50% of women who have delivered a baby will develop some degree of prolapse. Often prolapse develops postnatally, but it can also develop in women who have not had babies or later in life.
What is vaginal or pelvic organ prolapse?
The vaginal walls are soft and elastic, supported by soft fascia attached to the firmer fascia of surrounding muscles, primarily the pelvic floor muscles (PFM), and the ligaments of the pelvis. The vaginal walls are hormonally sensitive and will become more elastic under the influence of pregnancy hormones such as Relaxin and during arousal. The fascia is weaker after menopause.
The PFM lift and tighten in preparation for increases in abdominal pressure. This limits the impact of abdominal pressure which otherwise forces pressure down onto the vaginal walls and supports.
If there is a great or repetitive increase in abdominal pressure and/or weak support for the vagina, the vaginal walls may gradually, or sometimes suddenly, stretch and lose elasticity to develop what is vaginal prolapse. The vaginal walls may appear looser/lower and if the ligaments at the top of the vagina are stretched the cervix may sit lower in the vagina.
What symptoms might I experience?
Many women with mild prolapse feel nothing at all. The first time you feel or sense a prolapse can be shocking. Some women mistake it for a tumour because they can feel or see a ‘lump’ in the vagina that wasn’t there before.
The most common symptoms of prolapse are vaginal heaviness, aching, dragging or the sensation of a tampon falling out. This is partially a result of gravity tensioning your fascia and ligaments. You are more sensitive if you are breastfeeding or post-menopausal. The sensation will likely worsen with activity on your feet and improve when you are resting or lying flat.
If the stretch affects the front wall of the vagina (cystocele) it can change the bladder position and result in bladder sensitivity. Sometimes the bladder outlet (urethra) is kinked which may make it slower to empty your bladder or send the urine in different directions. If the vaginal stretch affects the back wall of the vagina (rectocele) it can alter the rectum position and result in difficulty passing bowel motions. If the cervix is low (cervical or womb prolapse), it could have either effect.
Many women have a hard time resuming sexual intercourse after realising they have a prolapse because of the effect it can have on body image. It’s ok to have sex and it can make the prolapse feel better afterwards. The PFM are most important for sensation.
Risks we can’t change
Anyone who has been pregnant is at risk of developing a prolapse and the more vaginal or difficult deliveries the higher the risk. Many women develop symptoms in the year after having a baby when the PFM are weaker and potentially wider than normal, and with all the heavy lifting involved with caring for a growing baby.
With aging and the menopause collagen in the fascia weakens. Many women will have been experiencing stretching over the years but suddenly develop symptoms during the menopause.
If you have a family history of prolapse you are more likely to experience it due to the type of collagen you are born with. Likewise, if you have a collagen disorder such as hypermobility your fascia is more vulnerable to stretch.
How to protect yourself against prolapse
- Keep your BMI in the normal range. Check it out here: https://www.nhs.uk/live-well/healthy-weight/bmi-calculator/ The weight you carry, particularly around your tummy, pushes down into the pelvis. You can expect to put on 12-15kg over the course of pregnancy.
- Avoid straining and constipation. Eat 5-10 portions of fibre and drink 1.5-2 litres of fluid daily. If you are breast feeding double your fluid intake. Make time for regular exercise such as a walk. Putting your feet on stool while you are on the toilet can make a huge difference. Read more here: https://pogp.csp.org.uk/system/files/publication_files/POGP-BowelFunction.pdf
- Treat your coughs and colds. Seek over the counter medications as appropriate from your pharmacist and see your doctor if your cough persists. Contract the PFM as a matter of habit when you cough or sneeze.
- Avoid heavy lifting. Break heavy jobs into smaller loads, get someone to help you or do it smarter e.g. online shopping. Make sure you use good lifting technique and again contract the PFM as you lift.
- Take care with exercise. Exercise involving heavy lifting, high impact and strong abdominal contractions may be your trigger for developing a prolapse if the supports are weak. Avoid this sort of exercise during and until 3 months after pregnancy. Gradually build up low impact exercise and light weights from 6 weeks postnatal and make sure your PFM is strong before progressing.
- DO YOUR PELVIC FLOOR EXERCISES! You should be completing PFM training through pregnancy and for at least 3 months postnatal. Maintain PFM strength through life to minimise your risk of prolapse. Check out this video: https://www.csp.org.uk/publications/personal-training-your-pelvic-floor
If you suspect you might have a prolapse ask your GP or midwife for a vaginal assessment to rule out any other cause for your symptoms. The GP may diagnose a prolapse or say everything looks normal. Sometimes a minor prolapse is not identified if you are lying down.
Read this evidence based leaflet from the POGP: https://pogp.csp.org.uk/publications/pelvic-organ-prolapse-physiotherapy-guide-women
See a Specialist Women’s and Men’s Health Physiotherapist to check that you are doing your PFM exercises correctly. In pregnancy this may entail an assessment of the perineum. From six weeks postnatal a vaginal assessment is permitted to check the degree of your recovery.