What is Vaginal Prolapse?
Usually our pelvic organs (bladder, uterus and bowel) are supported by a hammock of connective tissue and muscles. If this support system isn’t working as it should, it can lead to one or more of these organs descending into the vagina, which is called a ‘vaginal prolapse’.
A prolapse can be categorized into different types – a front (or anterior) wall prolapse, which is the bladder or urethra coming down, a back (or posterior) wall prolapse, which is the rectum or small bowel coming down, or a uterine prolapse, which is the womb dropping down. It is still possible for the top of the vagina to drop down if someone has had a hysterectomy.
It often seems to be assumed that it’s the uterus that most commonly drops down, but actually the front wall of the vagina is the most common type of prolapse to occur.
Prolapses can also be divided into ‘stages’, depending on how far down the lowest part descends when you do a maximal downward strain:
- A stage 1 prolapse means that the lowest part of the wall/organ is still more than 1cm inside the vagina
- A stage 2 prolapse means that the lowest part of the wall/organ is between 1cm inside and 1cm outside the vaginal opening. This stage of prolapse, when the organ descends to the opening, is often when women become aware of their prolapse for the first time.
- A stage 3 prolapse means that the lowest part of the wall/organ is more than 1cm outside the vaginal opening
- A stage 4 prolapse means that essentially the whole organ has come outside the body – this is relatively rare.
How do I know if I have a Vaginal Prolapse?
The symptoms of a vaginal prolapse are different in everyone, and it’s important to note that sometimes people with mild to moderate prolapses don’t have any symptoms.
The most common symptoms are:
- A bulging sensation (or being able to see a bulge) or a feeling of ‘something being there’ in the vagina
- A feeling of not being able to completely empty the bladder or the bowel (usually because the prolapse is causing a sort of ‘pocketing’ making it difficult to evacuate).
- Lower back or lower abdominal ‘dragging’ pain
Sometimes women can complain of a ‘heaviness’ or ‘pressure’, but this needs to be confirmed on diagnosis as this can also be a symptom of over-worked, tired pelvic floor muscles.
Sometimes prolapse can be associated with discomfort with sex, and sometimes with bladder or bowel leakage, but again – this isn’t always the case and should be confirmed on a physical examination, because there are many people who have these symptoms without having a prolapse.
The health professionals who work specifically in the area of Women’s Health are best placed to make this diagnosis – gynaecologists, Women’s Health & Continence Physiotherapists, or Continence Nurses. However, your GP is a good place to start and many GP’s will have a vast degree of experience in diagnosing and staging prolapses, and can then refer on to one of the aforementioned professionals for further management.
How common is a Vaginal Prolapse?
Unfortunately, it’s very common for women to experience vaginal prolapse, mainly due to our anatomy. We are animals that stand upright, and have a large proportion of our body weight going through our pelvis, but we also need a wide pelvic opening to be able to birth very large offspring through!
That mix of a large pelvic opening with a heavy load on top of it is unfortunately not ideal for supporting pelvic organs.
Studies have shown that up to 50% of women who have given birth will have some degree of prolapse, with other research showing that 1 in 3 women will have a prolapse that extends at or beyond the vaginal entrance (ie a stage 2 or more prolapse).
Unfortunately, there is a high proportion of women who will require surgery for either prolapse or stress urinary incontinence. Statistics show that 1 in 9 women will undergo one of these surgeries, which are not without risks and have relatively high recurrence rates.
What factors increase your risk of Vaginal Prolapse?
The main risk factor for prolapse is having had one or more vaginal births, with specific risk factors including:
- Forceps deliveries
- Giving birth to a baby over 4kg (9 pounds)
Prolapse is not limited to only those who have delivered babies vaginally, however, with other risk factors including:
- Family history of prolapse
- Increasing age
- Increasing BMI
- Chronic Cough
- Heavy lifting
The main reason that pregnancy and vaginal childbirth are risk factors is because of their effect on what is called the ‘levator hiatus’. This is the name for the space in the pelvis between the two sides of the pelvic floor, and is essentially ‘the gap into which things can fall’.
Studies on women who have recently given birth show that this ‘gap’ in usually increased from normal for up to 4-12 months after having a baby. This is one of the main things that Women’s Health Physiotherapists will assess for when doing a vaginal examination at a postnatal assessment, because it helps to determine your individual risk for prolapse occurring or worsening with return to higher load or impact activities.
This ‘gap’ would be increased more significantly, and more permanently, if the woman experienced a birth injury called a ‘levator avulsion’. This means one or both sides of the pelvic floor muscle having a partial or full tear away from the pelvis bone. This can also be assessed for with a vaginal examination.
How is Vaginal Prolapse managed without surgery?
Pelvic Floor Muscle training, under the guidance of a physiotherapist with post graduate qualifications, is recommended as the first line of treatment for vaginal prolapse.
We probably assume that this training is all about improving the strength of the pelvic floor muscles (measured out of 5), but studies have shown only a minimal link between a woman’s maximal squeeze pressure improving and prolapse improving.
This makes sense, because a vaginal prolapse needs to be supported all throughout the day while you’re in an upright position, but we probably only maximally squeeze our pelvic floor muscles for 1% of the day – at times like in response to a big sneeze or lifting something that’s heavy.
Instead, it is more likely that pelvic floor muscle training helps to decrease prolapse signs and symptoms because it improves the ‘stiffness’ and support of the area, and it decreases the ‘gap into which things can fall’ (the levator hiatus) both at rest and under load.
Other management strategies would include:
- Teaching women how to empty their bladder and bowels effectively and without straining
- Determining if symptoms can be improved by incorporating rest periods in ‘anti-gravity’ positions throughout the day
- Weight loss
- Exercise modification
- Use of support pessaries
What is a Vaginal Support Pessary?
Vaginal pessaries are devices worn inside the vagina that help to give support to the vaginal walls. If fit properly, they should give symptom relief, be comfortable and should stop a prolapse from descending.
They can be a huge help for women with prolapse who wish to remain active or become more active. Pelvic Floor Muscle Training, while essential in the overall management of prolapse, can take a long time for symptoms to improve. Pessaries could be used in a ‘stop gap’ role to prevent further descent, and possibly give feedback on what types of things cause descent to occur, while concurrently working on pelvic floor training.
What exercise should I avoid if I have a Vaginal Prolapse?
Now this is an interesting one… and if you’re after a list of Do’s and Do Not’s, I’m sorry… it’s not coming from me!
Let’s start with what the recommendations are for exercise for general health. The Australian Government’s “Physical Activity Guidelines for Adults” states that we should participate in:
- >150 minutes of moderate intensity activity/week
- OR 75 minutes of vigorous activity/week (or a mixture)
- >2 days/week
- >1 set of 8-12 reps per area
- Maximum health benefits are gained when you would struggle to do another set
And recommendations for Bone Density and prevention/management of Osteoporosis:
- Regularly doing a combination of resistance training and moderate to high impact weight-bearing activities
But historically (and I’m not talking that far in the past either) the recommendations for anyone diagnosed with, or at risk of, vaginal prolapse were:
- Minimise weights
- Keep all exercise low impact
But although well-intentioned, how evidence-based was this blanket recommendation? And by giving this advice, are we compromising overall health (in particular our heart and bones) for the health of the vagina?
Recent studies have looked a lot more into the pressures created in the abdomen, and more specifically in the vagina, during different types of exercise and although we can extrapolate some general information, the main message that comes out is “It’s not what you do, it’s how you do it”.
If you give the same exercise to a variety of different women, then their individual anatomy, injuries, technique etc will mean that the way they perform that exercise results in a wide variety of different effects to their pelvic floor muscles and vaginal walls.
It’s highly recommended that in order to tell a woman what exercise they should and shouldn’t do, we should understand:
- Their individual risk profile for prolapse occurring or worsening
- Whether a certain exercise is likely to be on the higher or lower end of the ‘risk’ spectrum
How do I know which risk category I fall into for Vaginal Prolapse?
A Pelvic Health Physiotherapist is a physio who has done a huge amount of extra training in Women’s Health and Pelvic Floor Health. They can do vaginal examinations to check a number of things such as:
- The Pelvic Floor Muscle function
- The structural support of the vaginal walls both at rest and on straining (and very important to assess this in standing too!)
There’s a specific test that we can do called ‘GH+PB’, which measures the amount of movement of the tissues at the opening of the vagina when you strain. This measurement, taken externally, has been proven to be a good indicator of what’s happening internally to the size of the space into which our organs could potentially descend. The larger the GH+PB measurement is (in cm) the higher the risk is that a prolapse could occur or worsen when the area is put under strain.
Some important points to note:
- It’s important to check if you currently have a prolapse (it’s not always symptomatic) but it’s just as important to pick up those who don’t currently have a prolapse but are at high risk of it developing
- Pelvic floor muscle exercises are important but there’s a lot more to it than just getting the best maximal squeeze possible, especially for endurance activities like running and playing a game of sport (because when you think about it… how much help is a grade 5/5 squeeze going to be during a run if you’re not squeezing maximally while you’re running?)
Which exercises are likely to be higher risk?
There are lots of unknowns here, and we don’t know what the ‘safe’ level of intra-abdominal pressure is for preventing prolapse. We also don’t know, without individual assessment, how different women respond to the same exercise.
But we can understand generally which exercises tend to come out as creating higher intra-abdominal pressure and perhaps these can be the ones that are more closely tested and monitored.
Things we can assume about strength and resistance exercise:
- Standing exercises have higher pressure than sitting, and both of these have higher pressures than lying down. On this note – abdominal crunches and lying down abdominal exercises usually come out as one of the ‘lowest risk’ exercises in the studies that have been done, although traditionally these have been amongst those that were the most highly cautioned against.
- Increasing weights and resistance increases intra-abdominal or intra-vaginal pressure
Things we can assume about aerobic exercise (note that this is probably the hardest type of exercise to investigate, but there is some exciting current research happening in this area):
- Running, jogging, skipping etc are likely to be high risk due to the fact that they have an endurance nature to them, they’re always done in upright positions, and there are ground reaction forces involved.
Things we can assume about Crossfit-style exercise:
- In low risk women (those who are young and have never had children), there is unlikely to be a negative impact on prolapse between those who choose to do Crossfit compared to those who choose to do ‘gentle’ exercise (but there are likely to be many benefits in other areas of health)
- There is limited/no research on prolapse risk in women who are considered ‘high risk’
Things we can assume about pilates exercise:
- Most pilates mat and reformer exercises are considered low risk and are unlikely to increase intra-abdominal or intra-vaginal pressures significantly (many are performed in lying down and with relatively low resistance)
- There are lots of benefits to pilates but in isolation it doesn’t meet the guidelines mentioned previously about Disease Control and Prevention and needs to be considered in conjunction with other forms of exercise.
How can a Women’s Health Physio give you individualized information about the type of exercise you should consider?
A Women’s Health Physio should be able to put all of this together and come up with a plan that suits you regarding an exercise regime.
They might assess you and find that you’re very low risk for prolapse occurrence or worsening, and then you can work out together whether any monitoring needs to occur as you increase your load and intensity in your workouts.
They might assess you and find that you’re currently in a high risk category and they can help you to work on a pelvic floor program (and possibly a pessary fitting) to allow you to gradually return to the exercise you love with close monitoring.
They might assess you and find that you fit somewhere in the middle. Perhaps there are certain things that either make your prolapse symptomatic, or that cause vaginal wall descent without you realizing. Rather than advising you to stop exercising completely, they should be able to help you to come up with regressions or variations of these movements, and perhaps supplement them with other forms of exercise that you enjoy to allow you to still meet the health guidelines.
The women’s health physios at FitRight HQ specialise in prolapse and exercise. Click here to book a consult.
Some final points to remember about Prolapse and Exercise…
- Exercise is vital to overall health, and women unfortunately often decrease exercise due to fear of worsening a prolapse.
- Remember that a large number of exercises that were previously suggested to be ‘not pelvic floor safe’ don’t actually have much evidence to back that up (and might be really good for overall health)
- Individual assessment and reassessment is key – and remember that you can’t assess prolapse or risk of prolapse with only an external examination. So if you’ve only had a real time ultrasound screening assessment on your abdomen, this isn’t able to be used to determine your risk profile.