By Alison Heyerdahl

What is prolapse?

Prolapse is a common condition where the pelvic organs (such as the bladder, uterus, and sometimes bowel) drop down into the vaginal space. About a third of all women are affected by prolapse or similar conditions over their lifetime. It can be a devastating condition that affects one's emotional health and causes social discomfort and isolation. The good news is that in most cases, it can be successfully treated.

What are the symptoms of prolapse?

Prolapse often causes a heaviness, or 'dragging' and pressure type of feeling in the vagina, which is often worse at the end of the day. Symptoms include:

• Bladder incontinence (or not being able to control the bladder).

• Bowel incontinence (or not being able to control the bowel).

• Difficult bowel movements and incomplete emptying

• Lower back or pelvic pain

• Pain or discomfort with sexual intercourse

There are different grades of prolapse — mild, moderate, and severe. A mild prolapse will often be unnoticeable, with very few symptoms indicating its occurrence. Moderate prolapse is when the pelvic floor organs can be palpated halfway into the vagina, and severe prolapse is when the organs are seen or felt at the entrance of the vagina.

There are four main types of prolapse:

• Cystocele (bladder prolapse): the bladder drops down and bulges into the vaginal space.

• Rectocele (prolapse of the rectum): the rectum drops down and bulges into the back wall of the vaginal space.

• Enterocoele (prolapse of the small intestine): the small intestine prolapses into the vaginal space from above).

• Uterine prolapse: the uterus and cervix descend into the vaginal space.

What causes prolapse?

The pelvic organs are suspended in the pelvis with supporting ligaments above and muscle and fascia below. If any of the structures begin to weaken or become loose, the pelvic organs will descend into the vaginal space.

There are several factors that contribute to the weakening and loosening of the ligaments, muscles, and fascia:

• Pregnancy is one of the most common causes of prolapse. During pregnancy, a hormone called relaxin is released to prepare the pelvis for birth. Its job is to relax the ligaments so that the pelvis can accommodate the baby's head. It also causes the opening and softening of the cervix and the vagina to aid birth and prevents rupturing of the membranes. Secondly, the baby's weight pushes down on the pelvic organs, stretching the supporting structures and putting the pelvic organs at risk of prolapse.

• Natural childbirth causes further stretching of the pelvic floor structures, which is complicated if the pushing phase lasts unusually long or it is a big baby. The muscles need to be strengthened and toned after birth to prevent the prolapse from occurring.

• Following birth, gravity can have a negative impact on the pelvic floor. Too much walking and upright activity put pressure on the pelvic floor, stretching and weakening the pelvic floor muscles, ligaments and fascia.

• Chronic straining during bowel or bladder movements also puts downward pressure on the pelvic floor, resulting in stretching of the supporting ligaments. Straining during a bowel movement causes stretching of the rectum, which could complicate the rectum's let-down reflex and emptying.

• Injury to the pelvic floor through an impact or rough sexual contact can damage the supporting ligaments, muscles, and fascia.

• Genetics also plays a role in determining whether or not the supporting ligaments, muscles, and fascia will hold the pelvic organs in place.

• Surgery such as a hysterectomy can cause complications in the pelvic floor. Sometimes when the uterus is removed, the support structures weaken, and a prolapse occurs. Furthermore, surgery in the pelvic floor region can cause damage to the pudendal nerve, which supplies the urethral (or bladder) and anal sphincters.

How can a prolapse be treated?

Treatment is based on the severity and type of prolapse. Most women first consult a general practitioner about the problem only when it limits her activities of daily living. The doctor will refer the woman to an obstetrician or gynecologist who may recommend the insertion of a pessary device. Pessaries are made from silicone and come in many shapes and sizes. The pessary is inserted into the vagina to support the prolapsed organs and is often very effective. It is custom-fitted to the pelvic floor, and it can be removed.

The doctor may also recommend physical therapy, which is an extremely effective way of dealing with prolapse. Physical therapy will not be able to return the organs to their original position, but it will prevent further prolapse and help manage the symptoms of prolapse.

How do physical therapists treat a prolapse?

Physical therapists first perform a comprehensive assessment of the history of the prolapse. They ask questions about bladder and bowel control and past medical history. They then carry out a physical examination of the pelvic floor. The examination and treatment will be carried out in a private setting, with the same physical therapist every time who will provide a sensitive, supportive and professional environment.

Physical therapy will involve a lot of education, teaching women methods to improve bladder and bowel control, providing instructions on how to pass bowel movements without straining, and retrain the bladder. Physical therapists also educate women on what activities to avoid to reduce the prolapse.

Physical therapy also involves training the pelvic floor muscles — the support system of the pelvic floor that helps maintain the pelvic floor organs' position. The physical therapist may employ a biofeedback unit that electrically stimulates the pelvic floor to retrain the muscles' contraction and relaxation and make one aware of their position and function. Treatment also includes re-education of the posture and breathing and core muscle strengthening.

If the prolapse does not respond to conservative treatment, and it continues to negatively impact the quality of life, surgery may be indicated. There are several different types of surgery that one can consider. Sometimes, a hysterectomy is indicated if there is a severe uterine prolapse. Other times, one may need to undergo a procedure known as a sacrocolpopexy to reposition the pelvic organs.

Conclusion

Prolapse is a common condition that can cause significant discomfort and even warrant major lifestyle changes. Women need to be educated on the condition, as well as what can be done about it. Physical therapists are experienced in dealing with prolapse and will refer patients to the relevant medical professionals for help.