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Dr Anu Kaur MBBS,FRANZCOG
Specialist Obstetrician and Gynaecologist

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Pelvic Organ Prolapse

Pelvic organ prolapse refers to loss of support for the uterus, bladder, colon or rectum, leading to prolapse of one or more of these organs into the vagina. Although not life-threatening, it has a significant impact on the quality of life, can affect perception of body image and can cause depressive symptoms. Pelvic organ prolapse is more than an anatomical defect; it is associated with significant functional disturbances including anorectal, urinary and sexual function. It is common, with up to 40% of women experiencing a degree of pelvic organ prolapse in their lifetime

  • Uterine prolapse occurs when weakened or damaged muscles and ligaments allow the uterus to slip into the vagina.
  • Common causes include pregnancy, childbirth, hormonal changes after menopause, obesity, severe coughing and straining on the toilet.
  • Treatment options include pelvic floor exercises, vaginal pessaries and vaginal surgery.
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Treatment is targeted to the compartment which is prolapsed ie:

Bladder prolapse or cystocele :

Bladder prolapse or cystocele is when the bladder bulges onto the front wall of the vagina. Other names for this include ‘fallen’ bladder and anterior vaginal wall prolapse.

Bladder prolapse usually occurs due to a weakening and stretching of the vaginal walls, resulting from childbirth or repetitive straining. Risk factors include pregnancy, childbirth and anything else that puts pressure on the pelvic floor, including inappropriate gym exercises.

Uterine prolapse :

The uterus (womb) is an organ of the female reproductive system. It is shaped like an upside down pear and is located inside the pelvis. The uterus, bladder and bowel are supported by a hammock of muscles slung between the tailbone (coccyx) and the pubic bone. These muscles are known as the pelvic floor, or the levator ani muscles. Ligaments and connective tissue also anchor the uterus in place. If these tissues are weakened or damaged, the uterus can slip down into the vagina.
Common causes of uterine prolapse include childbirth, obesity, severe coughing, straining on the toilet and hormonal changes after menopause. Treatment should include pelvic floor muscle strengthening exercises, taught by a pelvic floor physiotherapist or continence nurse.

Rectocele

A rectocele occurs when the rectum pushes the back wall of the vagina forward, causing a prominent bulge into the vagina.
Risk factors include difficult childbirth and the use of forceps during delivery, but women who have never had children can also develop rectocele.

The pelvic floor muscles are tightly slung between the tailbone (coccyx) and the pubic bone, and support the bowel, bladder, uterus and vagina. Muscular bands (sphincters) encircle the urethra, vagina and anus as they pass through the pelvic floor. When the pelvic floor muscles are contracted, the internal organs are lifted and the sphincters tighten the openings of the vagina. anus and urethra. Relaxing the pelvic floor allows passage of urine and faeces.

If the muscles are weakened, the internal organs are no longer fully supported and you may not be able to control your urine. Common causes of a weakened pelvic floor include childbirth, obesity and the associated straining of chronic constipation. Pelvic fioor exercises are designed to improve muscle tone and prevent the need for corrective surgery.

Symptoms of a weak pelvic floor

The symptoms of a weakened pelvic floor include:

  • Leaking small amounts of urine when coughing, sneezing, laughing or running
  • Failing to reach the toilet in time
  • Uncontrollably breaking wind from either the anus or vagina when bending over or lifting
  • Reduced sensation in the vagina
  • Backache
  • Tampons that dislodge or fall out
  • A distinct swelling at the vaginal opening
  • A sensation of heaviness in the vagina.

Causes of a weak pelvic floor

The pelvic floor can be weakened in many ways, including:

  • The weight of the uterus during pregnancy
  • Vaginal childbirth, which overstretches the muscles
  • The pressure of obesity
  • Chronic constipation and associated straining to pass motions
  • Constant coughing
  • Some forms of surgery that require cutting the muscles
  • Lower levels of oestrogen after menopause.

Complications of a weakened pelvic floor

Loss of bladder control is a common symptom of a weakened pelvic floor. Some people experience bowel incontinence, which means they can’t always control the passage of wind or faeces. Weak pelvic floor muscles can also cause sexual difficulties such as reduced vaginal sensation. In severe cases, the internal organs supported by the pelvic floor. including the bladder and uterus, can slide down into the vagina. This is called a prolapse. A distinct bulge in the vagina and deep, persistent vaginal aching are common symptoms.

Familiarising yourself with the pelvic floor

Pelvic floor exercises are designed to strengthen the muscles. Each sphincter (vaginal, urethral, anal) should be exercised, so you need to familiarise yourself with these muscles in order to contract them at will. If the pelvic floor is especially weak, it may be difficult to detect any muscular contractions at first.

Suggestions on identifying your sphincters include:

  • Vaginal — insert one or two fingers into your vagina and try to squeeze them.
  • Urethral — when you are urinating. try stopping the flow in midstream. This should only be done to identify the sphincters. Do not do it on a regular basis.
  • Anal — pretend you are trying to stop yourself from breaking wind and squeeze tightly.

The exercises

You can perform these exercises lying down, sitting or standing. Ideally. aim for five or six sessions every day while you are learning the exercises. After you have a good understanding of how to do the exercises, three sessions each day is enough.

Before you start, direct your attention to your pelvic floor muscles. Try to relax your abdominal muscles. Don’t bear down or hold your breath. Gradually squeeze all three sphincters and increase the tension until you have contracted the muscles as hard as you can. Release gently and slowly.

Then perform the exercises. Which include:

  • Squeeze slowly and hold as strongly as you can for 5 to 10 seconds while breathing normally. Release slowly. Repeat 10 times. Relax for 5 to 10 seconds between each one.
  • Perform quick. short. strong squeezes. Repeat 10 times.
  • Remember to squeeze the muscles whenever you clear your throat or cough.

It is important to perform these exercises correctly. You can consult with your doctor. physiotherapist or continence advisor to ensure proper performance. It may take weeks or months before you notice a substantial improvement. In severe cases. pelvic floor exercises aren’t enough to solve the problem and surgery may be needed. Be guided by your healthcare professional.

Other considerations

You can further improve the strength of your pelvic floor in many ways. including:

  • Lose excess body fat
  • Cure constipation by including more fruit. vegetables. fibre and water in your daily diet
  • Seek medical attention for a chronic cough.