Treatment for Prolapse
Welcome back, Bestie! I personally needed to get a refill of some instant coffee before moving on (and don't come for me—my partner and I don't really drink coffee aside from the occasional Saturday latte amiright, but my in-laws were in town and they asked us to grab some for them and now we have leftovers and I just can’t stand for anything to go to waste blah blah blah ok onward!). If you missed part one of this chat, find it here.
Let’s quickly review prolapse before we get into how it’s treated. Prolapse is the descent of any of the organs of the pelvis. These organs include the urinary bladder, the uterus (in folks with uteruses), the rectum, and the small bowel (also known as the small intestine).
Pelvic Organ Prolapse can be measured in a couple of different ways. First, your provider may give you a form to fill out that asks questions about how bothersome your symptoms are. Answering questions about how much your symptoms bother you will help your provider to understand how these symptoms affect you and how you view them. For the physical examination of a prolapse, there are many different options. You will likely experience different methods if you get measured at your gynecologist versus your physical therapist. Even so, the method used is valid and your provider will use the most appropriate test or measure for the setting you are in.
How is prolapse graded:
In physical therapy, your therapist will likely use a method that grades prolapse on a scale from no prolapse (grade 0) to a fourth degree prolapse (or grade 4 prolapse). If you’re interested in the actual grading scale, here you go: grade 0 describes no prolapse, grade 1 describes prolapse that is present but not visible at the vaginal opening, grade 2 describes prolapse at or approaching the vaginal opening, and grade 3 describes prolapse that is outside the vaginal opening, and grade 4 describes severe prolapse (such as in cases of procidentia).
Pelvic Organ Prolapse Grades/Stages
As mentioned, there are MANY different ways to grade prolapse; some scales are up to grade 3, others are up to grade 4; some are measured with sight/feel while others use an actual measuring device. Your provider should explain to you the severity of your prolapse and what means—if you are still confused, ask more questions and don’t be shy! We love when patients take an interest in their own anatomy and their own care and running to Dr. Google can sometimes do more harm than good.
Prolapse is measured while lying on your back or on a slight incline with knees bent and feet flat on the table. Once in this position, your provider will ask you to bear down as hard as you can, and this is when the measuring will occur. Don’t worry, measuring a prolapse is quick and should be a pain-free experience. If you notice pain during the experience, tell your provider because 1. they may be able to modify their approach and 2. they can help you with your pain! Please note that this is not a perfect measuring system, and your provider recognizes that. Measuring POP while on your back (a position in which prolapse is typically not bothersome) and while performing maximum Valsalva (an activity you may not even typically do once during your day) does not always give the most practical information about the prolapse during your regular activities. It does, however, provide us with an accurate way to assess prolapse systematically and get, at the very least, a baseline measurement.
Hooklying Position
The reason prolapse is so often assessed this way is because it is based on how this assessment is performed in the available research and, in research, patients must be assessed in the same way in order to avoid variation of technique. In many cases, when a patient mentions that they only notice their prolapse while standing up, or while carrying their newborn, etc, your therapist will make an effort to assess your prolapse in a simulation of that activity. I’ve done many a standing prolapse assessment, and while it requires notably more contortionism from me, it provides valuable insight into the descent of the organ in the position that is most bothersome to the patient.
Treatment for prolapse:
Okay, now onto the fun part and probably what you've been waiting for. How is prolapse treated? There are tons of treatment options for prolapse and the treatment that works for you will depend on your particular situation. Let’s start with physical therapy because, of course I’m biased, but also because it is a first-line treatment for POP.
If you’re experiencing POP, a good place to start is in physical therapy. POP often occurs because the support of the pelvic organs is impaired. This could be related to the non-contractile structures like your ligaments or your contractile structures like your muscles. If your pelvic floor muscles are weak, strengthening them could help with POP. Studies show that pelvic floor muscle training helps to improve prolapses of grades 1 and 2 and should be the first line of treatment (1,2).
If you are having difficulty emptying your rectum or bladder due to your prolapse, your therapist will be able to teach you positions that can help. For example, if your bladder isn’t emptying, sometimes moving forward, backward, and side-to-side can help get that last little bit of wee out. If you’re having a hard time completely defecating, using a squatty potty or similar stool can make it easier.
Your therapist might also recommend splinting. Ok—what? I didn’t break my arm, why in the world would I need splinting? Thanks for the solid question—this is a totally different kind of splinting! The term “splinting” in this case refers to a manual maneuver used to help empty the bladder or rectum. One uses their hand or fingers to provide support to the organs of the pelvis, which is where the term comes from. By pushing on the area in front of the anus, the prolapse can be reduced, which can help with complete defecation. Finally, your therapist will be able to talk with you about lifting techniques, avoiding the Valsalva maneuver during activity, and how to reduce constipation. If needed, you may be referred to a dietitian. Constipation and chronic pushing can cause prolapse to worsen, so this is an important part of any treatment plan.
Ring Pessary with Support
Another option is a pessary. Pessaries are devices that are inserted into the vagina. They have all sorts of functions, but one of the potential functions is reducing prolapse. The ring pessary with support can provide that necessary support to the pelvic organs and help to keep them in place. This is a good option if pelvic floor strengthening hasn’t been enough to eliminate symptoms, if you don’t want surgery, or if your prolapse is higher than grade 2 (3,4,5).
A more aggressive and invasive option for prolapse management is surgery. Folks with apical prolapses (prolapsed uteruses) may opt to get a hysterectomy to resolve the issue of uterine prolapse. Other procedures also exist for reducing anterior and posterior prolapse, as well as rectal prolapse. This can be a good option if you have had minimal success with more conservative methods of treatment, or if your symptoms of prolapse are severe. Note that even if you end up taking the surgical route, studies show that previously working on pelvic floor muscle training is still beneficial and can help with recovery after surgery (6). After surgery, you may also want to return to pelvic health physical therapy. Talk with your doctor about what is the most appropriate treatment pathway for you.
This may have been our first chat about prolapse, but it won’t be our last. I can’t stress enough how many folks suffer from prolapse and how few seek treatment. If you are experiencing any of the things we talked about today, please know you are not alone and you can get help!
Let’s talk soon,
XOXO, Your Pelvic Bestie
References:
1. Hagen S, Stark D. Conservative prevention and management of pelvic organ prolapse in women. Cochrane Database Syst Rev. 2011 Dec 7;(12):CD003882.
2. Bø K. Pelvic floor muscle training in treatment of female stress urinary incontinence, pelvic organ prolapse and sexual dysfunction. World J Urol. 2012 Aug;30(4):437-43.
3. Brazell HD, Patel M, O'Sullivan DM, Mellen C, LaSala CA. The impact of pessary use on bowel symptoms: one-year outcomes. Female Pelvic Med Reconstr Surg. 2014 Mar-Apr;20(2):95-8.
4. Lamers BH, Broekman BM, Milani AL. Pessary treatment for pelvic organ prolapse and health-related quality of life: a review. Int Urogynecol J. 2011 Jun;22(6):637-44.
5. Patel MS, Mellen C, O'Sullivan DM, Lasala CA. Pessary use and impact on quality of life and body image. Female Pelvic Med Reconstr Surg. 2011 Nov;17(6):298-301.
6. Culligan PJ. Nonsurgical management of pelvic organ prolapse. Obstet Gynecol. 2012 Apr;119(4):852-60.
*The information contained in this article is for educational and informational purposes only and is not intended as health or medical advice. Always consult a qualified health provider regarding any questions you may have about a medical condition or health objectives.
