20 Oct Pelvic Organ Prolapse: Understanding and the Role of Pelvic Health Physiotherapy
Pelvic Organ Prolapse (POP) is a condition that affects 1 in 3 women who have had children (POGP, 2020). RCOG, 2022 state it affects 1 in 10 women over the age of 50 years. It can affect women who haven’t given birth also. It often remains undiscussed and misunderstood. It occurs when the muscles and tissues supporting the pelvic organs, such as the bladder, uterus, or rectum, weaken or become damaged, leading to a descent of these organs into the vaginal canal and this can remain inside or sometimes protrude outside of the vagina too. Terminology over the years for POP has changed but most commonly these terms are used now:
- Anterior wall POP (affects the front wall of the vagina, the bladder and urethra)
- Posterior wall POP (affects the back wall of the vagina and the rectum)
- Uterine / Apical POP (affects the apex of the vagina and the uterus)
- Vaginal vault POP (affects the vaginal vault which is left after surgery such as hysterectomy when the uterus has been removed). Yes, you can still get a POP after a hysterectomy!
- Rectal POP (affects the rectum which can descend and protrude out of the back passage)
While it can be a distressing condition, Pelvic Health Physiotherapy offers effective solutions for managing and improving the symptoms associated with POP. POP is most commonly graded using the POP-Q assessment and this is considered the gold standard. It is graded 0-4. Whilst a grade 0-1 may be deemed as normal. A grade 2b- 4 are descent past the hymen (a bulge of the tissue from inside the vagina to outside of the vagina due to descent inside pushing it down and out, and lack of support from around the area to hold it up. The walls of the vagina are much like the tissue on the inside of your mouth, delicate tissue that you can imagine if protruding outside the vagina can become sore and painful. Symptoms of POP often get worse at times when Oestrogen levels are lower such as when we are breastfeeding, certain points in our monthly cycle, or at times in our life when we have hormonal changes such as menopause. Just because our symptoms have worsened at these times, it does not mean our POP level of descent has worsened too, it may just be the tissue is more sensitive, and dry due to the low oestrogen making us more aware of it. Vaginal Atrophy is the term used here where the tissue in the vagina has become dryer, more fragile and more sensitive. You can help improve this by using a topical oestrogen and or oestrogen pessary’s prescribed by your GP. As well as improving your personal hygiene routine down below, ensuring you wash with just water and avoid putting soap and chemicals on the delicate area which can dry it out further. You can use other creams and ointments such as cetraben (available at most chemists to moisturise and even wash with in the shower, as well as specific vaginal moisturisers too life Dr Wolffs Vagisan moisturising cream (other brands are available). If sexually active it is important to think about the products you are using to lubricate the vagina too, as many have harsh chemicals, so find a brand such as YES that has natural PH balanced lubricants (water based if using condoms, oils are fine if not using condoms).
Pregnancy, childbirth, obesity, chronic coughing, genetics, previous pelvic surgery, or heavy lifting are all things that can increase your risk of getting POP. Women with POP may experience symptoms such as a sensation of pelvic pressure or fullness, vaginal bulging, urinary incontinence, difficulties with bowel movements, or discomfort during sexual intercourse. These symptoms can have a significant impact on a woman’s quality of life and overall well-being.
The POP Symptom Score is a validated outcome measure that is used to score symptoms of POP. Please see the POGP (2020) POP leaflet reference below to complete it if you think maybe, you have POP. Postnatally often POP symptoms improve in the first 6 weeks, but if breastfeeding due to low oestrogen, symptoms can feel more until after breastfeeding stops and oestrogen rises, (low oestrogen when breastfeeding helps to stiffen up the tissue in the body and helps the body to heal). It is important women get a postnatal Pelvic Health Physiotherapy check to see how they are recovering and healing in general, but in particular to assess the vagina if it was a vaginal delivery and they have any signs or symptoms of POP, as sometimes birth injuries occur that need specific input especially if you delivered your first baby, who was over 4kgs, and instruments such as forceps were used, or you were pushing longer than 2 hours. Injuries such as Perineal tears, Obstetric Anal Sphincter Injuries (OASI), levator avulsions and more need appropriate rehabilitation to reduce likelihood of future POP, as well as manage and prevent symptoms related to bladder and bowels such as incontinence.
Pelvic Health Physiotherapy, is a specialised branch of physiotherapy that focuses on the assessment, treatment, and management of conditions affecting the pelvic floor muscles and associated structures. When it comes to POP, Pelvic Health Physiotherapy plays a crucial role in addressing the underlying issues and improving and managing the symptoms to lessen the impact of the symptoms on your life. Pelvic Health Physiotherapists have extensive training in assessing the pelvic floor muscles, as well as other structures in the pelvis that contribute to POP including integrity of other connective tissues. They work holistically and look at the whole picture and will assess your spine and pelvis fully as a stiff spine, and altered breathing mechanics will also contribute to increasing POP symptoms. Through a comprehensive evaluation, they can determine the severity of the POP and identify any contributing factors. Based on the findings, a personalised treatment plan is developed to meet the specific needs of each woman. This will include a combination of treatment approaches such as exercise therapy, manual therapy and more.
One of the primary treatment approaches for POP is pelvic floor muscle training. NICE, 2019 clinical guidelines for POP and urinary incontinence recommend 16 weeks of supervised pelvic floor muscle training as first line management for those women with grade 1-2 prolapse. Supervised means done under supervision weekly the research shows much better improvements are seen this way. Pelvic Health Physiotherapists teach women how to correctly contract and relax their pelvic floor muscles, which are essential for supporting the pelvic organs. These exercises, when performed regularly and correctly, can strengthen and improve the endurance of the pelvic floor and provide better support for the organs, potentially reducing the symptoms of POP. It is really important that the pelvic floor muscles are strong through full range able to contract and lift and support when increased pressure from above to keep the organs lifted, as well as to help keep us continent, but they also need to relax to allow us to empty our bladder and bowels. Flexible support is what is needed. For Grade 3-4 POP other interventions are needed and likely they are needed in conjunction with pelvic floor muscle training, as pelvic floor muscle training here is not enough alone.
Pelvic Health Physiotherapists also educate women about lifestyle modifications that can help manage POP. They provide guidance on proper body mechanics, modifying heavy lifting, and advise on how to lift appropriate loads with good intraabdominal pressure management and how to progress this without increasing POP symptom. They provide advice on maintaining a healthy weight, and managing conditions like constipation or chronic coughing, which can exacerbate POP. They educate on correct defecation dynamics (how to go to the toilet) by sitting with your feet up on a stool and a slight forwards lean, this can help you to empty your bowels putting your rectum in a more optimal position; other techniques can be taught here too, to support areas like the back wall of the vagina that may have descended to help you fully empty your bowel. The bladder is slightly more complex and it depends on how the POP is affecting you but techniques such as rocking forwards and back a few times before standing, or standing up and sitting down a couple of times can help too. Being active, staying well hydrated, and eating plenty of fibre to keep your digestive system stay regular are all super important to help too. By making necessary lifestyle changes, women can reduce the strain on their pelvic floor muscles and connective tissue, and promote overall pelvic health, reducing and resolving their POP symptoms, and preventing them from getting worse.
In addition to pelvic floor muscle training, Pelvic Health Physiotherapy may involve the use of therapeutic modalities such as biofeedback (to help ensure good quality contractions), electrical stimulation (to help strengthen initially when weak and struggling independently), and vaginal pessaries (to support connective tissue that has become stretched and isn’t supporting the organs as it should). These techniques can complement pelvic floor exercises and provide additional support and relief for women with POP. Pessaries are particularly helpful here, the more flexible silicon pessaries are preferred as they are gentler on the vaginal walls and these can be inserted and removed on your own, once you have been taught how to do so. There are many different types and sizes of pessaries that can be used to support different types of POP, as well as some that can help with Stress Urinary Incontinence (SUI) too. Once a pessary is fitted and you are taught how to self-manage it, regular reviews are needed to ensure your vaginal tissue is staying healthy and that you are able to continue using the pessary. NICE 2019 recommend 6 monthly reviews to ensure all is well and prevent any complications such as tissue breakdown. Currently GP’s and Gynaecologists are often fitting these pessaries but they are not always using silicon options (often PVC is used which is not so gentle on the tissue), so make sure you check which you are offered and make an informed decision to ensure you are happy with that device. Pessary fitting is not something that is not provided by all Pelvic Health Physiotherapists currently but is something in the future that will be seen more. Here at Halo this is a service that will hopefully be offered in the future. Pessaries are a great device to use to help support the tissue and lessen the impact of the POP symptoms. Pessary’s can be used as often as they are needed, some people just use them for exercise, some use them for so many months in the postnatal period, others use them daily. Pessaries however can only do so much and sometimes further intervention is needed as below.
Pelvic Health Physiotherapy is not a one-time solution but a comprehensive approach to managing POP. Pelvic Health Physiotherapists provide ongoing support and monitor progress throughout the treatment process. Sometimes further input is needed and they will guide you here on this such as seeing your GP to optimise skin health down below, and check and rule out any infections down below. They may also advise/refer you to seek further assessment and review with a gynaecologist as it may be a surgical opinion that is needed and here, you’ll be able to discuss the options and associated outcomes too to make an informed decision on the best next step for you. Surgery is not the magical answer to POP however and all conservative management should be addressed first as the statistics vary, but depending on the type of POP repair often repeat surgery is needed again in the future.
POP is a common condition that can significantly impact a woman’s quality of life. However, with the help of Pelvic Health Physiotherapy, women can find relief and regain control over their pelvic health. By addressing the underlying issues through personalised treatment plans, pelvic floor muscle training, lifestyle modifications, pessaries and ongoing support, it plays a vital role in managing POP and helping to signpost to further input as indicated too.
NICE (2019). Urinary incontinence and pelvic organ prolapse in women: management; NICE guideline [NG123] Published: 02 April 2019 Last updated: 24 June 2019 [online]. Last accessed 28th September 2023 at; https://www.nice.org.uk/guidance/ng123/chapter/Recommendations
POGP (2020) [online]. Pelvic Organ Prolapse- a guide for women. Last accessed on 28th September 2023 at; 20xxx-POGP-ProlapseUpdated (thepogp.co.uk)
RCOG (2022). Pelvic organ prolapse patient information leaflet [online]. Last accessed 28th September 2023 at; https://www.rcog.org.uk/for-the-public/browse-all-patient-information-leaflets/pelvic-organ-prolapse-patient-information-leaflet/
Blog compiled by Gemma Joiner, Senior Physiotherapist & Women’s Health Specialist