Tuesday, November 20, 2012

"POP" goes the bladder

Today's topic is one where the symptoms can increase around this time of year, so you might start to notice that something isn't quite right. Do you ever have a feeling of heaviness or pressure in the vagina that gets worse if you are on your feet for long periods, like when you've been holiday shopping? Are you having more constipation due to rich holiday meals and noticing it feels like something is coming out "down there" when you have to push or strain to have a bowel movement? Wondering what in the world could be going on down there?

The answer could be Pelvic Organ Prolapse, or POP. POP occurs when any of the pelvic organs descend below their normal position in the pelvic cavity.  POP can occur as a consequence of many things, such as chronic constipation, pelvic surgery, obesity, and multiple vaginal births, just to name a few.

So how does this happen? In simple terms, support for your pelvic organs comes from your pelvic floor muscles and ligaments. When pelvic floor muscles become weak, the connective tissue and ligaments have to hold all the weight of your organs. Over time, ligaments may stretch and fail, letting your pelvic organs drop and press down into the vaginal wall.

Depending on what type of POP you have, you may experience different symptoms. Three common types of prolapse are: cystocele (bladder prolapse), rectocele (rectal prolapse) and uterine prolapse.

If you have a cystocele or uterine prolapse, you may experience urinary symptoms such as stress urinary incontinence, or difficulty emptying your bladder. With a rectocele, a pocket forms just above the anal sphincter which can lead to stool becoming trapped, causing pain, pressure, and constipation. With any of these, but especially with uterine prolapse, a woman may experience discomfort with a feeling like something is falling out of your vagina, or just feeling a heaviness and pressure in the vagina. Many women experience discomfort with intercourse due to irritated vaginal tissues or even pain, with many women reporting that they feel like their partner is hitting something inside them.

Often there is little correlation between the level of descent of the organ and the severity of symptoms. In other words, I have seen many patients with a minimal level of prolapse, whose symptoms were very concerning and bothersome, and had a great impact on their quality of life and level of comfort every day.

So what can be done?

Women with no or very mild symptoms don’t necessarily need treatment, although they should avoid anything that might worsen the prolapse, like lifting heavy objects or straining to have a bowel movement. Those who are overweight may want to discuss a weight loss program with their doctor.

If you think you have a pelvic prolapse condition, and your symptoms are bothering you, you should see your primary care provider or gynecologist. A pelvic examination is the only way to diagnose POP.

Your doctor can discuss some of the options for treating POP with you including:

Physical Therapy
A physical therapist who specializes in pelvic dysfunction can help change the symptoms of prolapse. As I mentioned earlier, their are two areas of support for the pelvic organs, the ligaments and the pelvic floor muscles. A pelvic PT can instruct you how to correctly perform a pelvic floor muscle contraction and instruct you in exercises to strengthen and improve the endurance of those muscles, to support your organs from below. They can also teach you how to integrate breathing and abdominal muscle activity and instruct you in ways to decrease downward pressure on your organs.


In some cases it is necessary to also restore the ligament support to the organ. Pelvic reconstruction surgery may be performed through the vagina or the abdomen. Laparoscopic surgery, in which repairs are made with instruments, including a camera, inserted through a few tiny abdominal incisions, is now also an option. With surgery, the prolapsed organ will be repositioned and secured to the surrounding tissues and ligaments. You should discuss the benefits and complications with your doctor and a surgeon with experience with this type of surgery.

Whether or not surgery is necessary, it is helpful to have strong pelvic floor muscles supporting your organs. In my experience, many patients can improve their symptoms with physical therapy alone, to a level where they are comfortable and are able to forgo surgery. Even if a patient does ultimately go on to have surgery, strengthening the pelvic floor muscles prior to their operation is beneficial.


Another, non-surgical option, is a pessary. A pessary is a small silicone medical device which is inserted into the vagina or rectum and held in place by the pelvic floor muscles. It is similar to a diaphragm. Pessaries provide support for the uterus, bladder, or rectum and decrease symptoms of prolapse. A pessary may be a good option for women wanting to postpone surgery, or those who might not be good surgical candidates. A pessary is prescribed and must be fitted in a physician's office to ensure proper fit and comfort.

In my practice, I commonly hear women say that they never talked to their doctor about these issues because they just thought that it was the way things were after having children or with getting older. I want you to know that it doesn't have to be that way and there is help out there! Talk to your primary care physician or your OB/GYN if you are having of the issues mentioned here, and find out if any of these options are right for you.

To hear more about this topic, click on the link below where Angela Dobinsky, PT, DPT, BCB-PMD talks to Audrey Baum, WHNP, RNC about POP.

Pelvic Organ Prolapse - Listen on Blog Talk Radio