Carolina Solá is a physiotherapist specializing in pelvic floor health. In this article, she explains the approach to vaginal prolapse from a physiotherapy perspective.

What is prolapse, and how is it classified?

Pelvic prolapse is a common pathology; its prevalence and severity increase with age. We speak of prolapse if one or more of the anterior and posterior vaginal walls are descending. Although there is usually one main organ affected, by modifying the internal distribution of the viscera, the other organs are often affected as well in the long term.

Additionally, prolapse is usually associated with severe symptomatology: urinary urgency, sensation of incomplete urination or defecation, constipation, dyspareunia, sensation of vaginal heaviness, urinary or fecal incontinence, which can have a considerable negative impact on the quality of life of the women who suffer from it.

Prolapse can be classified according to the organ that is descending:

• Uterine or vaginal vault prolapse (hysterocele)
• Bladder prolapse (cystocele)
• Prolapse of the rectum (rectocele)
• Prolapse of the urethra (urethrocele)
• Prolapse of the small bowel (enterocele)

It can also be classified by stage, according to the Simplified POP-Q classification, depending on the descent of the organ (from less severe to more severe):

• Stage 1: the closest part of the prolapse does not reach the hymen.
• Stage 2: the closest part of the prolapse is between 1 cm above and 1 cm below the hymen.
• Stage 3: the closest part of the prolapse is more than 1 cm below the hymen but not more than 2 cm less than the total length of the vagina.
• Stage 4: complete involution of the entire vaginal length. The closest part of the prolapse protrudes at least the total vaginal length minus 2 cm.

Stages 1 and 2 are the most common in postpartum women, and in most cases, they can be treated with pelvic floor physiotherapy treatment and won’t require surgical intervention. However, stages 3 and 4, in most cases, will require the use of pessaries or surgical intervention because this pathology’s progression affects the anatomical and functional level of the pelvic floor.

Treatment of pelvic prolapse

Very often, prolapse is not treated correctly because the treatment that is usually proposed to patients to improve prolapse is usually surgical (such as the application of the controversial mesh or other techniques).
On the other hand, physical therapy treatment based on pelvic floor physiotherapy should be the first choice of treatment. It is essential, either before/after surgery or as the only treatment. There are different etiologies of prolapse:

• Poor management of pressures
• Lack of tone or control over pelvic floor muscles
• Poor breathing technique
• Lack of abdominal control
• Excessive weight or pressure maintained on the pelvic floor

Therefore, this work based on physiotherapy is important. With a pelvic floor physiotherapist, patients can improve their body awareness, strength, and tone of their pelvic floor muscles, pelvic mobility, breathing patterns, abdomen activation, body posture control, and pressure management when lifting daily loads. Improving all these things can enhance the decrease of prolapse and, consequently, improve symptoms in patients.

Nowadays, prolapse is becoming more and more common among young women after a first, second, or third birth. So, it is no longer associated exclusively with older people or women with menopause or obesity. That is why, as healthcare professionals, patients should be encouraged to start pelvic floor physiotherapy, either as a pre-intervention treatment in the case of stages 3 and 4 or as a stand-alone first-line treatment for patients with stages 1 and 2 prolapse.

 

References

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Collins, S., & Lewicky-Gaupp, C. (2022). Pelvic organ prolapse. Gastroenterology Clinics of North America, 51(1), 177–193. https://doi.org/10.1016/j.gtc.2021.10.011

Espiño-Albela, A., Castaño-García, C., Díaz-Mohedo, E., & Ibáñez-Vera, A. J. (2022). Effects of pelvic-floor muscle training in patients with pelvic organ prolapse approached with surgery vs. Conservative treatment: A systematic review. Journal of Personalized Medicine, 12(5). https://doi.org/10.3390/jpm12050806

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Quaghebeur, J., Petros, P., Wyndaele, J.-J., & De Wachter, S. (2021). Pelvic-floor function, dysfunction, and treatment. European Journal of Obstetrics, Gynecology, and Reproductive Biology, 265, 143–149. https://doi.org/10.1016/j.ejogrb.2021.08.026

Resende, A. P. M., Bernardes, B. T., Stüpp, L., Oliveira, E., Castro, R. A., Girão, M. J. B. C., & Sartori, M. G. F. (2018). Pelvic floor muscle training is better than hypopressive exercises in pelvic organ prolapse treatment: An assessor-blinded randomized controlled trial. Neurourology and Urodynamics, 38(1), 171–179. https://doi.org/10.1002/nau.23819

Romeikienė, K. E., & Bartkevičienė, D. (2021). Pelvic-floor dysfunction prevention in prepartum and postpartum periods. Medicina (Kaunas, Lithuania), 57(4). https://doi.org/10.3390/medicina57040387

Shi, W., & Guo, L. (2023). Risk factors for the recurrence of pelvic organ prolapse: a meta-analysis. Journal of Obstetrics and Gynaecology: The Journal of the Institute of Obstetrics and Gynaecology, 43(1), 2160929. https://doi.org/10.1080/01443615.2022.2160929

Verbeek, M., & Hayward, L. (2019). Pelvic Floor Dysfunction and Its Effect on Quality of Sexual Life. Sexual Medicine Reviews, 7(4), 559–564. https://doi.org/10.1016/j.sxmr.2019.05.007

Weintraub, A. Y., Glinter, H., & Marcus-Braun, N. (2020). Narrative review of the epidemiology, diagnosis and pathophysiology of pelvic organ prolapse. International Braz j Urol: Official Journal of the Brazilian Society of Urology, 46(1), 5–14. https://doi.org/10.1590/S1677-5538.IBJU.2018.0581

Carolina Solá is a physiotherapist specializing in pelvic floor health. You can find her at LactApp Barcelona and @alos_fsp