[1] Disclaimer
[2] Title
Nurse: In this video, we look at a very common issue called pelvic organ prolapse.
[3] The objectives for this module are:
- to understand what pelvic organ prolapse is
- to find out about treatment options for prolapse
- to know what you can do to stop prolapse from getting worse and make your symptoms better
Nurse: Prolapse means “falling down."
It refers to your bladder, uterus or top of your vagina (after a hysterectomy), or rectum moving from their normal position and pushing into your vagina.
This can cause it to bulge and change shape and position.
You may remember from the first video that certain factors can make prolapse more common:
[4] having a baby
your genetics, which means you have a family history of prolapse
[5] getting older
chronic coughing from smoking or for other reasons
[6] carrying extra weight
having long-term problems with constipation and straining
[7] doing activities with lots of high impact or lifting heavy things
Nurse: Prolapse is only a problem if it bothers you, such as feeling pressure or heaviness in your vagina, or a bulge that you feel or see at the vaginal opening.
You may have trouble peeing or having bowel movements.
Prolapse may start suddenly or happen slowly over time.
You may notice your symptoms more when you do things like walk, exercise, housework, heavy lifting, strain on the toilet, or if you're on your feet for several hours a day.
Your symptoms often get better after sleeping or on quieter days when you're sitting or resting more.
If you have no symptoms, that's good.
You only need treatment for prolapse if your symptoms are affecting your life.
But it's also important to stop prolapse from happening so you don't have problems in the future.
There are many things you can do now to protect yourself.
Let's look at some pictures of the different types of prolapse.
[8] In the first video, we showed you the normal position of the pelvic organs.
In this diagram, the front of the body is here
- this is the pubic bone; the bladder, which stores urine collected from the kidneys;
- the urethra, which empties urine;
- the uterus, where babies grow; the vagina, which is the birth canal babies pass through during vaginal birth and where sex may happen;
- the rectum, where stool collects before a bowel movement;
- and the anal canal, where stool leaves the rectum with a bowel movement.
The first type of prolapse can happen if you lose support in the front wall of your vagina, and the bladder shifts and starts to fall towards the vagina.
This is called “anterior wall prolapse" or “cystocele."
It can be mild or get worse over time.
Look at what is happening to the urethra as the bladder shifts down.
It can bend or even kink—like folding a garden hose or a drinking straw.
This can make it hard to start the flow of urine when you need to pee.
You may have a weak stream, it might spray in different directions, and it may take a long time to empty your bladder.
When you finish emptying and stand up, you may leak a bit as the urethra shifts, which we call a post-void dribble.
You may feel like you need to pee again.
At bedtime when you lie down, the bladder naturally shifts back into a better position, and this pocket of urine may be easier for you to empty.
If the front wall of your vagina is prolapsing, your urethra may lose support and you can have “stress incontinence."
We talk about this more in the video on urinary incontinence.
One last point: If you don't empty your bladder completely you may be more likely to get bladder infections.
Next let's look at what happens with the back wall of the vagina.
With this second type of prolapse, the rectum changes position and falls towards the vagina.
This is called “posterior wall prolapse" or “rectocele."
Stool may collect in this pocket and you may feel a hard lump in your vagina.
It can be hard to have a bowel movement.
As the stool waits in the rectum, it gets harder and drier.
You may need to use your fingers to push up on the bulge to empty your bowel—called splinting.
This type of prolapse is more common with long-term constipation and straining.
The third type of prolapse happens when the uterus comes down.
The uterus can move down and up the vagina as you go about your daily activities.
The more you're on your feet, the more you may notice the symptoms.
The uterus can come all the way down to the opening of the vagina, and sometimes stick outside of the vagina.
This is called a “procidentia."
Notice that as the uterus gets lower in the vagina, it brings its neighbours with it.
So symptoms of a cystocele and rectocele happen with a uterine prolapse.
Having a hysterectomy, when your uterus is surgically removed, does not always prevent prolapse.
Let's take a look at this situation.
Here you see a pelvis with the uterus surgically removed.
After a hysterectomy you can still have a “cystocele" or a “rectocele."
And it is still possible for the top or vault of the vagina to prolapse.
Imagine taking a sock and turning it inside out by pushing the heel of the sock through the top.
In this way, the vagina falls down or caves in, and you can see how it brings the bladder with it.
These illustrations help you understand how support of one pelvic organ is related to support of the others.
If one part of the vagina is prolapsing (or sagging), it can drag other parts down.
It is common to have more than one type of prolapse at the same time.
[9] There are 4 options for treatment: training your pelvic floor muscles, protecting your pelvic floor by changing the way you do some things, wearing a pessary for support, and surgery.
First, we will look at pelvic floor muscle training.
Physio: In the first video, you learned how your pelvic floor muscles are like a trampoline that supports the weight of your abdomen.
Trampolines stretch and give, but can be damaged.
Your pelvic floor muscles can also be damaged, often without you knowing it.
You need to protect your pelvic floor muscles so they give you the support you need and keep the openings strong for your whole life.
Nurse has described how your organs can shift and move down from their normal spot.
By strengthening your pelvic floor muscles, they can keep working as the supportive base for your abdominal canister.
We will look at how to do this the right way, and how strengthening these muscles can help if you already have prolapse.
[10] With this quick review, we see this hammock of muscles and ligaments that extend from the front to the back, and side to side across the bottom of your pelvis.
[11] They attach to your pubic bone in the front,
[12] to your tailbone at the back, and
[13] between your sitting bones on each side.
The three openings through the pelvic floor are the
[14] urethra, through which you pee, in the front,
[15] the vagina in the middle, and
[16] the anus in the back.
Physio: The pelvic floor muscles keep you dry by tightening or closing around these openings.
The muscles must also relax so you can empty your bladder and bowels and have pain-free sex.
Very importantly, they help support the pelvic organs inside.
[17] These muscles also help with your posture as they work together with your deep abdominal muscles, deep low-back muscles, and your breathing muscle, the diaphragm.
How can you find and feel your pelvic floor muscles?
[18] Can you stop or slow the flow of urine while emptying your bladder?
Do this only as a test to see if you can find these muscles—do not exercise them while on the toilet.
If you can slow or stop the flow, you are using the muscles towards the front of the pelvic floor around your urethra.
Secondly, are you able to squeeze the muscles around your vagina?
Imagine squeezing a tampon or closing your vaginal opening.
These muscles are the ones that are in the middle part of your pelvic floor.
Can you tighten the muscles around your anus, as if trying to stop passing gas?
These muscles are toward the back of the pelvic floor.
If you are not sure if you are using the right muscles, check with your family doctor, physiotherapist, or whomever you see in a pelvic floor clinic.
[19] Pelvic health physiotherapists can help you with pelvic floor issues, and they can help you find and exercise these muscles.
Go to Physiotherapy Alberta's website to find a physiotherapist near you.
[20] How do you do pelvic floor muscle exercises?
[21] It helps to think about closing the 3 openings as your pelvic floor muscles lift “up" inside while doing a pelvic floor exercise.
[22] If your organs are sagging down, think of pulling them back in.
Try and visualize that you are pulling these organs up towards your head from the inside.
As you lift these pelvic floor muscles, don't tighten your legs, bottom, or tummy.
[23] Do not push down or hold your breath.
It is also important to completely relax the muscles.
Think about gently lowering them back down after lifting them up.
There are two different ways to do these exercises:
[24] One way is to do them slowly.
Close the openings, and pull up and in slowly, and hold for up to 10 seconds.
Relax completely after each time.
Do this 10 times in a row.
[25] Another way is to do them quickly by squeezing and lifting, holding for only 1 second, and then relaxing completely.
Do this up to 10 times.
[26] Try to do these exercises at least three times a day, repeating each exercise 10 times.
You'll need to do these exercises for the rest of your life.
Start by doing them in positions that are easier for you to feel your pelvic floor muscles, such as lying down or sitting.
As you get stronger, try doing them while standing.
Physio: Will you notice a difference in your prolapse?
It depends on how severe it is and how well you can squeeze and lift these muscles.
With prolapse, not only are the muscles sagging—also the organs, fascia, and stretched ligaments.
Strengthening these muscles can help make prolapse feel a bit better, but is unlikely to fix it.
It may stop prolapse from getting worse.
It is also important that you think about the things that may have caused the prolapse—lifting heavy things, straining and bearing down with emptying your bowels, coughing hard, or having extra weight.
Strengthening your pelvic floor muscles alone may not be enough if you don't make other changes.
As well, like any exercise program, you must keep the muscles strong.
As the saying goes, “if you don't use it, you lose it."
You need to keep up with the changes and take care of your pelvic floor for life.
[27] It is important to use good posture in all of your movements.
Always tighten your pelvic floor muscles right before any lifting, pushing, or pulling of any kind.
This helps support your pelvic organs inside your pelvis.
Then breathe out slowly.
Don't hold your breath because this puts more pressure on your pelvic floor.
Physio: If you want more information on how your daily and leisure activities can affect your pelvic floor muscles, see the “Exercising Your Pelvic Floor" video on this website.
[28] Nurse: Now that you understand more about how your pelvic floor muscles support your pelvic floor organs, I want to summarize things you can do, or change, to help protect prolapse from getting worse.
These things are important no matter how severe your prolapse is.
Even if you plan to have surgery or wear a pessary, your pelvic floor health will be better if you are protecting it.
[29] Straining down to push out stool or to empty your bladder will damage your pelvic floor.
It also contributes to prolapse from the back wall—or rectocele.
Even if you wear a pessary or have surgery, you have a high chance of the problem returning if you continue to strain.
You may have trouble relaxing these muscles enough to have a bowel movement.
If straining or relaxing are issues for you, see the extra videos focusing on bowel issues.
[30] Coughing and sneezing put sudden and intense pressure on your pelvic floor.
If you cough from smoking, asthma, or a cold, try to deal with the coughing.
Consider quitting smoking.
There is medicine that might help with coughing from asthma or a cold.
Learn how to use your muscles before you cough or sneeze to support your pelvic floor.
[31] Think about the activities you do, especially if you already have prolapse issues.
Prolapse can get worse with ongoing high impact activities or heavy lifting.
If you have surgery, you still must be careful with these things.
Pelvic Floor First is a helpful Australian website all about pelvic floor issues.
[32] Extra weight is a very important factor in stopping prolapse from happening and getting worse.
It can affect how well a pessary or surgery will work for you.
Talk to your healthcare provider or registered dietitian if weight is an issue for you.
Only you can make these changes, but support is there to help you.
[33] Let's talk about using a pessary to treat pelvic organ prolapse.
Many people don't know what a pessary is or that it can successfully treat prolapse instead of having surgery.
[34] Pessaries are devices you wear inside your vagina to reposition and support your organs like your bladder, uterus, and rectum.
They work like scaffolding inside your vagina.
You can use them for all different types of prolapse. They are made of silicon and come in many shapes and sizes.
[35] Here are some pessaries to support vaginal prolapse.
[36] Some styles like these help to suppress leaking urine by supporting the base of the bladder.
We will talk more about them in module 3.
Nurse: Pessaries are not a new invention—they have been used for thousands of years.
When you are wearing one, you should not even know that it is there.
Many people find them helpful.
Find more information about pessaries in the video about pessary use.
Pessaries are not for everyone.
But over the years our experience is that 9 out of 10 people who want a pessary can be successfully fitted for one.
[37] A third option for treating prolapse is surgery.
This is for cases when a pessary is not right for you or if you want a more permanent solution.
Urogynecologists are trained specialists who deal with pelvic medicine and surgery.
Doctor: If your prolapse bothers you, and other treatments haven't worked, then surgery may be an option for you.
You might worry that your prolapse will get worse as you age, and you would rather have it repaired now when you are younger and healthy.
But it's important to understand that not all pelvic organ prolapse gets worse with age.
Large population studies have found that prolapse gets worse for some people as they age, but not for everyone.
So it doesn't make sense to have surgery for an issue that doesn't bother you.
There are many factors to help you know the best timing for surgery, and it's best to talk about them with your surgeon.
Sometimes you may feel prolapse symptoms because your vagina and its opening are dry.
This is common when you're over 40 as you approach and enter menopause.
Adding some vaginal estrogen and making the tissues healthier may be enough to take those symptoms away.
[38] You'll have bladder tests before surgery, even if you don't have any current bladder complaints.
As explained, if the prolapse is causing your urethra to kink, having surgery may “unkink" it, which can make you more likely to leak with exertion, or have stress urinary incontinence, after surgery.
If your healthcare team knows about this before surgery, then they can try and fix that along with the prolapse surgery.
The bladder tests also give your healthcare team a better idea about how well surgery will work for you.
[39] There are two types of surgeries for prolapse.
The first places everything back up to where it should be by attaching your tissues to ligaments in your pelvis.
This is called pelvic floor reconstructive surgery.
It can be done through your vagina or your abdomen, either through an incision or with laparoscopy or “key hole" surgery.
The second surgery closes the vagina so that nothing can fall out, called obliterative surgery.
The type of surgery for you will depend on the type of prolapse you have, your health, and the discussion you have with your surgeon.
Overall your success in surgery is about 70 to 90%.
It depends on the type of surgery you have, the severity of your prolapse, your age, and other factors.
Up to 30% of the time, the surgery is not successful, and you may need another repair or a pessary.
[40] The second type of surgery I mentioned was closing the vagina, so that nothing can bulge through.
This is an option only if you know for sure that vaginal intercourse is not part of your future, and it's usually reserved for older people.
This type of surgery has excellent success rates and a fast recovery.
The surgery will place everything back where it belongs.
The healing and scarring will keep everything in place for the long term.
After surgery you still need to take care of your pelvic floor, manage constipation, and have good voiding habits.
Surgery is not recommended for you if are thinking of getting pregnant. Any surgery has risks.
Your surgeon will discuss the risks with you and answer all your questions.
Your choice will depend on the balance between how much your symptoms bother you and the surgical risks you are willing to take.
The decision is yours.
When you have surgery for pelvic organ prolapse, you can expect to be in the hospital either for a day procedure or overnight.
There is a chance you may have to go home using a catheter (a thin, flexible tube that helps empty your bladder), but you likely won't need it for more than a week.
You cannot lift, strain, or push for 6 weeks after surgery.
Again, you need to avoid getting constipated, carrying heavy items, and doing vigorous activities.
You can walk around and use stairs.
You can start driving as soon as you are not taking any pain medicine.
[41] Nurse: This video has reviewed pelvic organ prolapse—what it is and the different ways you can deal with it.
Do you think you have some type of prolapse?
What symptoms, if any, are you noticing?
Do you think that there are things you can change to stop your prolapse from getting worse?
If your symptoms affect your lifestyle, then treatment is an option.
No matter what treatment you choose, you need to continue to protect your pelvic floor for the rest of your life, which includes practicing pelvic muscle exercises every day.
The third video is about bladder issues, such as urinary incontinence.
Even if that is not a problem for you, you can still watch the video to learn how to stop incontinence from becoming a problem.
