Pelvic organ prolapse: physiotherapy strategies for management and symptom relief

In an interview with HT Lifestyle, Richa Bathla, lactation consultant and women’s health physiotherapist at Cloudnine Group of Hospitals, Faridabad, explained that there are several factors that weaken the pelvic floor and increase the chances of developing pelvic organ prolapse –

• being overweight
• History of hysterectomy
• going through the menopause phase
• Multiple vaginal delivery, carrying twins or triplets
• Long-term pressure in the abdominal cavity such as chronic coughing, chronic constipation, and heavy weight lifting increases the risk of developing POP.
• family history of POP
• Collagen irregularities such as Ehlers Danlos syndrome in which the connective tissue of the pelvic floor weakens, leading to pelvic organ prolapse.

Different Types of Prolapse,

According to Richa Bathla, the type of prolapse depends on the weakness of the pelvic floor and the organs affected.

• Prolapse of the anterior vaginal wall (dropping of the bladder) – This is caused by weakening of the pelvic floor muscles above the vagina, causing the bladder to slip out of its place and bulge into the vagina. This prolapse of the vaginal wall is the most common type of POP, also known as cystocele.
• uterine prolapse – This is due to weakening of the pelvic floor muscles, causing the uterus to drop into the vaginal tube.
• Prolapse of the posterior wall of the vagina (dropped rectum) – this is caused by weakening of the pelvic floor muscles between the vagina and rectum, causing the rectum to bulge into the back wall of the vagina. This type of prolapse is known as a rectocele.
• Vaginal vault prolapse – This basically occurs after a hysterectomy when the uterus is removed and the upper part of the vagina drops into the vaginal canal.
• Enterocele – This is due to weakening of the pelvic muscles, causing the small intestine to bulge up into the vagina.

symptoms,

Uterine prolapse is the most common condition after childbirth. Richa Bathla explains that the symptoms of uterine prolapse are –

• Feeling of heaviness in the pelvis
• Feeling of tissue protruding from the vagina.
• uncontrollable leakage of urine (incontinence)
• discomfort in the pelvis or lower back
• Sexual concerns-Feeling as if vaginal tissue has become loose.
• Constant urge to urinate even when the bladder is empty.

“Other symptoms include a feeling of heaviness, bulge inside or outside the vagina, lower back pain, pain during intercourse (dyspareunia), bladder and/or bowel problems such as a feeling of incomplete emptying after urination,” he added.

Diagnosis and assessment,

Richa Bathla explains, “The diagnosis of POP begins with a medical history and examination of the pelvic organs, which helps the healthcare professional to determine the type of prolapse the person has. There are a few tests that are done to detect POP. These include a pelvic floor strength test (healthcare professionals test the strength of the pelvic floor and sphincter muscles during a pelvic examination) and a bladder function test (this measures how well the bladder empties and also whether the bladder leaks during a pelvic examination).” She elaborates –

Pelvic Examination: In case of urinary incontinence the patient needs to be examined with a full bladder and the patient is asked to cough or strain and leakage of urine confirms a positive stress stimulation test. Examination can be done in lithotomy position if any bulge is visible in the vagina. In standing, dorsal position, transvaginal and rectal vaginal examination can be done if there is prolapse of the vaginal wall and uterus.

assessment: Depending on the presence of symptoms and the severity of the prolapse, various tests are included such as-

• Urological ultrasound to assess bladder emptying.
• Urodynamic studies to investigate obstruction related to prolapse, bladder function and severity of urinary incontinence.
• A trial of a vaginal pessary was done to test whether the prolapse could be corrected.

Grading of prolapse:

• first degree: The lowest part of the prolapse is located above the introitus (the opening to the vagina).
• second degree: When straining, the lowest part of the prolapse extends to the level of the introitus.
• Third degree: The lowest part of the prolapse extends through the introitus to outside the vagina.

Pelvic Organ Prolapse Treatment:

According to Richa Bathla, conservative treatment involves –

• Pelvic floor exercises,
• drink plenty of fluids And eat high-fiber foods like fruits, vegetables, and whole grains to prevent constipation.
• Avoid lifting heavy weights– While lifting weights, one must take care of posture.
• maintain weight By following a healthy lifestyle and diet.
• quit smoking
• Strengthen and retrain your pelvic floor muscles To support the pelvic organs.
• Posture movement– Advise on correct posture and gait to prevent strain on the pelvic floor muscles. Avoid standing for long periods of time and try to take frequent breaks.
• Bowel retraining– Training to have a bowel movement without straining the pelvic floor muscles.
• try low-impact exercises Do exercises like Pilates, yoga, swimming, walking and cycling. High impact exercises like jumping and running should be avoided.
• Vaginal Pessary Can be used.
• Stomach or abdominal massage Helps improve the natural movement of the bowel.
• Holding technique for patients with an urgent need to defecate

On the other hand, surgical treatment depends on the type and degree of prolapse. It includes-

• Mesh repair-It is indicated to support the pelvic floor in cases of severe prolapse, to prevent its recurrence.
• Pelvic floor repairIf the urethra, bladder, rectum, or bowel protrudes through the vaginal wall, the pelvic floor will be repaired and strengthened with stitches to correct the prolapse.
• Vaginal Hysterectomy-This is done when the uterus protrudes out of the vaginal opening.
• Sacrospinous ligament fixation, This is done in cases of severe uterine prolapse and to reduce the chances of recurrence of the prolapse.

Impact of POP on women’s lives:

• Patients suffer from anxiety and depression, isolation in relationships, disturbed sleep patterns, increased stress and low self-esteem.
• Patients feel lonely when suffering from prolapse. This creates an embarrassing situation among friends, family, and partners. It has been observed that patients experiencing incontinence face a lot of anxiety while traveling as they are always worried about toilet access, which makes them restrict themselves to a certain space, restricting social interactions and even short trips, resulting in a loss of confidence.
• Emotional stress is increased due to personal hygiene issues, such as foul smell from urine or faeces and fear of soiling clothes in public places.
• POP can affect the most intimate parts of our body, thereby affecting sexual relationships. The fear of being accepted and understood by a sexual partner can cause anxiety.

According to some studies, pelvic muscle weakness may contribute to a woman’s inability to achieve orgasm, and women who have anorgasmia have significantly less pubococcygeus muscle strength than women who can achieve orgasm.