Vaginal prolapse by Elaine Walpole

Prolapse is one of those words you’ve heard of but possibly never fully understood – even if you have been diagnosed with prolapse. The diagnosis can be devastating, and emotional support can be lacking. It can evoke feelings of shock, disappointment, fear for the future and even shame.

Here is the good news: I am a specialised women’s health physiotherapist, so I help lots of women with vaginal prolapse.

Research published in 2013 proved that pelvic floor exercises reduced prolapse symptoms – but, in addition, vaginal pessaries really help symptoms. Vaginal WHAT??

Vaginal pessaries are small devices which insert into the vagina and support the prolapsed tissue. There is an 84% success rate in reducing symptoms when their use is combined with physiotherapy. I have many patients who LOVE their pessaries!

Patients in our clinic arrive saying things like:

• I feel like my insides are falling out
• I feel broken
• I think about this horrible sensation of bulging all the time

They say that prolapse symptoms affect how they live – feeling useless as a parent as they can’t pick up their toddler, or can’t run, have difficulty lifting weights or simply going for a good walk.

After diagnosis, the majority of women have felt alone. But prolapse is actually very common, a reported one in four women will experience prolapse – and it’s not always older women, either. The misplaced shame involved with this condition means we don’t talk about the problem, so it’s hard to find emotional support.

In most cases I’ve dealt with, women haven’t been told that it’s okay, you can live well with a prolapse and that there are ways to help other than surgery. Prolapse doesn’t have to steal a woman’s sparkle.

After treatment and with pessaries, my patients report they can run, lift, exercise, walk and enjoy life without feeling symptoms or dreading worsening their condition.

For more medical information on what a prolapse actually is - read on, it will be explained later in the article. But now, let’s deal with the pessaries.

What exactly are pessaries?

Pessaries come in many shapes and sizes but there are two types: some for you to self-manage at home and some that a GP or gynaecologist will fit, remove and replace for you at six-monthly intervals. Both types are safe, effective and under-used.

The type of pessaries which are fitted and left in place for six months may occupy space in the vagina so sex is not possible. This has led to many medical practitioners viewing pessaries as an option only appropriate for an older woman who is no longer sexually active.

More good news…the self-management types can be removed and re-inserted, so sex is entirely possible.

These are usually made of soft, flexible silicone. Some women’s health physiotherapists, like me, are trained to measure and fit these – it’s normal if it takes a few attempts to get a good fit, it is worth persevering.

You will then be shown how to insert and remove your pessary, and how you take care of the hygiene side of things. You can then use your pessary at any time you wish and for any activity you do that provokes the prolapse symptoms. You simply remove it when you don’t need it.

Some menopausal women may need use topical oestrogen to protect their vaginal tissue before having a pessary fitted. Your GP will be able to assess this and prescribe something.

Research shows pessaries can slow the progression of a prolapse and improve the prolapse severity. A reduction in the genital hiatus size after two weeks to three months following fitting has been noted. A pessary can also assist pelvic floor muscles to work.

It can feel like a weight off your mind (and your pelvic floor!) if you’re not constantly reminded about prolapse symptoms, especially when you’re trying to lead an active life including caring for young children.

Access to pessaries varies across the UK. It is best to see your GP to find out what options are available locally. Some hospitals have a continence clinic where specialist nurses fit pessaries, other areas may require a visit to a gynaecologist, and some women’s health physiotherapists fit pessaries.

Pessaries offer an effective alternative to surgery for many women. With recent concerns regarding surgical mesh procedures for prolapse, a conservative approach is worth pursuing for most women.

So how does the physiotherapy part work?

Your physio will make a detailed assessment of your condition then devise a treatment plan with a whole-body approach.

The assessment will consider how your breathing, core muscles and pelvic floor muscles work together. The strength and function of these muscles are key to reducing the symptoms of prolapse. Good, clear advice also helps women cope and live better with prolapse.

Most women have heard of Kegel exercises. These exercises in isolation won’t help the prolapse very much. The entire muscle system needs to function effectively, the pelvic floor is just one part of the system to fix.

If you have a split (diastasis) of your abdominal muscles, we will look at this as well. Our deep abdominal muscles work with our pelvic floor and are crucial for good function. A diastasis causes a loss of pressure or tension in the abdomen when we cough or lift. This pressure is transferred downwards to the pelvic floor and can increase prolapse symptoms. We need to help regain a functional abdominal wall.

Your physiotherapist may use ultrasound to scan your tummy and show you your muscles in action so you can see how the exercises will help to lift the prolapsed tissue.

A few other lifestyle changes will help you as well. Good nutrition is important because constipation, full intestines or bloating increases pressure on the pelvic floor, which in turn can increase symptoms of prolapse.

During your assessment, your physio can advise about activities that increase pressure on the abdomen, such as lifting, coughing etc and help you manage these.

What exactly is a vaginal prolapse?

This is when structures such as the uterus, rectum, bladder, urethra, small intestine or the vagina itself may fall out of their normal position.

Without intervention, they may eventually drop further – even into the vaginal opening if the supporting muscles and ligaments are particularly damaged or weak.

This condition commonly affects sexual function as well as bodily functions such as urination and defecation, so it’s no wonder it has such an emotional impact.

Timely treatment is important because if prolapse is left untreated, it’s likely to get worse.

The first thing to acknowledge is that prolapse doesn’t just happen to older women – many childbearing women have a prolapse. True, it is often related to ageing and the onset of menopause as the pelvic floor weaken, but many factors increase the risk of prolapse in young women, including:

• Family history of prolapse
• Hypermobility (caused by very flexible tissues)
• Large babies,
• Forceps delivery
• Constipation and straining
• Diastasis recti (abdominal muscle separation)
• Chronic cough

Physiotherapy has been proven to work for prolapse.

Women shouldn’t be living with miserable prolapse symptoms, often combined with a misplaced sense of shame. Prolapse is a physical condition not dissimilar to hernia, and no one is ashamed of those.

Writes: Elaine Walpole. Elaine is a Chartered Physiotherapist with 30 years post-graduate experience the last 16 of which have been in private practice. Her initial focus was on musculoskeletal issues including time working in Sports Injuries clinics. She became interested in how pelvic floor function influenced back and sacro-iliac problems and for the last 8 years she has additionally focused on women’s health, incorporating her musculoskeletal knowledge to benefit patients.

Elaine treats pelvic floor dysfunction in women, including bladder and bowel dysfunction, pelvic organ prolapse, chronic pelvic pain and overactive pelvic floor disorders. She also sees patients with pelvic girdle pain, other pregnancy/post-natal related problems and is a certified MummyMot practitioner. Elaine is also qualified to use real-time ultrasound scanning to evaluate pelvic floor function and is trained to fit pessaries for pelvic organ prolapse.