 Pelvic Organ Prolapse (POP) is a downward descent of pelvic organs into the bony pelvis. POP is extremely common after child birth and after menopause. The structures that are usually implicated with pelvic organ prolapse include the bladder, urethra, uterus, rectum and small intestine. The type of prolapse is named based on the structure that has shifted and graded based on how far the pelvic organs are dropping into the pelvis (Graded 0-4). See figure below.
Risk factors for developing POP include having children (increased risk with each subsequent pregnancy), chronic coughing, respiratory disease, repetitive heavy lifting, straining with constipation, increased BMI: specifically increased abdominal tissue. It is estimated that about 50% of women have a prolapse (Beck, 1991). Some women are completely asymptomatic and some have symptoms. Women that have symptomatic prolapse will often report pelvic heaviness, pressure, bulging, inefficient toileting, and/or just a general feeling that something is right “down there”. While a woman is breastfeeding and after menopause, estrogen levels in the vaginal tissue decrease, which decreases vaginal wall strength and support, and can thus give rise to symptoms. Evaluation of the prolapse will be performed by a physician or pelvic physical therapist. Assessment should be performed in a variety of positions to determine how the organs are shifting in response to different movements and postures. Research shows that pelvic floor physical therapy is very effective at helping reduce symptoms and sometimes severity of prolapse. Some things that help women manage their symptoms include:
Sometimes depending on severity and symptoms, women may benefit from wearing a pessary, which is essentially an intra-vaginal support for your pelvic organs. The goal with rehabilitating prolapse is always to reduce or abolish a patient’s symptoms and to discuss ways to prevent further progression of the prolapse. Symptoms should always guide what activities are safe to perform. A pelvic floor physical therapist is trained to help manage prolapse symptoms and can help guide you to what activities are safe, according to your specific prolapse.
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Thanks to social media influencers like Kim Kardashian, waist trainers have gained popularity in recent times. Waist trainers are hard, rigid, corset-like binders (not to be confused with a soft binder that is sometimes worn for a week or so after birth). The goal of a waist trainer is to cinch the waist and narrow the waist line through prolonged use.
With every single client, we discuss ways to best control their abdominal wall and protect their pelvic floor. We sometimes spend an entire treatment session (if not more!) working on coordinating breathing, controlling rib position and improving recruitment of the abdominal muscles and pelvic floor to allow a client to handle increased load without increasing symptoms. We discuss bowel habits, bladder habits, lifting mechanics and more, all so that we can help the abdomen and pelvic floor can manage force. Overtime, increased downward pressure on the pelvic floor through a poorly coordinated core can cause muscle tightness, weakness, pain and other symptoms such as incontinence and prolapse. Waist trainers provide constant inward pressure into the abdominal wall, increasing the pressure in the abdomen. This does not allow the diaphragm and ribs to participate in breathing, slows motility of the GI system, and puts a constant downward force on the pelvic floor. All of these things can make symptoms worse, and with continual use, can bring symptoms that might be at bay, to light. It is important for the abdominal wall to move in order to dissipate forces put on the body! Failure to have the abdominal wall, diaphragm and ribs move is detrimental to core stability and resiliency and can have serious implications to the pelvic floor! So, just say no to waist trainers! “Just do your Kegels”. This is often a statement told to my clients at some point, whether it be from their Doctor, or from a close friend.
A lot of clients coming to see me report urine leakage: often with activities such as coughing, laughing or higher impact activities like running or jumping jacks. I often hear: “I am doing my Kegels but they aren’t working!”. Kegels are voluntary, isolated contractions of the pelvic floor muscles, and are named after Arnold Kegel, a gynecologist who invented a device used for measuring strength of the pelvic floor muscles. Research shows that many women incorrectly perform pelvic floor muscle contractions (Talasz et. al 2008, Thompson and O’Sullivan 2003). The most common compensations include: tightening the abdomen, squeezing the gluteals and tensing the inner thighs. A Kegel contraction is one way to strengthen the pelvic floor and can be a starting point for a patient with an under-active pelvic floor. Sometimes in therapy, we will combine a Kegel contraction with a functional movement (such as a squat) in order to help manage their symptoms. However, isolated pelvic floor muscle contractions do not address why someone is having their symptoms. If the pelvic floor is “weak”, it is likely that there are other muscles that are not functioning properly, and thus need to be addressed. Therefore, Kegel contractions are a start, but should not be the only exercise that a person performs. We must recruit other muscles and tie the pelvic floor in with the rest of the body, in order for the patient to have success at abolishing their symptoms. There are cases in which Kegels can actually make a patient’s pain or symptoms worse. In cases of pelvic pain, and an over-active, or excessively tight pelvic floor, doing repetitive Kegel contractions will likely worsen the symptoms. If you are performing Kegel contractions and they are making your symptoms worse, then do not perform them and definitely consult with a pelvic floor physical therapist. The pelvic floor is a delicate area that can be easily affected by other areas of the body. It is important that the pelvic floor is strong, but also flexible. It is very important that before someone routinely does isolated Kegel contractions, they are evaluated by a pelvic PT to ensure that they are doing them correctly, that Kegels are in fact an appropriate exercise for them, and that they are instructed on other ways to strengthen the pelvic floor. Many people are nervous for their first visit with a pelvic floor physical therapist. Your therapist will ensure that you are very comfortable and will explain all tests and procedures that she is doing. Our evaluations take 90 minutes to complete. This is because we want to get a thorough history and hear your story regarding your symptoms so that we can best help you manage them! During the first part of you evaluation, your therapist will thoroughly review your medical history. She will ask you questions about when your symptoms started, contributing factors, what makes your symptoms worse/better, and more. Your therapist will also ask about bowel, bladder and sexual function and likely ask that you keep a thorough bowel and bladder diary. Once your therapist has taken a thorough history she will examine how you are moving and may ask you to perform functional movements such as squatting, walking, lunging and more. She will look at how some of the larger muscles in the abdomen, back, hips and legs are functioning. With your permission, your therapist will then ask you to undress from the waist down and will perform an examination of the muscles that sit inside the pelvis. This is very similar to a gynecological examination. Your therapist will be assessing how the muscles in the pelvis are functioning and may be playing a role in your symptoms. Often, dysfunction in these muscles can cause radiating pain, and bowel, bladder and sexual dysfunction. After your internal examination, your therapist will discuss her findings with you and come up with a treatment plan that is agreeable between you and her. Your therapist will throughly discuss your goals for therapy and will make sure that they are being addressed at each visit. Your therapist will give you specific exercises and education to address your symptoms and will ask you to complete them in between your treatment sessions with her. We understand that pelvic floor physical therapy deals with private issues and ensure that you, the patient, is most comfortable prior to performing any assessment or treatment. Pelvic floor physical therapy involves physical therapy (PT) performed by a physical therapist who has specialized, post-doctoral training in pelvic floor conditions. A pelvic floor physical therapist is often the best medical professional to treat your pelvic floor symptoms, conservatively. Pelvic floor physical therapy involves assessment and treatment to the muscles, joints and organs that sit at the bottom of the pelvis. Many people don’t even know that there are muscles down there! See image below which illustrates a bird’s eye view of the female pelvic floor.  Like any other muscle in the body, the muscles of the pelvic floor can get tight, stretched, weak and can go into spasm. A pelvic floor physical therapist looks to determine whether the pelvic floor muscles and joints could be causing your symptoms and further investigates why the pelvic floor muscles are not working properly.
Often symptoms such as pain, leakage and constipation don’t just affect the pelvic floor, but affect neighboring joints as well. Sometimes the pelvic floor is just a victim in a poorly coordinated system and many times patients will report other areas of pain, besides the pelvic floor. Pelvic floor physical therapy is a highly researched area and shows profound results at improving quality of life and symptoms such as urinary and bowel incontinence, diastasic recti, pelvic organ prolapse and more! |
AuthorDr. Jenn Perna PT, DPT, OCS Archives
February 2022
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