Pelvic Organ Prolapse Primer

Important note: DO NOT GOOGLE IMAGE SEARCH "PROLAPSE." You will only find worst-case scenarios and it will freak you the F out if you have recently been diagnosed with prolapse. Just trust me on this one.

Pelvic organ prolapse is a difficult subject to find information about. Moms commonly talk about their achy backs, pain in the early days of breastfeeding, or even joke about peeing while jumping (common but NOT normal!), but hardly anyone talks about prolapse. For many women, this is an embarrassing topic. And that's a shame, because prolapse is probably more common than you realize. We don't know what the true incidence of prolapse is, but chances are you know someone affected by it. You might even have a mild prolapse, but no symptoms.

If you're new here, you might not know that I have a mild prolapse and have gone through pelvic floor physical therapy, so this is a topic that's near and dear to my heart.

So let's start with the basics.

What is pelvic organ prolapse?

Pelvic Organ Prolapse occurs when one or more of your pelvic organs (uterus, bladder, rectum) is no longer fully supported by your pelvic floor muscles and the fascia (layers of connective tissue), and begins to descend. The vaginal wall starts to droop inward and, in severe cases, might protrude outside the opening of the vagina. 

Types of Prolapse

There are four basic categories of pelvic organ prolapse. I've adapted these definitions from Voices for PFD; see their page for more information. As you are reading these descriptions, it might be helpful to open a separate tab to the ACOG website, where you will find animations of the various types of prolapse (this is safe for work).

 Normal pelvis

Normal pelvis

Anterior Vaginal Wall Prolapse

 Cystocele (anterior vaginall wall prolapse)

Cystocele (anterior vaginall wall prolapse)

Anterior wall prolapses include Cystocele (bladder) and Urethrocele (urethra). Anterior means "front," so these prolapses affect the front vaginal wall (closer to your pubic bone than your tailbone). Cystocele and urethrocele can often occur together, and happen when the fascia (supportive tissue) of the bladder stretches or detaches from where it's connected to the pubic bone. The bladder falls down into the vagina, causing a bulge, loss of bladder control/stress urinary incontinence, feelings of heaviness, fullness, or achiness, or feeling like you're sitting on a ball.

Posterior Vaginal Wall Prolapse

 Rectocele (posterior vaginal wall prolapse)

Rectocele (posterior vaginal wall prolapse)

If anterior means "front," then posterior means, you guessed it, "back." Posterior vaginal wall prolapses include rectocele (rectum) and enterocele (intestines), and happen when the supportive tissue between the vagina and rectum stretch or detach. The rectum or intestines then bulge or descend into the vagina. Symptoms include a bulging sensation and straining during bowel movements or feeling like you're not able to completely empty the bowels.

Uterine Prolapse

Uterine prolapse. This is a grade 4 prolapse, which means the uterus is now outside of the vaginal opening.
Uterine prolapse. This is a grade 4 prolapse, which means the uterus is now outside of the vaginal opening.

A uterine prolapse is when the uterus moves down into the vagina. In severe cases, the cervix can protrude outside the vaginal opening. Feelings of pelvic pressure or bulging are very common if you have a uterine prolapse. If the uterus and cervix are low enough, the cervix might rub on your underwear, causing bleeding and irritation.

Rectal Prolapse

Unlike the other types of prolapse, a rectal prolapse does not affect the vaginal walls. This type of prolapse is less common and occurs when the rectum's supporting structures stretch or detach, causing the rectum to fall out through the anus. Symptoms include painful bowel movements, mucus or bloody discharge from the protruding tissue, and an inability to control your bowel movements. A rectal prolapse could also be mistaken for a very large hemorrhoid.

Prolapse Diagnosis and Severity

If you suspect you have a prolapse because you can either see or feel a bulge, or because you have any of the other symptoms mentioned above (especially heaviness or achiness in your pelvis; that's a big red flag), please go see a pelvic floor physical therapist! Many OB-GYNs are not well-versed in prolapse and may dismiss your symptoms as being totally normal after having a baby. THEY'RE NOT. Don't accept a shrug as an answer. Go see a pelvic floor physical therapist or a urogynecologist, as these are the two professionals who are the best suited to help with this particular condition.

To find a pelvic floor physical therapist near you, use this website or email me -- I'll help you find someone.

Prolapses are graded on a scale from 0-4. Your physical therapist or doctor will ask you to cough or gently bear down to see how far your prolapse moves, and then measure according to how close the prolapse is to your hymenal ring (just inside the vaginal opening; where your hymen is or used to be).

Grade 0: No prolapse is present.

Grade 1: Lowest part of the prolapse is more than 1cm above hymenal ring.

Grade 2: Lowest part of the prolapse is within 1cm of the hymenal ring.

Grade 3: Lowest part of the prolapse is below the hymenal ring, but the vagina has not completely prolapsed.

Grade 4: The vagina has completely prolapsed outwards.

Source: https://www.pelvicexercises.com.au

Prolapse Risk Factors

I like to talk about the risk factors for prolapse rather than saying "causes of prolapse," because you often can't say for sure what the cause was.

Ok, now you have a good understanding of the mechanics of pelvic organ prolapse: organs descend when their support weakens. But why does that happen? Why do some women get prolapse and others don't?

That's a tough question and one that can drive you insane after receiving a prolapse diagnosis. I can tell you from personal experience that after my diagnosis, I spent a long time mentally dissecting everything I did after my youngest daughter was born, trying to pinpoint what, EXACTLY, I did that caused my prolapse.

This way lies madness. Please, if you're reading this and you have a prolapse, be kind to yourself. It happened, for whatever reason, and it is entirely possible you didn't do anything to cause your prolapse. 

Risk factors include:

  • Vaginal birth (risk increases in cases of vacuum or forceps delivery)
  • Genetics: Some women are born with stronger bones, muscles, and connective tissues than others. Those with weaker connective tissues have a higher risk of POP.
  • Smoking
  • Pelvic floor injury
  • Hysterectomy
  • Surgery to treat pelvic organ prolapse (yeah, how's that for unfair)
  • Chronic constipation, straining, or coughing
  • Obesity
  • Menopause
  • Nerve and muscle diseases that contribute to the deterioration of pelvic floor strength
  • Heavy lifting and intense repetitive activity (running, CrossFit, etc)

Please note that you can have all of these things and not have POP. You can have NONE of these things and still have POP. 

Treatment

There's really only two options here: pelvic floor physical therapy or surgery. In cases of mild to moderate prolapse (read: the organ in question is not outside of your body), PT can be hugely successful in lessening or eliminating symptoms. This is the case for me. I still HAVE a prolapse, since once the structural support has been compromised it's highly unlikely that the grade will ever be reduced to zero. Most women who have had children are walking around with a grade 1 prolapse anyway with zero symptoms, so eliminating the bulge is not usually the goal of PT. You can have a grade 3 with no symptoms, or you can have a grade 1 with severe symptoms. There's not necessarily a correlation between the grade of your prolapse and your symptoms. For a wonderful post on this subject, check out Julie Wiebe's "What is the goal of prolapse rehab?"

Surgery is usually recommended in severe cases, and I would argue that PT should be included as part of this. A pelvic floor physical therapist can work with you following your surgery to help you develop better movement strategies, which increases the odds of your repair holding up. Prolapse surgery has about a 30% failure rate. Not a typo. Yeah, that's not exciting at all, which is why PT is usually the first line of defense.

In conclusion, for now

This is just an overview, and I hope it's been helpful for those of you who are searching for answers on the great, wide internet. In the next post I'm going to answer common questions about POP. Got a specific one you'd like me to answer? Email me!

POP Journal: Catching Up

Quick recap for those of you who are just tuning in: I was diagnosed with bladder prolapse when my little one was about 8 months old. I went to pelvic floor physical therapy and it changed my life. No joke, no exaggeration. That was a little over two years ago, and while it certainly hasn't been a direct route, I can now run, lift weights, and basically do all the things that websites about prolapse tell you not to do, with no symptoms. I've squatted 210 lbs, deadlifted 260, and my prolapse is no worse for the wear. 

(Your mileage may vary. This should in no way be considered medical advice and you should talk to a pelvic floor physical therapist before doing those things.)

What I haven't talked about is that I had to take a big step back in January of this year. Last summer and through the fall I felt amazing. No symptoms. Felt strong as hell. Give me all the things and I will pick them up and put them down. Got a phone book handy? I'll tear that mf-er in half. 

I was feeling so great that I decided to register for a powerlifting meet that would take place in January. Not to COMPETE, just to do it and hopefully set some personal bests. 

Have you seen anything about a powerlifting meet on this blog or on Facebook? No? No. Why? I didn't do it. 

About a month before the meet, I did something. I'm pretty sure it was holding the bottom position of a back squat that did it, and my pelvic floor was all NOPE. I called the workout for the day and left the gym almost in tears.

I was sure that I'd gone too far, pushed too hard, made everything worse and now I'd need surgery and how can I train women with POP when I can't even manage my own and what have I done oh god oh god OH GOD.

I went back to my pelvic floor physical therapist who checked me and said that she didn't think anything was different. I still had the one prolapse (I was convinced I'd also given myself a rectocele -- when the back wall of the vagina falls forward -- in addition to making my existing prolapse worse). She told me she didn't see any reason why I couldn't continue with my heavy lifting.

But I couldn't. Mentally, I just couldn't. I was terrified. 

If you have POP, you know what I'm talking about. You're afraid to move, afraid to pick anything up, unable to live your life for fear of making your prolapse worse. Because that's the worst case scenario and once those supportive ligaments have been pushed too far and they just give up, they don't go back. There is no cure. You either live with it or you get surgery, and the failure rate is about 30%.

How do you like them apples? Not well, actually, not well at all.

I talked about it with my trainer. He's a fantastic coach and defers to me when I say nope, my pelvic floor is not ok with that exercise right now. And yes, I do have those conversations in those exact words. You don't necessarily have to be that blunt, but your trainers, coaches, and instructors have to know what's going on. 

We dialed everything back effective right that second. Cut out all squats. Cut out everything heavy. Pivoted to low weight/high rep stuff while I monitored my strategy. Was I breathing? Was I thrusting my ribs? Was I clenching my pelvic floor because relaxing it felt scary? Actually, yeah. 

It's been almost five months since then and I've made enormous progress. We've added sprinting to my workouts, and that feels great. No heaviness or pressure and no pelvic floor problems during or after, always being careful of my strategy. I've recently started back squatting again, keeping the weight to less than half of what my max was before and deciding on a set-by-set basis how much to do that day. 

The hardest part of all of this is my pride. If I go to special events that my gym hosts and everyone else is testing their lifts, I'm not going to do that. Could I? Sure. Should I? Nope. The whole risk vs. reward question becomes a lot clearer when you're talking about irreparable damage and you're able to put your ego aside. 

I still feel strong. I still feel great about my workouts, and I'm not just lying on the floor doing clamshells and kegels for an hour. 

Every so often someone who knew I was registered for the meet asks me about it. I'm very open and tell them that my pelvic floor just wasn't ready, and I needed to take a step back. They always ask if I'll do one in the future, and the honest answer is that I don't know.

I might have maxed out on my big lifts and never PR again. I might never do a powerlifting meet. 

Can I live a happy and healthy life without any more PRs or powerlifting? Yes. Am I sad that that's a possibility? Yes. 

Most women, myself included, feel a very real grief after their POP diagnosis. It's not something that you "get over," though, because there's a constant recalibration of what works for you and what doesn't. That can and does change even from day to day. There's a lot of hope, especially for those who are diagnosed soon after having a baby. So much healing occurs during the first year, and even beyond, especially for breastfeeding moms, so I hope this doesn't come across as EVERYTHING IS AWFUL AND YOUR LIFE IS RUINED, because it's not. There have actually been a lot of positive changes in my life as a direct result of my prolapse, believe it or not, but that's a post for another time. 

Prolapse can feel so isolating, and it's invisible to well-meaning strangers, friends, and relatives. You wouldn't tell someone with a cast on their leg to go for a run; there's no such marker for prolapse. I will talk about my pelvic floor with literally anyone, but most women aren't quite so comfortable - and that's ok! So how do you explain to your friend that you can't go for a run with her when you look fine? What do you tell people at the gym when they want to know why you're not lifting heavy anymore, when it was going so well? 

Every time a conversation like that happens a fresh wave of grief, anger, and bitterness sweeps over me. Sometimes it's just a ripple that passes through my mind and then it's gone and I'm fine. Other times it crashes into me and drags me down to the depths where I just want to scream THIS IS NOT FUCKING FAIR.

Because that's the hardest part. You can do everything "right" and still get prolapse. You can do everything "wrong" and be totally fine. But at the end of the day, if you have POP, you have it. Trying to dissect the causes and pinpoint exactly what caused it is unproductive, yet we still do it. You can get to the point where you're totally or almost completely asymptomatic -- that's me, most days -- but your awareness of it is always there to some extent.

And that's what I grieve -- the ability to take my pelvic floor for granted. 

 

What does it mean to be "pelvic floor-friendly"?

I may have mentioned the pelvic floor once or twice or a million times on this website and on my Facebook page. But how does that factor into our workouts?

What does it mean for a class to be "pelvic floor-friendly"?

It starts before you even walk in the door. I have all my moms fill out a detailed health questionnaire before coming to their first class so I have a lot of the information I need to make sure the workout is not only appropriately challenging, but also appropriate for whatever stage they may be in of pregnancy or the postpartum period.

These are questions you probably haven't been asked before by a personal trainer or group fitness instructor.

Do you have any bladder or bowel incontinence? Did you have a vaginal birth or a c-section? How old are your children? Are you currently breastfeeding?

There are all REALLY important questions and I write all my class workouts with these answers in mind.

A mom whose youngest child is five years old and who had a vaginal birth and no incontinence issues has different workout needs than a mom of a 5-month-old baby who experiences leaking every time she coughs or sneezes and is exclusively breastfeeding.

Are these personal questions? Yes. And I am so grateful for all the moms that trust me with this information. Because unless I know the honest answers, I'm not going to be able to help you work towards running without leaking, or whatever your goal may be.

What kinds of workouts can you do?

We mostly just sit around and take deep breaths while we stretch our hamstrings.

Kidding ;)

If you have any pelvic floor problems, whether it's leaking, pelvic organ prolapse, or anything else, you might think one of two things: 1) I can't do ANYTHING and the only kind of exercise I'll ever be able to do is walking, or 2) I already leak/have a prolapse, so it doesn't matter what I do. I'll just wear a pad or plan on surgery later.

There is a middle ground, I promise you.

It's really, really important that your first stop is not to my class, but to a pelvic floor physical therapist. I'm not a doctor or a physical therapist, I don't diagnose or treat anything, and obviously I'm not going to do an internal exam to figure out what, exactly, is going on with YOUR pelvic floor. That the job of your friendly neighborhood pelvic floor physical therapist.

But assuming that's all taken care of, I'm sure you're wondering what, exactly, a pelvic floor-friendly workout looks like.

stroller strong fitness for moms
stroller strong fitness for moms

And the answer is, it looks a lot like strength training. High impact exercise (running, jumping, etc.) is the primary culprit when it comes to bladder incontinence, but strength training takes those jarring movements out of the equation.

If you've never set foot in a weight room, I don't want you to freak out. No previous experience is required to join us at Stroller Strong. I will coach you through everything we do, and I'm not going to start you off with 200-pound deadlifts. Fear not -- this is a kind, supportive environment.

Moms doing bodyweight squats in a fitness class
Moms doing bodyweight squats in a fitness class

Strength training is SO GOOD for moms. You'll feel like a badass, and because we are also mindful of the pelvic floor while we lift weights, we're actually improving our pelvic floor function at the same time.

But what about cardio?

I can sense your panic. You love to sweat during a workout, and you don't feel like you've accomplished anything if your heart isn't racing when you're done. But if we're not running or jumping, how do we accomplish that in a pelvic floor-friendly framework?

Scroll back to the top of this post and check out that picture for just one answer. You see the sleds those mamas are pushing? If you think that won't get your heart-rate up, have I got a surprise for you!

Is anyone else concerned about the insufficient lighting in this facility? That just seems like an accident waiting to happen. I'm also sad to say that there will not be a fog machine at Stroller Strong.
Is anyone else concerned about the insufficient lighting in this facility? That just seems like an accident waiting to happen. I'm also sad to say that there will not be a fog machine at Stroller Strong.

We can also use battle ropes! There are few things as satisfying as the THWACK of the ropes on the floor, and trust me, you're gonna FEEL it. We can use one arm at a time, both arms, sitting on a box, standing, hang it from a squat rack and use it to pull ourselves up to standing -- for a single piece of equipment, we can do a lot of conditioning exercises with it.

Or if those aren't your cup of tea, how about medicine balls? Try to smash the ceiling (you won't, they're super high for a reason!) or knock your partner over as you use all the power in your body to fling that ball.

There's also an exercise bike. Full disclosure, I personally hate the bike. But if YOU like it that's cool and it's totally fine to use that to do some intervals!

My point is, WE HAVE OPTIONS. Sweating and improving our cardiovascular system is not the sole provenance of running.

Does that mean we're never going to run sprints or anything like that in class? No, it means that I take your personal needs into account, and if you are experiencing leaking when you run, I'm definitely not going to have you do sprints until that improves. Pushing through an exercise even when you're leaking is not going to help and your pelvic floor is not going to magically improve on its own.

Essentially I treat running and plyometric exercises (any kind of jumping movement, even something as basic as a jumping jack) as exercises that need to be earned. Remember how I said I wasn't going to start you off with a 200-lb deadlift?

Running sprints is essentially the same thing as a 200-lb deadlift for your pelvic floor. Just as we strengthen all the muscles that allow us to deadlift and gradually pick up more and more weight, we also gradually add in higher-impact exercises to be sure the pelvic floor can handle it.

Final answer: it depends

What it really comes down to is this: a pelvic floor-friendly workout is a little different for a mom with prolapse, vs. one with no prolapse or leaking but significant diastasis recti, vs. no pelvic floor issues at all. The beauty of strength training and finding alternatives to cardio other than running is that we can tweak a lot of different variables to make it work for YOU.

Links:More information about Stroller Strong Ready to give it a go? Schedule your free FITSTART session here!