described as an ‘anterior vaginal wall prolapse’, ‘posterior vaginal wall prolapse’ or an ‘apical prolapse’. This language is preferred because the specific anatomical structures on the other side of the vaginal bulge is uncertain in the absence of diagnostic imaging.

There are a few different ways to measure or grade a prolapse. One of the most widely used staging systems is the POP-Q (Pelvic Organ Prolapse Quantification System). It uses a four point system to determine the degree of prolapse that someone has.

  • Stage 0 = no prolapse
  • Stage 1 = prolapse is at 1cm above the vaginal opening or higher
  • Stage 2 = prolapse is 1cm away from vaginal opening or has protruded up to 1cm out of the vagina
  • Stage 3 = prolapse protrudes more than 1cm out of the vagina but no more than 2cm
  • Stage 4 = vaginal walls have completed everted and prolapse has maximally protruded

In our practice, we may adopt slightly different language when describing your prolapse. We may rate it as mild, moderate, or significant rather than refer to a specific grade.

This is because prolapse grading can appear to change based on a number of factors such as time of day, position of evaluation, and method of evaluation. Further, not all healthcare providers grade in the same way – so it can be confusing for you if different grading systems are used or different testing methods are adopted and you’re unsure which one is being used!

Pelvic floor physiotherapy is very effective at treating prolapses in stages 1 to 3 using the POP-Q.

It’s important to note that there is no correlation between prolapse stage and symptom severity. Some women with a mild prolapse can rate it as very heavy or bothersome; some women with more significant prolapses do not complain of many symptoms at all.

But why? The scientific community is also beginning to conduct research studies which seek to answer this question. We know that the way our body experiences sensations is very much linked to the representation of various body parts on the sensory-motor cortext in the brain.

This is one reason why we involve some brain remapping and nervous system retraining when we treat a prolapse. Involving your brain while restoring your physical body is one way we produce effective and lasting results in someone’s sensory experience of prolapse.

Fascia and ligaments that suspend the organs in place may become lax, suddenly torn, or lose integrity over time. This causes the pelvic organs to lose suspensory support from above (kind of like a marionette that has had one of it’s strings overstretched or cut).

If the pelvic floor muscles are also compromised or weak, it can result in lack of pelvic support from below.

These factors, coupled with poorly managed pressures in the abdominal canister result in a downward descent of the pelvic organs. They will lean into the vaginal walls which will then collapse in on itself and descend towards the vaginal entrance. More significant prolapses can bulge or protrude from the vaginal opening.

There is more and more research emerging showing the causal relationship between levator ani muscle avulsions and the development of prolapse.

The levator ani is a muscle group housed in the pelvic floor; it anchors to both the left and right side of the pubic bone and it is a key muscle in the support of pelvic organs.

During vaginal childbirth (particularly with forceps delivery or prolonged pushing stage), the muscle can be pulled off one or both of its attachment points on the pubic bone.

When this muscle is no longer anchored, it cannot offer as much support to the pelvic organs as usual. It is also more difficult to strengthen a muscle that has avulsed. This may may be one reason why your pelvic floor does not seem to be getting stronger despite your dedicated training.

Although 20-36% of woman have levator ani muscle avulsions following childbirth, the good news is that some do spontaneously heal. However, in the majority of cases, pelvic floor rehabilitation is needed to retrain the pelvic floor and recover as much function and support as possible.

There are a number of different strategies to treating prolapse, depending on the healthcare provider you see. Usually it is a combination of lifestyle management, education, pelvic floor training, use of support pessaries, or surgery.

We work with family doctors, nurse practitioners, gynecologists, obstetricians, and pelvic-health aware fitness trainers, to help you reach your goals.

POP is a condition which can be effectively managed with strategies taught by a pelvic health physiotherapist. We may be biased, but for mild and moderate prolapses, you really should work with us first.

In fact, the body of research evidence recommends conservative management (ie. pelvic floor training) as the first strategy for treating pelvic organ prolapse.

At our practice, we take a multi-pronged treatment approach.

  1. We start with a comprehensive physiotherapy evaluation – looking at your pelvic floor in the context of your entire body.
  2. We retrain your pelvic floor. We teach it whatever it needs (whether strengthening, improved coordination, or learning to let go).
  3. We analyze other elements of your pressure system which are impacting your pelvic floor (such as your breathing, daily movements and positions, toileting habits, and more).
  4. We talk about your lifestyle and strategize around ways to complete your daily tasks (work, childcare, etc) while boosting your pelvic health.
  5. We discuss what makes you happy and thrive (eg. working out, hobbies and sports, long walks, etc) and strategize ways you can continue to participate in these.
  6. We help you figure out how your brain and nervous system may be impacting your sensory experience of prolapse – and how to make it better.
  7. We might recommend you do a trial run with a pessary – and if it helps, you may consider using it temporarily or as a longer term option. The goal is to help support your pelvic floor recovery and healing.

Absolutely. In fact if you are considering surgery as treatment option for pelvic organ prolapse we have two important recommendations for you:

1) Do your research on surgical procedures and materials – particularly those that may involve mesh.

2) Come see us (or a pelvic floor physiotherapist in your area) before AND after surgery.

The unfortunate truth is that surgery for POP has poor long term outcomes. Around 50% of women who have surgery for a POP have to have it repeated within five years. That’s not the best rate of success as far as surgery goes!

Here’s how we see it: if you were going to have surgery for your knee or hip, it’s standard protocol to work with a physiotherapist to strengthen the tissues, optimize range of motion, improve muscular endurance, maximize function, and minimize pain – all BEFORE surgery.

The same goes for ACL reconstruction and many other orthopaedic procedures. Why should it be any different for the pelvic area?

By working with a pelvic floor physiotherapist pre-operatively, you will improve your chances of functional recovery. And who knows, you may even get to the point where you feel you no longer need to undergo surgery.

After having a surgery, we still absolutely recommend pelvic floor rehabilitation. A number of women are surprised when they experience unwanted side effects from surgery such as incontinence, a new onset of pelvic pain, or restrictive scar tissue.

And since prolapse is fundamentally a pressure problem, many women continue to have poorly managed pressure systems even though they have had surgery. Ultimately, this inability to manage intra-abdominal pressure will take its toll on the pelvic floor and likely accounts for the need to repeat surgery within five years.

Bottom line: if you’re planning to have or have already had surgery, you can improve your long term outcomes by working with a pelvic floor physiotherapist.

So yes and no.

A prolapse is something that once you have it, it’s usually there.

BUT it doesn’t have to be a death sentence. Just because it’s there doesn’t mean that you have to feel it. It doesn’t mean you can’t get on with your life.

Consider this: a number of women who live with prolapse have zero symptoms. It doesn’t bother them. It doesn’t affect their life. It doesn’t limit them.

Our goal is to get you to the point where you can do whatever you want to do – even if the prolapse technically still remains. And in some cases (for example, with mild or moderate prolapses where no levator ani avulsion is involved) it is possible for a prolapse to fully resolve with the correct, functional, whole-body training.

With pelvic floor physiotherapy and other complimentary strategies, it is very possible to become completely symptom free and lead an active lifestyle, even if the prolapse itself does not disappear.

Our Prolapse Treatment Programs

We start by getting to know you and understanding your story. We want to know how prolapse is affecting your life, what you have tried, and what your ultimate goals are. We’ll ask questions about your pelvic health and look at your overall health as well.

After this, we check out how your unique body is working and let you know what we find. Our programs include custom recommendations, hands on strategies, practical advice, step by step home exercise protocols, email support, accountability, educational resources, product recommendations, letters to your healthcare team, and more.

All that we offer is designed to help your body function better so that you can get back to doing what you want to do without having to worry about making your prolapse worse.

Our prolapse programs will work well if you…

  • Are willing to consider the whole prolapse picture and not just the pelvic floor

  • Have patience with yourself and with the process for recovery and healing

  • Have tried doing a bunch of kegels but found they did not really help

  • Are considering surgery for or have already had surgery for pelvic organ prolapse

I came to Ibbie in October after being diagnosed with pelvic organ prolapse. I was experiencing pretty constant discomfort and was unable to stand or walk for more than 15 min at a time without significant pain. Lifting my grandchildren was out of the question for me. By December, I was symptom free. Not only did Ibbie devise an effective physical therapy plan for me, she treated me with optimism, sensitivity and respect. I am so grateful to her and recommend her highly.

~S.L.

How Do You Want To Treat Your Prolapse?