Prolapse management

Prolapse Management

Prolapse is a change in the vagina where one or more of the pelvic organs move down into the vagina.

The pelvic organs - the bladder, the uterus and the bowel - are held and supported inside the bony pelvis by ligaments and muscles; commonly called the ‘pelvic floor’.

The pelvic floor muscles help to support the pelvic organs and control the bladder and bowel to prevent incontinence. If the pelvic floor muscles or the ligaments weaken, the pelvic organs can bulge into the vagina causing the vaginal walls to move downwards resulting in a prolapse.

Prolapse is very common, up to half of all women may have prolapse at some point in their lives.

What does a prolapse feel like?

• Bulge inside or outside the vagina
• Heaviness or dragging around the vagina
• The feeling of sitting on a tennis ball or a tampon inserted incorrectly
• Discomfort in the lower back or tummy
• Bladder or bowel symptoms (see below)
• Sexual problems (pain or less sensation)
• Symptoms of prolapse may come and go depending on your activity during the day
• Quite often there is no discomfort at all but patients may report difficulty emptying the bladder or bowel

What are the risk factors for a prolapse?

• Pregnancy and childbirth
• Heavy or repeated lifting
• Being overweight
• Constipation
• Constant cough due to smoking or asthma
• Menopausal changes
• Family history
• Age
• Previous pelvic surgery such as a hysterectomy

Front vaginal wall prolapse (previously called a cystocele)

This is the most common prolapse. The wall supporting the bladder bulges down into the vagina.

This may contribute to bladder symptoms such as:

• Problems with emptying the bladder which can cause frequent urinary tract infections (UTI).
• Urgency - a strong need to empty the bladder.
• Frequency - needing to go to the toilet more often including at night (nocturia).
• Incontinence - leakage of urine related to stress (coughing/activity) or urgency.
• Difficulty in starting the flow of urine or a slow flow.
• You may find that you have to change position on the toilet to empty your bladder properly.

Back vaginal wall prolapse (previously called a rectocele)

The wall supporting the rectum/back passage bulges down into the vagina.

This may contribute to bowel symptoms such as:

• Difficulty emptying your bowels or incomplete emptying.
• You may feel the need to strain to empty the bowel.
• Bowel or wind leakage.
• Smearing or staining of stool (poo) at the anus.
• Bowel urgency - a sudden need to open your bowels.
• Needing to use your fingers to press around the vagina or anus to help empty your bowel.

Uterine prolapse

The uterus (womb) moves downwards into the vagina due to the lack of ligament support from above. The cervix will then sit lower in the vagina. You may experience bladder, bowel or sexual symptoms.

A vaginal vault prolapse may occur after a hysterectomy (where the womb is removed). The top of the vagina, known as the vault, can bulge downwards into the vagina.

Your Pelvic Health Matters: Insights from NHS clinicians (youtube.com)

What can I do to help?

Manage constipation

Make sure you have enough fluid and fibre in your diet.

Constipation - NHS (www.nhs.uk)

Try to manage weight

A safe and gradual weight loss can help reduce symptoms of urinary incontinence and pelvic organ prolapse. Try to achieve this through a healthy diet and exercise. Speak to your GP for further assistance or see the following page for more advice.

Weight Management and Type 2 Diabetes Prevention Service | NHS Fife

Avoid heavy or repeated lifting where possible

• If you have to lift, try splitting the load into lighter amounts e.g. three shopping bags instead of one.
• When lifting breathe out on the effort.
• Practice ’the Knack’ by contracting the pelvic floor muscles before you lift the load.

Control your coughing

Coughing puts increased pressure on the pelvic floor muscles.

Now is a good time to stop smoking.

Stop smoking service | NHS Fife

Pace activities

• Break up activities into small chunks, have time off your feet in between.
• Pushing, pulling or standing for too long should be avoided.
• If you experience prolapse symptoms this may indicate you need a rest.

Pelvic Floor Exercise

How to do pelvic floor exercises | NHS (youtube.com)

You might find it easier to do them lying on your back or sitting. It is easy to use the wrong muscles instead of the pelvic floor. Try not to squeeze your buttocks or tummy. Remember to keep breathing throughout.

If you get any pain, or your symptoms worsen after doing these exercises, stop and seek help from your specialist physiotherapist.

Long Squeezes

Tighten your muscles as described and hold this squeeze for as long as you can (up to 10 seconds). Rest for the same amount of time.

How long can you hold for? ……….. Seconds

Repeat this as many times as you can (up to 10 repetitions)

How many times can you repeat? ……… times

Now gradually increase your hold time and number of repetitions until you can do 10 seconds x 10 repetitions.

Fast Squeezes

Squeeze and relax your muscles as quickly as you can. Do not hold this time, just let it go. Repeat up to 10 times. Make sure you relax properly between each squeeze.

You should practise both long and fast exercises at least 3 times a day, e.g. morning, lunchtime and evening. You may find it easier to do them ‘little and often’ to start with.

Keep going! It can sometime take about 3-6 months of daily exercise to increase your muscle strength. After this, keep doing them regularly, at least once per day, to maintain the strength.

It is important to maintain your belly breathing while doing your pelvic floor exercises.

You can have a look at our Pelvic Floor Exercise Program for further information.

“The Knack”

It is important that you can tighten these muscles quickly when they are needed, e.g. every time you cough, sneeze, laugh or lift. This is called “The Knack”. With practice this can help to reduce the prolapse symptoms you may be having.

Remembering to do your exercises

It can be easy to forget to do your exercises at first. Try to use daily activities such as brushing your teeth or having a shower to remind you to do your exercises. You could practice them on a daily journey such as train, car, or bus. Or use a pelvic floor app such as Squeezy below.

Pelvic Floor Exercise App

“Squeezy” is the NHS App for pelvic floor muscle exercises and is available from the App Store and Google Play. This app has been designed by physiotherapists working in the NHS. It is discreet, informative and has helpful visual and audio prompts to support your exercise programme. It can give you reminders to exercise and records the number of exercises you have completed. There are also other pelvic floor exercise apps available.

Sex and prolapse

Having sex is safe and will not cause damage to the prolapse. Find positions that are comfortable and consider lubricant if the vagina is dry or penetration is uncomfortable.

What else can be done for my prolapse?

Vaginal Pessary

A vaginal pessary is a device inserted into your vagina. It holds your vaginal walls in place and pushes the prolapse back. Pessaries are usually made of latex (rubber) or silicone, and come in different shapes and sizes.

A pessary might not be right for everyone. Your doctor will discuss with you to find out if it is the best option, and you can ask any questions you may have. Some side effects can include:

• vaginal discharge
• irritation, bleeding or sores inside your vagina
• stress incontinence
• difficulty with bowel movements
• difficulty having sex (although most women can have sex without problems)
• an imbalance of the usual bacteria found in your vagina

If you have a pessary and experience any of these symptoms, speak to your healthcare professional. They can usually be treated.

Hormone Replacement Therapy (HRT)

HRT replaces the female hormones that are at a lower level as you experience the menopause.

There is little evidence that HRT can directly treat pelvic organ prolapse, but it can relieve some of the symptoms associated with it. For example, vaginal dryness or discomfort during sex. Depending on your symptoms, you may wish to ask your doctor for more advice on whether this would be a suitable treatment option for you.

Surgery

Depending on your circumstances and how severe your symptoms are, your doctor may discuss with you whether a surgery might be helpful. They will go through the options with you.

Medication

There are no medicines used to treat prolapse but there are creams that may help with vaginal dryness. Speak to your GP for assistance.

POGP pelvic organ prolapse physiotherapy guide for women

Pelvic Floor Muscles Explained (youtube.com)