Identifying Pelvic Organ Prolapse
By Mary O'Dwyer
Many women are interested in learning self-examination skills for detecting pelvic organ prolapse (POP). Self-examination for POP is done in supported lying then standing, with one foot on a stool so gravity helps with assessment. Angle a mirror for observation and keep a pad and pen close to note any findings.
Empty your bladder first and be conscious of relaxing PF muscles during the examination.Cough strongly and look for movement of a vaginal wall down to/out of, the vaginal entrance. Note if a smooth bulge balloons towards the front or back of your vagina or if the firmer cervix is descending.Bear down firmly (pelvic floor relaxed) for 6-8 seconds, looking for any movement down to/out of the vaginal walls.When the cervix or a vaginal wall protrudes like a golf or tennis ball shape, this is a significant prolapse. When the prolapse skews more to one side, a levator ani tendon tear (from the pubic bone) is suspected. When a vaginal wall bulges into your inserted fingers (and not out of the vaginal entrance), the prolapse is contained internally.
Insert 1 or 2 freshly washed fingers vaginally, and note how many finger joints penetrate before feeling the firm cervix at the top of the vagina (feels like a dimpled chin). If the cervix is descended, push it upwards to gauge how far it lifts. Note how far it descends with coughing, then bearing down.
Tighten and lift PF muscles to determine if this action lifts or pushes the cervix down. If the PF muscles feel strong and coordinated during the lift, the utero- vaginal prolapse is more likely due to damage of supporting ligaments and connective tissue (rather than muscle weakness). If the cervix descends, a bearing down action is being used.
Anterior (front) vaginal wall prolapse:
Insert 1 or 2 fingers and place over the front vaginal wall (facing the bladder) to feel any bulging under your fingers, first with strong coughing and then with sustained bearing down. A definite bulge of the wall under your fingers indicates a front vaginal wall prolapse. Next, tighten the PF muscles before coughing to gauge if this action controls any front wall bulging.
Posterior (back) vaginal wall prolapse:
Insert 1 or 2 fingers and place over the back vaginal wall (facing the rectum), to feel any bulging under your fingers, first with strong coughing and then sustained bearing down. A definite bulge under your fingers indicates a back vaginal wall prolapse. Next, tighten the PF muscles before coughing to gauge if this action controls any back wall bulging.
To identify a small intestinal prolapse, hold a tongue depressor (looks like a thick ice cream stick) over the back vaginal wall and reach your fingers up to the top of the back wall. Repeat the coughing and bearing down tests. The small intestinal prolapse presents with the upper back vaginal wall (the area between the back wall and cervix) descending down from above the depressor.
Discuss any positive findings with a gynaecologist and women’s health physiotherapist to determine suitable treatment options.
Habits Contributing To Pelvic Organ Prolapse:
Below are listed the daily habits and conditions that greatly contribute to and aggravate an existing pelvic organ prolapse (POP).
Straining to open the bowel progressively damages nerves supplying PF muscles, causing a loss of bladder and bowel control.Chronic straining weakens bladder, uterine or bowel supports and contributes to POP. Delayed or incomplete emptying is typically due to prolapse of the back (posterior) vaginal wall or failure to release the anal sphincter.
Too Much Fat
Women with a larger waist measurement have a higher risk of pelvic floor dysfunction (incontinence and POP). Visceral fat accumulates internally around the pelvic organs forcing PF muscles to work harder to support the weighted organs. Visceral fat acts like an endocrine gland releasing chemicals that weaken connective tissues ability to recover after damage, e.g. after childbirth or pelvic surgery. Overweight incontinent women gain significant improvement of their continence when they lose weight. Research shows that a diet high in calories and saturated fat (found in cream, cheese, processed meats, fried food) causes a 2.5 times increased risk of incontinence in women, possible due to the inflammatory effect of saturated fat and associated endothelial dysfunction (associated with urinary incontinence).
The internal abdominal pressure created by heavy lifting overwhelms pelvic floor control when the muscles lack quick strength, coordinated lift and hold. If PF muscles fail to lift and hold during heavy tasks, internal supporting ligaments are at risk of being stretched, leading to POP.
Over challenging Exercise
The pelvic floor is a smaller muscle group that is rarely trained to counter internal pressure rises and often fatigues long before the heart or lungs during exercise. The endurance required for a long run, a 60-minute interval class or prolonged exercise is considerable. Pelvic floor damage occurs when the pelvic floor fatigues part way through a workout. Building abdominal strength with upper abdominal bracing exercises increases intra abdominal pressure that has the potential to overwhelm pelvic floor control.
Repeated rises of intra-abdominal pressure or even one sudden, heavy episode may result in pelvic floor damage, even POP, in some women. If continued fast or high-load exercise results in loss of PF and core muscle control, other muscles substitute to provide trunk stability. Over time the body adopts incorrect muscle substitution and altered posture when the PF and core muscles repeatedly fail in their roles of strength and endurance.
Returning to exercise or lifting heavy weights before regaining PF muscle strength and postural alignment postpartum, results in more strain and damage to pre-weakened muscle, supporting ligaments and connective tissue supports.
Conversely, sustained vigorous exercise (without rest periods) in some women results in increased PF muscle tone causing continued muscular over activity. Poor bladder and bowel control, painful intercourse and some pelvic pain syndromes are related to increased resting tone (tightness) in PF muscles. Muscular hyperactivity during exercise is avoided by building in regular relaxation breaks, and changing over challenging exercise or training programmes.
Poor postural control
Sitting and standing tall keeps pelvic floor and core muscles active in their low-level endurance mode. The inner cylinder of postural muscles switches on when we become upright each morning and responds with higher bursts of activity depending on the task involved. Our commonly adopted position of slumped sitting switches off these muscles which help provide pelvic organ support, spinal stability and protect joints against wear and tear from gravitational loading when we sit, stand, walk and exercise.
Women with chronic lung or respiratory disorders (asthma, cystic fibrosis, bronchitis) or who smoke, have a higher rate of stress incontinence. Lifting up PF muscles, described as the ‘knack,’ before coughing helps prevent urine loss and future POP.
Pregnancy and Childbirth
The use of forceps or ventouse (vacuum extraction) to assist birth is associated with a higher rate of damage to PF muscles and tendons. Anterior vaginal prolapse is associated with rupture on the levator ani tendon off one or both sides of the pubic bone when rotational forceps are used to assist birth. POP is more common when the first time mother is over 35, baby is malpositioned, and a higher birth weight, and second stage is prolonged.
Weak Connective Tissue
Collagen is the protein in connective tissue giving strength to skin, joints, muscles, ligaments and tendons. Studies indicate when a mother experiences POP, daughters have a higher risk of future POP. Hyper mobile joints (knees, elbows, fingers and thumbs that bend too far backwards) due to joint laxity and soft tissue elasticity are a predicator of a higher risk of POP following childbirth. It is important for mums with hypermobile joints to focus on PF exercises and protective habits and discuss birthing options with their caregiver. For more information: www.hypermobility.org.
Women’s Health Physical Therapist-Austalia
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