Urine leaks, a feeling of pressure while standing or walking and pain during sex are just a few of this all-too-common disorder that you've probably never heard of but have a 50 percent chance of developing. Nobody's talking about pelvic organ prolapse (POP)—it's time to get the conversation started.
Rachel* has a morning ritual. One of the first things she does, before she has a shower, pours a cup of coffee or even gets out of bed, is her pelvic-floor workout. The 69-year-old from Bolton, Ont., uses a pelvic-floor stimulator, which employs biofeedback via a paddle inserted into her vagina, to help her effectively perform a series of Kegels—contracting and then relaxing the pelvic-floor muscles on and off for five seconds. She's been doing this for 10 minutes a day, three to five days a week, for months, since her symptoms of pelvic organ prolapse started—again.
A PRIMER ON PROLAPSE
POP occurs when muscles and tissues in the pelvis become stretched or damaged and the pelvic organs (including the uterus, rectum and bladder) begin falling down into, and sometimes through, the vagina. The condition is classified by stage (1 through 4), which is determined by the severity of the prolapse and the organs affected.
"Women who've had a vaginal delivery will have some damage to their pelvic floor," says Dr. Magali Robert, head of the Pelvic Floor Clinic in Calgary. If the muscles and tissues damaged during delivery don't heal properly, a prolapse can occur, either right away or years later as the organ(s) slowly slide out of place. Other factors that can increase a woman's risk include a family history of POP, obesity, a prolonged cough and frequent constipation.
Many women have some degree of prolapsed bladder (cystocele), rectum (rectocele), intestines (enterocele) or uterus—and the majority don't even know it. "Most patients become symptomatic when it gets to Stage 2 and the organs begin to reach the opening of the vagina," says Dr. Maryse Larouche, a urogynecologist at St. Mary's Hospital in Montreal. "The most common symptom is a feeling of pressure or a bulge when standing or walking." The heaviness that many women report is often accompanied by urinary incontinence, increase in frequency of urination or difficulty urinating or passing bowel movements (causing constipation and, in turn, worsening the condition). Pain, in general or during sex, is not a typical symptom of prolapse but can coexist with it.
"Pelvic organ prolapse is not a medically dangerous condition, unless it is very severe and a patient is unable to completely empty her bladder, which can lead to recurring bladder or kidney infections," says Dr. Larouche. But that doesn't mean it's insignificant—far from it, in fact. "What we're trying to treat is the impact on quality of life, which can be huge," she says.
Imagine not being able to lift your baby or grandbaby or do your job because you can't move anything heavier than a bag of groceries. Imagine not being able to walk your dog because the heaviness in your vagina limits how long you can walk, or even stand, comfortably. Many women give up high-impact sports, like running.
"I stopped going to the gym and started to exercise at home because I was having so many urine leaks and it was embarrassing," says Jessica, who asked us not to use her last name. The 37-year-old Toronto fundraising manager and mom of two has been diagnosed with a cystocele (though her physician didn't specify whether it's Stage 2 or 3).
"It can feel like your insides are going to fall out," says Trista Zinn, a 48-year-old Toronto-based fitness expert who specializes in pelvic health and experienced her own Stage 2 cystocele six years ago. At first, she thought she'd have to give up running for good. "I also wondered if I should tell my husband about it, if it would affect our intimacy," says Zinn. "It can make you feel isolated; it can be emotionally tough to deal with a prolapse—it's not just physical," she says. Zinn has since become a Canadian pioneer in Hypopressives, a postural and breathing technique that relieves pressure from the pelvic cavity and improves the function and tone of the pelvic-floor muscles. It's not designed to treat POP, but it often improves the condition of the area and relieves symptoms.
Unfortunately, many women don't understand POP or its treatment options, and they think they just have to deal with the symptoms or resort to surgery. "Some of the seniors I've worked with have been living with a Stage 2 or 3 prolapse for years," says Zinn. "Those with Stage 3 or 4 are literally pushing their internal organs back up inside them in the shower every morning."
When it comes to surgical treatments, guidelines published in the Journal of Obstetrics and Gynaecology Canada in last November advise physicians to exercise caution when using transvaginal mesh. (In 2016, the U.S. Food and Drug Administration changed its classification of surgical mesh repair from moderate to high risk.)
Rachel had this surgery eight years ago to prop up a prolapsed bladder, which seems to have fallen again. Her symptoms, including the sensation of heaviness, urinary incontinence and discomfort during urination, have returned. "I was lucky back then—my surgery went well and I didn't have any problems," she says. She's waiting for an appointment with a specialist but concerned about undergoing another operation.
Many of the permanent one-size-fits-all meshes used in the past are off the market, and surgeons now have access to a new crop of nonpermanent and biodegradeable meshes that can be tailored to a patient's body, and have a better success rate. Procedures utilizing mesh are only one of the surgical options, though. Jessica will be having a laparoscopic Burch procedure, whereby the vagina is sutured to the pelvic ligaments, supporting the bladder.
Nonsurgical alternatives are preferable whenever possible, says Dr. Robert. For mild to moderate urinary incontinence, pessaries, which she describes as "scaffolding for your vagina," are hugely successful. The removable device (typically ring-shaped, but it can come in other shapes and a variety of sizes to fit each patient individually) is put in to hold up the vaginal wall. A pessary can be inserted when a woman thinks she needs it, like for a trip to the gym, or left in place for weeks or even months at a time.
Conservative management does the trick for many of Dr. Robert's patients. This includes maintaining a healthy weight, avoiding heavy lifting, quitting smoking, avoiding constipation and doing pelvic-floor exercises.
It's not always as simple as doing Kegels, though.
"If I were to treat just the pelvic floor, I wouldn't get many of my patients that much better," says Anniken Chadwick, a pelvic-floor physiotherapist in Vancouver. The majority of her patients have alignment issues—in the neck or rib cage, for example—that create a downward pressure on the pelvic organs and can worsen a prolapse. "That's why I will always prioritize postural and alignment work over Kegels," she says.
PREVENTION IS POSSIBLE
POP can be prevented, at least to some degree. "I wish more pregnant women would come see me in their second or third trimester," says Chadwick. She'd like to see more moms-to-be educated on pelvic-floor health and damage prevention before D-Day. "Women who experience serious vaginal tears or require forceps or vacuum during delivery have more pelvic-floor trauma," she says. These interventions can't always be avoided, but using proper breathing and pushing techniques can reduce the risk.
Postpartum, correct ergonomics for feeding and carrying baby can help prevent the postural problems that often make a prolapse worse, says Chadwick. New moms should also know that a heavy feeling in the vagina and mild incontinence for the first six to eight weeks after delivery will likely settle, so thereʼs no need to worry at that stage. "If these symptoms don't resolve after a few months, women shouldn't ignore them; they should be seen by a pelvic-floor physiotherapist," says Dr. Robert. It's her belief that treating POP early, when symptoms are mild, can help women avoid more serious problems later in life.
Ultimately, women need to be more informed about their bodies and their choices when it comes to POP. "Some women will accept that they have a certain amount of urine leakage and be OK with wearing a pad from now on, but they have to know there are other choices," says Dr. Robert. "A woman should realize that she has options and doesnʼt need to suffer in silence."
*Name has been changed.