What is POP?

Hi Pelvic Care family,

This month we’re talking about pelvic organ prolapse. Please join us! PM or text us your questions and concerns–we love talking about all things pelvic floor. And we’re here for you.

Pelvic organ prolapse (POP) is a hernia in your genital region. A hernia is where an organ has lost its initial fascial and ligamentous structural support, and so is occasionally shifting out of its original location. Imagine a ship’s sails, when the rigging is taut and well controlled. This is how most of us are when we’re first born–our organs are structurally supported in specific locations, tacked in place by webs of filmy fascia and bands of taut ligaments, just as a ship’s sails are controlled by the ropes and cables that suspend them and the crew that manages the shifts of wind and atmospheric pressure. But then life happens. We have babies! We lift heavy things without proper training! We hold our breath when we poop! And we cough really hard, for a long time, because we have terrible allergies! All these activities increase our intra-abdominal pressure (IAP, if you want to enjoy the jargon with me). If our bodies lack the coordination to manage these pressures (neuromuscular and neurofascial coordination = the ship’s crew, in this analogy), our fascia and ligaments may get distorted. A hernia or a prolapse can be the result.

Prolapses are not life threatening, and so they’ve been largely ignored by the traditional medical system for a long time. Gynecologists may notice prolapses when they do internal exams, but unless they’re severe most gynos don’t comment on them. I think this comes from a benevolent place–why comment on a change, unless it’s clinically relevant? Well, for pelvic floor physical therapists, prolapse is VERY clinically relevant. Why? Because often when clients come in with constipation, urinary urgency/frequency/incomplete emptying/stress urinary incontinence, or reduced sexual sensation–prolapse is a main reason why! If we can identify prolapse as the heart of the problem in the first session; get started learning compensatory toileting strategies, pressure management strategies for when we cough/sneeze/lift or push heavy things, and/or sexual positioning strategies–then often some of the main bothersome symptoms a client comes in for, are effectively addressed in that first week of working together. 

Let me explain with an example. Susie Q comes into our clinic because she has to pee all the time and she has a bothersome feeling of lower abdominal pressure when she is on her feet for too long. It’s a major pain! She’s a teacher, so she’s seldom sitting down, and the pressure feeling she has by the end of the workday is beyond unpleasant. Also, she can’t get halfway through a grocery shopping trip or her busy workday without feeling like she needs to stop by the restroom. She also thinks she’s not getting all the way empty when she pees. Sometimes she’ll stand up after wiping, and more pee dribbles out. She wears a pad 24/7 even when she’s not on her cycle, because she tends to leak a few drops when she coughs and sneezes and she worries about the smell. After chatting with her about her symptoms, getting to know her, explaining what to expect, and obtaining her informed verbal consent, her pelvic floor PT does an internal vaginal exam including a prolapse screen–the PT inserts two fingers vaginally, gently presses down toward her tailbone, and asks Susie to bear down gently like she’s trying to push out a fart. The PT sees a slight bulge at the front of Susie’s vagina when she does this–it looks a little like a turtle head emerging from inside a shell, then retracting back when Susie stops pushing. The PT explains that an anterior vaginal wall/bladder and urethra prolapse may be the root cause of some of Susie’s symptoms. She talks to Susie about toileting strategies, recommending she do deep breathing and lean forward when she’s peeing to help all the urine come out. The PT says, if this doesn’t get the job done, try “double voiding” (pee once, then stand up and turn around in a circle or do other movement, then sit back down and pee again). The PT also teaches Susie how to do “the knack”--before she sneezes or coughs, do a kegel to secure the bladder in place and reduce urinary incontinence. Susie comes back the next week for her follow up session. She is very proud to report that she followed through on the PT’s suggestions, and she is now able to wait about 2 or 3 hours between pees, she’s no longer dribbling on herself after peeing, and she’s had a few times where she’s been able to cough or sneeze without leaks. The PT and Susie rejoice!

Here’s another example, this time on the colorectal side of things. Penelope P. comes in for her PT appointment very embarrassed and worried. Right before her appointment, she was trying to have a bowel movement, but it just wasn’t happening, and then she had to rush out of the house before she was done because she didn’t want to be late, and now she feels gross and her tummy and anus feel all confused and constipated. This is the case too often: She sits on the toilet forever but it seems like she doesn’t get all the way empty when she poops. If she holds her breath and pushes down, that helps push the poop out. She’s heard she’s not supposed to push when she poops, though, so she’s figured out how to insert her fingers in her vagina and press backward toward her backside–this helps her poop effectively, but she feels so weird for doing this! Her pelvic floor PT explains that Penelope may have a posterior vaginal wall prolapse, or rectocele, which is creating a pocket of poop when she’s on the toilet that is resistant to getting pushed out because it isn’t positioned in alignment over the anus. An internal vaginal exam confirms this. The pelvic floor PT teaches Penelope there are tools she can use for the “autosplinting” she’s already learned to do on her own with her fingers, and explains that either fingers or these tools are appropriate compensatory options to help reduce Penelope’s time on the toilet. Penelope comes back the next week for her PT follow up beaming. She has so much peace of mind now that she knows the autosplinting she was doing is a brilliant, healthy way to deal with her posterior prolapse, and so she uses this technique regularly and isn’t wasting so much time stressing out on the toilet. 

One more: Belinda B. comes in for pelvic floor PT for a variety of other concerns, but near the end of her initial conversation with her physical therapist she mentions, “I have an ok sex life with my husband, but I feel like I just don’t have the same amount of sensation that I used to have. I can orgasm, but it’s just not the same as it used to be.” During the physical examination, Belinda and the PT notice that Belinda has advanced prolapse of a few different areas, and a weak and discoordinated pelvic floor. When she tries to kegel, she can’t tell if she is or not, and the PT affirms that her pelvic floor contraction is just trace–a one out of five, on the strength scale. The PT and Belinda talk about her options–she is having numerous bowel, bladder, and sexual symptoms that are linked to her prolapses and her discoordinated pelvic floor and core system. The PT gently informs Belinda that PT alone may not be sufficient to resolve her symptoms because her prolapses are advanced. She discusses Belinda’s treatment options: they talk about pessaries (silicone devices inserted vaginally to support the prolapsed pelvic organs), surgical options, and the importance of pelvic PT before (prehab) and after (rehab) surgery–if she decides to get it–to regain her pelvic floor strength and coordination so the surgery lasts for the rest of her life and doesn’t need to be repeated. 

Belinda hates the idea of surgery and wants to try a pessary and PT first. The PT and Belinda work together for twelve weeks, and she is having fewer symptoms but also isn’t fully satisfied with the results she’s obtaining with just PT and a pessary. She meets with a urogynecologist recommended by the PT, and is able to ask detailed questions to address her concerns regarding surgery. After chatting with a friend who also had prolapse repair surgery with good results, researching online, and talking with her husband and her PT, Belinda decides to schedule her surgery. She heals well after, observing all of the urogynecologist’s recommendations for after surgery self care. She works with her PT to regain strength and coordination of not just her pelvic floor but also her low back, abdomen, glutes, legs, and upper back/shoulders after surgery. She consistently uses the pressure management strategies she learned from her PT before surgery, to avoid putting pressure on her pelvic organs and to maintain the integrity of her surgery. 

Belinda does notice sexual sensation has improved, but she wishes her sex life could improve a bit more, and she wants to keep getting stronger and start lifting weights. Her PT recommends a sex and relationship therapist, and a personal trainer who specializes in women’s health. Belinda and her husband attend relationship counseling for several months, gradually learning how to identify and communicate their sexual concerns and desires in a welcoming, safe, non-judgemental environment. They are overjoyed to realize they are having some of the best sex of their life, partly because of the surgery and PT, partly because of the relationship counseling, and partly because Belinda feels increasingly sexy and confident as she gets stronger with her personal trainer.

These are just a few examples of how working with a pelvic floor physical therapist can resolve bladder, bowel, and sexual function symptoms related to pelvic organ prolapse. Sometimes, pelvic floor physical therapy is all that is needed for symptom resolution. Other times, more is needed (hypopressives training, pessaries, surgery, etc.). Sometimes, the prolapses heal on their own and actually “go away” (they’re not detectable on an exam anymore). This is the case with many birthing and pregnancy related prolapses. Other times, however, the prolapse is still there after treatment but the symptoms associated with it are resolved because we learn toileting and pressure management strategies to accommodate the prolapse, and we get strong and balanced in our tissues surrounding the prolapse, so we just really don’t notice it anymore because its so well supported. 

Having prolapse does NOT mean (as certain websites and online sources suggest): Stop moving! Stop working out! Stop having sex! WE CAN STILL EXERCISE AND HAVE SEX WHEN WE HAVE PROLAPSE! (Please excuse my all caps–I just want to make sure that message is so clear because it’s so important to help people with prolapse to not live in fear!) We just need to learn how to manage pressures and take good care of our tissues if we have prolapse. Pelvic floor physical therapy for the win, here! That’s what we love to do–help you learn how to take good care of your body as it is, so that you can live your life without fear or unnecessary limitation!

If you think you may have a prolapse because you have bothersome bowel, bladder, or sexual dysfunction or because you have lower abdominal or genital pressure/heaviness, please chat with your ob-gyn, urogynecologist, colorectal specialist, or a pelvic floor physical therapist about your symptoms. Prolapse sounds alarming to some when they first learn about it–but the reality is that it’s incredibly common and we know what to do to help with prolapse.