THE ULTIMATE BEGINNER'S GUIDE TO PROLAPSE

By: Dr. Brianne Grogan, PT, DPT

Are you dealing with prolapse symptoms? Prolapse is a shift in organ position. Pelvic organ prolapse can lead to feeling a heaviness in your pelvic floor, urinary issues, and uncomfortable sex. I wrote the Beginner's Guide to Prolapse so that you can educate yourself about prolapse, and see rays of hope for relief and recovery! I resolved my own prolapse symptoms, and as a Doctor of Physical Therapy, I have helped thousands of women do the same. Let's get started.

DO YOU HAVE  PROLAPSE?

If so, you’re not alone. 50% of women who’ve given birth have some degree of pelvic organ prolapse (POP), and even women who’ve never been pregnant can develop the condition. POP is more common than you might think, and sadly, it’s under-discussed, under-recognized, and often passed off as something you “just have to live with.”

Spoiler alert: It’s NOT something you "just have to live with!" There are things you can do to help.

My Story

Three weeks after giving birth I made a mistake that changed my entire life. As a brand new, first-time mom I was emotional, exhausted, and anxious to get back to my “normal” routine. I laced up my running shoes and hit the pavement. Needless to say, my three-week postpartum body wasn’t ready for the stress and strain of a high-impact sport. A few minutes into my run, I felt something drop in my pelvic area. In that instant, I developed a mild bladder prolapse.

That’s the bad news. The good news is that with time and specific exercises and lifestyle changes, I was able to completely resolve my prolapse symptoms. Eighteen years later, I still maintain great pelvic health AND I teach my favorite tools and techniques to a global community of women with POP.

Prolapse changed my life, and now I use my personal healing journey to provide hope and help to other women who are scared and suffering in silence! If you have (or suspect you have) POP, please don’t despair; there’s so much you can do to relieve your symptoms naturally — without surgery — and I want to show you some tools right now.

WHAT IS PROLAPSE?

Knowledge is power and pelvic health is something that EVERY WOMAN should strive to understand! However, I also want to make clear that while self-exploration is important, you should always get confirmation of your self-diagnosis from a trusted healthcare provider. I recommend seeing a pelvic floor specialist in person. Look for a physical or occupational therapist in your area who specializes in pelvic health, and schedule an assessment.

That said, let’s discuss POP: what it is and how to know if you have it.

POP is a disruption (a shift) in organ position. With prolapse, one or more pelvic organs descend from their normal position, causing discomfort and/or a sensation of heaviness or bulging. POP can occur due to laxity in the connective tissues that hold the organ(s) in place, or due to lack of support from the pelvic floor muscles and fascia.

But please understand: POP isn’t just an issue of “saggy” or weak pelvic floor muscles!

Although pelvic floor weakness is typically involved, sometimes these weak pelvic floor muscles are actually too tight. "Tight" does not mean "strong!" Therefore, Kegel exercises aren't always the best place to start if you have prolapse. (Keep reading for more tips about natural prolapse relief.)

POP is generally due to dysfunctional patterns of muscular tension, scar tissue, and/or problems with intra-abdominal pressure management from years of poor posture, improper lifting, chronic coughing, pushing to pee, or straining to poo. These habitual ways of moving and living can cause (and perpetuate) pelvic organ shifts.

Physical symptoms for women with prolapse:

• heaviness in the pelvis or feeling like something is "stuck" in the vagina
• feeling or seeing a bulge in the vagina
• gut issues; troubles with constipation or difficulty having a BM
• urinary urgency or frequency, and sometimes bladder leakage
• low back or pelvic pain, and fatigue that worsens as the day goes on

THE MISSING LINK THAT’S RARELY ADDRESSED

Prolapse symptoms impact both the mind and the body. Excess pelvic muscle tension can occur because of a desire to grip and "hold in" the shifted organs, to "hold in" urine (due to worry about bladder leakage), and due to anxiety or emotional strain.

FEAR is the common denominator! The fear of things "falling out" causes the body to go into a protective brace mode of tension. 

Common emotional symptoms for women with prolapse:

• fear of moving wrong, exercising wrong, etc. (fear of making their POP worse)
• fear that it won't ever get better, and they'll never be able to return to their active life
• body image issues
• feelings of shame and/or embarrassment
• anger or betrayal that this has happened to their body
• feeling isolated like there's no one to talk to or that no one understands

All of the above-listed emotions can cause TENSION in the pelvic floor muscles. This tension is amplified if you're chronically stressed due to financial concerns, family concerns, career concerns (etc.), and it can also be compounded if you experience chronic muscle guarding from a history of trauma or abuse (for example, a history of sexual assault).

A huge part of POP symptoms is too much pelvic tension. If you're stressed and hold excessive tension in your pelvic area, it can make prolapse feel worse. Many of my clients feel so much better when they learn how to relax their pelvic floor. 

The mind-body connection is a genuine thing, and it contributes to how you EXPERIENCE your prolapse symptoms. The mind and body are in constant communication, and your brain's job is to interpret the sensations that come from your body. When your brain interprets the sensations of prolapse as a threat, or as warning signs of pain, danger, and "oh my goodness my life is over, I'll never get better, scary-scary-scary" (I think you get my drift!!!)... when your brain interprets the sensations of your prolapse in this way, it creates "alarm bells" of fear that make your POP symptoms feel worse.

Fear puts your body in "brace mode," which causes muscle tension. When the pelvic floor muscles tense up, they squeeze around the shifted organs and pull on the connective tissues surrounding them, making the prolapse feel worse. 

It's essential to do your body-based work — go to your pelvic floor physical therapist, do the exercises and lifestyle changes recommended in my Lift program, etc. — but focus on your thoughts and emotions as well.

Calm your mind via presence practices such as slow, deep breathing or guided meditations to relieve stress and reduce pelvic tension. I include an 11-minute guided meditation in my FREE Kickstart! For maximum results, do this with your hips elevated (keep reading for more about hips-up time)!

Also, redirect your attention (your mind) away from fear-based thoughts about POP, and toward more hope-filled thoughts. Better yet, direct your mind toward thoughts entirely unrelated to POP! You are so much more than your pelvic floor. People can become so wrapped up in their prolapse diagnosis that it can become part of their identity, but it's possible to disentangle yourself, and it is incredibly helpful. What did you enjoy thinking about or doing before developing POP? Do more of that.

I also encourage people to stop checking their prolapse multiple times per day. Constant checking keeps your brain in a state of fear and hypervigilance. So put down the mirror, stop checking, and start living!

Often women have never even heard of prolapse until they feel like “things feel different down there.” As mentioned above, developing prolapse after childbirth is very common. What is alarming is the lack of awareness about this common concern, the lack of support for women, and the lack of dialogue between healthcare professionals and their patients. Pelvic health is a taboo subject in society (and in some cases, even within the healthcare system), and it’s abhorrent that pelvic floor care isn’t “standard procedure” for women, like routine dental care or annual physical check-ups. Women all over the world suffer for YEARS — even their whole adult life — with bladder leakage or pelvic organ prolapse. This should not be the case. You need support physically and emotionally to healthfully understand the changes that occur and how to live a confident lifestyle when you have POP.

But keep reading, because there is help for prolapse. YES, you CAN reverse symptoms! Don’t give up hope!

TYPES OF PROLAPSE

These are the major types of POP that affect women. Cyctocele is the most common, and it also seems to be the most easily treatable! However, please know that ALL types of prolapse can be successfully treated. You do not have to live with heavy, bulging sensations forever.

• Cystocele: bladder descends and pushes into the anterior (front) vaginal wall
• Urethrocele: the urethra presses into the anterior vaginal wall and the urethral opening may protrude
• Cystourethrocele: both the cystocele and urethrocele occur together
• Rectocele: rectum descends and pushes into the posterior (back) vaginal wall
• Rectal Prolapse: the rectum droops and protrudes through the anus (note that rectocele is more common than rectal prolapse)
• Enterocele: the small intestine descends into the area between the vagina and the rectum, pushing into the upper wall of the vagina
• Uterine prolapse: the uterus descends and the cervix is more clearly seen/felt
• Vaginal vault prolapse: the top of the vagina descends down into the vaginal canal (this can occur after hysterectomy)
• Descending Perineum Syndrome: the perineum (area between the vagina and the anus) sinks below its normal position

STAGES OF PELVIC ORGAN PROLAPSE

The following staging system (called the POP-Q) is commonly used by gynecologists, and offers a simple strategy to “grade” a person’s level of POP.

• Stage 0 = no prolapse
• Stage 1 = bottom portion of the prolapse is more than 1 cm above the level of the hymen (it protrudes into the vaginal canal, but the bulge is not at the entrance of the vagina)
• Stage 2 = bottom portion of the prolapse is less than 1 cm above or below the level of the hymen (it reaches the opening of the vagina)
• Stage 3 = bottom portion of the prolapse is more than 1 cm below the plane of the hymen (the bulge protrudes outside of the vaginal opening)
• Stage 4 = vaginal eversion is essentially complete

*Stages 1 and 2 are considered mild to moderate. These stages are often TREATABLE without surgical intervention! Here are three studies with outcomes that suggest that conservative management is worth considering if the prolapse is mild to moderate: Study One, Study Two, and Study Three.

Physical Examination Technique to Determine Stage

While exams are often done lying down in supine, a standing exam is ideal to confirm the full extent of prolapse since standing is a functional position in which we (humans) spend most of our normal daily lives. Don't just test on an exam table. Stand!!!

The best part? You can try this at home, on your own.

• Empty your bladder
• Stand with feet apart, and knees softly bent (option: stand with one foot up on a stepstool)
• Separate your labia (the "lips" that surround your vaginal opening) and hold a handheld mirror under your vagina
• What do you see? Take note if you see a bulge (refer to the staging system above).
• Gently bear down, and observe. Your perineum should slightly descend, but you should not see a bulge. Refer to the staging system above, if you see a bulge.
• Try coughing a few times, and observe. Ultimately, your pelvic floor muscles should reflexively/automatically contract to prepare for the cough. If they do not reflexively contract, then you might experience and/or see a bulge. Refer to the staging system above.
• Gently insert 1-2 finger(s) into your vagina. What do you feel? Take note. Is the bulge/movement coming from the anterior/front vaginal wall, or the posterior/back vaginal wall? Or from the top? Try gently bearing down, and observe. Then try coughing, and observe.

*Note: you can also examine yourself while sitting on a toilet, or while sitting on the edge of a bathtub or the edge of a bench. In my personal opinion this is a "step up" from a supine examination (i.e. an exam done lying on your back).

WHAT TO DO IF YOU HAVE PROLAPSE

As noted above, stages 1 and 2 prolapse are considered mild to moderate. These stages are often TREATABLE using conservative management!

Conservative management includes exercises and simple lifestyle techniques such as those found in my Lift program. You can also ask your doctor for a pessary fitting. Pessaries are silicone rings inserted into the vagina to help address a prolapse; they’ve been referred to as a “sports bra for your vagina,” and have been life-changing for many women.

Surgery is typically required to correct more advanced stages of prolapse (i.e. stage 3 and 4). Surgery might be indicated (for various reasons) at earlier stages; however, it's not an ideal first line of defense. There's always risk involved in surgery, and the rate of surgical failure (or need for re-operation) for prolapse is high.

If you're diagnosed with a grade 1 or 2 prolapse, then I encourage you to explore conservative options first. Even if your doctor recommends surgery, consider asking for a trial of conservative treatment before making the surgery decision.

If you have more advanced prolapse that requires surgery, you can still benefit from conservative treatment (exercise and lifestyle changes). When you go into surgery with improved pelvic awareness, more muscular strength and control, and knowledge of how to live a pelvic floor-safe life, you will be better prepared to go into surgery. You'll also have better results post-op.

The take-home message: Reversing symptoms of stages 1 and 2 prolapse is possible, and preventing progression of prolapse is always possible… no matter how advanced it is! Follow my "Lift" video series, and seek guidance from a pelvic health expert who can provide a physical examination to best determine your condition.

DAILY PRACTICES TO RELIEVE PROLAPSE

10 Minutes of Pelvic + Core Friendly Movement

It’s important to keep moving when you have POP. Don’t let fear of your condition derail you from your health and mobility! Avoid high-impact activities and heavy weight lifting (for now), but continue to move your body throughout the day. Start with just 10-15 minutes at a time. Maintain your cardiovascular fitness by walking or doing other forms of low-impact exercise, and — in general — keep enjoying your life. I recommend “priming” your pelvic floor and core with a few minutes of core-focused movement each day, preferably in the morning. Wake up your muscles and set yourself up for success. My Lift program is perfect for this! 

Eat a Clean, Anti-Inflammatory Diet

What you eat impacts your energy level and your digestion, both of which impact your pelvic health. Fuel your body with healthy, whole foods with a focus on fiber, lean protein, and healthy fats to stay energized and motivated so that you can heal!

Avoid processed foods and any foods to which you are sensitive. Many people experience bloating when they consume sugar, and/or constipation when they consume dairy. Bloating and constipation can make your prolapse symptoms worse. To combat these concerns, drink plenty of water and load up on fruits and veggies.

A Mind-Body Practice (Meditation or Other Options)

This might surprise you, but your biggest problem is not your prolapse…. It’s your thoughts about your prolapse! Your mindset can hurt you, or it can help you. When your mind is racing, tense, and anxious about your prolapse, your brain sends signals to your body that create tension in your pelvic floor muscles. Your pelvic floor then squeezes around your shifted pelvic organ(s), making symptoms worse. To get to the root of this problem, spend time every day calming your mind and your body. Adopting a daily mind-body practice such as meditation (or even just a few minutes of hips-up time, see next step) is essential when it comes to prolapse relief.

I include an 11-Minute Guided Meditation for Pelvic Healing in my free Lift Kickstart, check it out!

Hips-Up Time

Hips-up time is a simple tool that you can use EVERY DAY to help relieve pressure on your pelvic floor and allow your muscles to relax and rejuvenate. You'll need a pillow (or two) or a yoga block. Place the prop under your sacrum (the back of your pelvis), and relax. Gravity does the work of pulling your pelvic organs back into ideal alignment, and your pelvic floor muscles get a chance to unwind!

I recommend 3-5 minutes of hips-up time daily to relax your mind and body. Avoid doing the hips-up position after a big meal, as post-meal inversions can cause heartburn and gastric upset.

Hips-up time during your period is a personal preference. From a physiological standpoint, it won't harm you to do a few minutes of hips-up time while menstruating; however, many women (including myself) prefer to avoid inversions while bleeding. I like to "let it flow" during that time of the month, and inversions prevent that. I skip hips-up and lie on my back for a few minutes in the afternoon, during my period. You still get the benefits of rest and some relief on your tired pelvic floor!

For hips-up time during pregnancy, use caution. At around 20 weeks of pregnancy, when you lie on your back for extended periods, the weight of your uterus can compress a major blood vessel called the vena cava. This disrupts blood flow to your baby and can leave you feeling nauseated, dizzy, and short of breath. Therefore, you need to be aware of the possibility of compression. It's usually fine to do hips-up time for a bit, but it might be uncomfortable — and possibly even unsafe — for more extended periods. I typically counsel pregnant women to spend most of their relaxing time in side-lying, ultimately with a pillow between the knees.

THINGS TO AVOID IF YOU HAVE PROLAPSE

• Poor posture (i.e. slouching/slumping when sitting, standing, or walking)
• Sitting or standing with your bum tucked under and your butt muscles clenched
• Wearing restrictive clothing, belts, or belly bands that pinch around your middle
• Holding your breath throughout the day due to stress/anxiety
• Holding your breath while exercising or lifting objects (instead of holding your breath, remember this simple trick: exhale with exertion)
• Pushing to pee or poo – do your best to stay regular and avoid constipation
• Smoking – you must stop smoking if you have prolapse! Anything that causes or exacerbates a chronic cough will make prolapse worse

LIFESTYLE CHANGES FOR A HEALTHY PELVIC FLOOR

How to Lift Safely with Prolapse

Learn to lift properly to protect your back and pelvic floor FOR LIFE! This is essential and something that I wish every child would learn in school. Learn it for yourself, and then teach your kids (or grandkids) to make the world healthier and stronger.

The keys to safe lifting are to get close to the item you’re lifting, engage your pelvic floor first, and exhale with exertion.

I explain safe lifting in detail in my complete Lift program!

How to Breathe

We take 17,000-20,000 breaths each day... make them count! Every breath is an opportunity to calm your mind, massage your digestive system, and mobilize (and strengthen) your core + pelvic floor.

Tips: Bring your breath down into your ribs, belly, and back... and don't try too hard! Many clients try super hard to "get it right," and then deep breathing feels like a struggle (and causes more stress and tension). Instead, "try SOFTER." Soften your ribs and belly, gently expand to inhale, then slowly exhale and feel your ribs glide in. 

I explain core breathing in my complete Lift program.

How to Exercise if You Have Prolapse

• Keep moving every day! Prolapse is NOT a reason to stop exercising, although you might need to modify your regular activities while regaining core strength and control.
• Low-impact exercise (staying within a symptom-free zone) is recommended at first.
• Prime your core muscles with 10 minutes of pelvic floor-friendly movement each day (see “Daily Practices,” above).
• Avoid most heavy weight lifting... for now!*
• Avoid high-impact activities/sports... for now!*
• Avoid abdominal crunches and sit-ups… for now!*

*This is just “for now.” You can gradually re-introduce many sports successfully as you gain strength, control, and learn how to manage your intra-abdominal pressure.

My Lift for Prolapse Relief program covers all of these topics (and more) in depth. Get started with it here, for FREE!

CONCLUSION AND PROGNOSIS

The best way to discover YOUR personal needs and staging is to self-evaluate (so that you KNOW YOURSELF) and then to FOLLOW UP with a women's health provider. If you think you have prolapse, schedule a consultation with your local gynecologist or with a women’s health PT. Your provider will give you a solid diagnosis (including exactly how far advanced your prolapse is) and can provide you with personalized recommendations regarding the next best steps.

There is SO MUCH you can do conservatively (i.e., through exercise and lifestyle) to help manage your symptoms — and to prevent things from getting worse — if you have prolapse! My "Lift" series is a great place to start, particularly when coupled with an individualized treatment program from a women's health PT. 

Last words of caution/advice:

Just like every person is different, so is every HEALTHCARE PROVIDER. If you are unsatisfied with the evaluation or examination you receive from one provider, don't be afraid to seek a second opinion.

Advocate for yourself! If you feel like something is "off" in your body, then LISTEN. If you feel blown off by a provider who says your prolapse is "normal" and just something you have to live with, then find someone else who can help.

If your provider says surgery is the only option but you think you can heal yourself naturally, then TRUST YOURSELF. It's at least worth trying! Many women have resolved their prolapse symptoms with conservative treatment, and there is hope for you, too.

Sending light and love… And don’t forget to grab your first week of Lift for FREE!!!