What is a prolapse?
A prolapse is the name used when the organs in your pelvis (your uterus, bladder and/or bowel), drop down into the vagina instead of sitting in their normal position. This can cause a heaviness, dragging or aching type of feeling in the vaginal area, which often feels worse at the end of the day, and better in the morning or after lying down. Some women also notice lower abdominal aching and backache due to having a prolapse. A bulge in the vaginal area may also be felt, and sometimes this bulge may actually be felt outside of the vaginal opening. Another way many women describe the feeling of having a prolapse is "that it feels like everything is going to fall out".
Why can a prolapse happen?
The pelvic organs are supported from above by supportive ligaments and from below by the pelvic floor muscles and fascia (fibrous tissue within the pelvic floor). If either or both of these structures weaken, there is less support for the pelvic organs and they can start to drop down.
There are many reasons that this could occur. These include:
Having a weak pelvic floor
Not doing your pelvic floor muscle exercises regularly can increase the chance of your pelvic floor muscles weakening during and after pregnancy. This means that they are less able to support your pelvic organs, and more pressure is placed on the supportive ligaments. If these stretch, then it is more likely that the pelvic organs can drop down and a prolapse can occur. A strong pelvic floor provides more support for your pelvic organs, and hence reduces the chance of a prolapse developing.
Body type. Some women have softer 'connective tissue' than others, which means the ligaments that support your pelvic organs loosen more easily. This means they are more likely to stretch during pregnancy and childbirth or after, so there may be a higher risk of developing a prolapse if this is the case. Unfortunately there is not a lot you can do about this, apart from following the advice on "What can I do if I have a prolapse?" as a precaution. Also, diligently doing your pelvic floor exercises will improve the ability of your pelvic floor to support your pelvic organs.
Pregnancy. Pregnancy weakens the pelvic floor muscles due to the weight of the growing baby, and due to the relaxin hormones, which soften the ligaments in the body together with the fascia in the pelvic floor. If the pelvic floor muscles are not strengthened during pregnancy, they are more likely to stretch and weaken, which can increase the chance of a prolapse occurring. There is not much that we can do to control the amount of relaxin hormone in our body, but we can strengthen our pelvic floor muscles so that they do provide the best support possible for our organs.
Childbirth. After the birth of your baby, your pelvic floor muscles are usually stretched, unless you had a caesarian without going through the pushing stage of labour. If your baby is quite big when he or she is born, or you were pushing for a long time (more than two hours), or you needed help to have your baby (suction or forceps), it is likely that your muscles are more stretched. They often feel quite weak and when you stand up or walk around, it may feel like things are dropping down, or "everything is going to fall out".
If the muscles are not strengthened and toned up again after the birth, and remain saggy, then there is more chance of a prolapse developing at some stage in the future.
The effect of gravity on a weak pelvic floor soon after the birth. A lot of walking or being on your feet in the first few days or weeks after the birth can mean your muscles get tired more easily and stretch more. This can cause an uncomfortable dragging or heavy feeling down below in your vaginal area. Frequent rests lying down are important at this stage, and only walking for short periods at one time can prevent or reduce this feeling until your muscles strengthen.
Increasing your activity levels.When you go home, if you suddenly start to do a lot more and are on your feet more than you were in hospital, sometimes this can cause a prolapse, or even just achiness or heaviness vaginally. Again, more frequent rests lying down can help at this stage if you do experience this.
Going for a walk and suddenly increasing your distance or the time you walk for is sometimes more than your pelvic floor can 'handle'. A certain amount of walking might be fine, but if you go further your muscles get tired, and then you can feel heaviness, discomfort or achiness. This is a warning sign that you should not push through, otherwise you could encourage a prolapse to develop.
Placing strain on the pelvic floor muscles. During pregnancy or after the birth, if the muscles of the pelvic floor are weak, and there is a lot of strain, eg from lifting placed on them, they are more likely to be overstretched and weakened further. Heavy lifting (more than the weight of a baby) may place undue stress on the muscles and they can weaken, increasing the risk of a prolapse developing. Some women can actually relate to a particular lifting episode when they felt some pain or pressure in their lower tummy or vaginal area. They then noticed a bulge and heaviness not long after this.
Being on your feet for a long time when the muscles are weak or have weakened can place strain on the pelvic floor. This may include doing all the housework in one go, or being out all day walking around at the shops. During pregnancy or after the birth you may notice any of the prolapse signs or weakness of your pelvic floor muscles. Again, consider this as a warning sign, and try to follow the advice on "What can I do if I have a prolapse?"
Straining to use your bowels or bladder. If you push or strain to empty your bladder, then this can increase the strain on the pelvic floor muscles and over time weaken them. You should be able to empty your bladder without having to strain. If you strain regularly to use your bowels, this also causes a lot of strain downwards on the pelvic floor muscles. If this happens over long periods of time, it can cause a prolapse to develop, and also can increase the chance of incontinence.
Going back to sport, aerobics or high impact exercise too soon. Returning to sport or high impact exercise soon after the birth can also increase the chance of a prolapse, if the pelvic floor muscles are not yet back to normal. Bouncing type of activities can increase the stretch also to the supporting ligaments, so that they do not hold the pelvic organs up in place so well. This can mean that a prolapse can occur, even though you may actually be feeling ready on the outside for more vigorous activity.
I thought prolapses only happened to women when they got older, but I heard that younger women can get them too. Is this true?
Yes it is true. Women can develop a prolapse even after their first or second baby. It does not only happen to older women. It is not uncommon to have women come in during the later stages of pregnancy, or soon after the birth of their baby saying "everything feels heavy down below in my vaginal area".
An example is Alicia (not her real name), who's story has been used with permission.
Alicia was 29 years old when she had her first baby. When her baby was 6 weeks old, Alicia noticed a bulge in her vaginal wall, which she felt and could see when having a look. It felt uncomfortable, and she thought at first that she had developed a growth overnight. She was quite worried as she didn't know what it was. She also felt some heaviness in her vaginal area and achiness in her lower abdominal area. After an exercise session she felt worse.
After seeing her doctor, she then went to see her Physiotherapist. She had been doing her pelvic floor muscle exercises, but after recently reading the article How NOT to do your pelvic floor exercises, had discovered that she hadn't been doing them correctly. She had been tightening her bottom and leg muscles more than her pelvic floor muscles. This had made her feel that she had been getting a good strong squeeze of her pelvic floor muscles, when in fact she hadn't.
Checking of her pelvic floor muscles by her Physiotherapist showed also that her pelvic floor was really only holding for about 1 - 2 seconds, rather than the longer hold she thought she was experiencing. Her muscles got tired very quickly, as she hadn't been exercising them correctly. She now realized that during her pregnancy, she probably wasn't exercising the muscles correctly either.
Once she learned how to really feel her pelvic floor muscles, she was able to work them properly together with her lower abdominal muscles (which can also help the pelvic floor to work when done correctly). She was given some other advice from her Physiotherapist, to help minimize strain on the prolapse.
Do Pelvic Floor muscle exercises really help?
Several weeks later Alicia returned for a follow up Physiotherapy appointment. She had not been able to do her exercises as regularly over the past week, due to having visitors staying with her. She had noticed that her pelvic floor muscles didn't feel quite as strong, and while exercising the day before, "things felt a bit looser" than they had previously. Her lower tummy muscles also felt less toned and “more saggy”, from not having time to do the postnatal abdominal bracing exercises regularly.
This weakening occurred even over a week, because Alicia was still in the process of returning back to normal after the birth. Once she starts her exercises again more regularly, she will again improve quickly because of the work she had done the weeks before. But it does show how the exercises do help!
Alicia admitted she didn't regularly do her pelvic floor exercises through her pregnancy as she didn't think they were that important. Now that she knows how to do them properly though, she will make sure she continues with them and will be extra diligent next pregnancy.
Another lady found that she was better after her second baby than her first, because she knew what to do. She did her exercises more regularly the second time around during her pregnancy, and also knew how to do her exercises really well, after having Physiotherapy following her first baby due to a prolapse.
How quickly can I expect to improve if I do have a prolapse?
Alicia followed the advice given about “What can I do if I have a prolapse", and diligently did her pelvic floor muscle exercises (correctly), after seeing her Physiotherapist.
The following week she came back for a check and was feeling a lot better. There was no heaviness or achiness and she could even squat down, holding her pelvic floor muscles in and not feel everything dropping down. She had exercised the day before and felt OK afterwards. She no longer had the bulging feeling, nor could see the bulge. She felt that it was getting much easier to do her pelvic floor exercises and when they were checked by her Physiotherapist, this was confirmed. They were working much better.
Not everyone will improve so quickly after experiencing prolapse symptoms. Sometimes it can take a few months and unfortunately for some women, it does not completely go away. Some women have found that they continue to gain improvement even over twelve months after the birth. Sometimes once women stop breast feeding, they continue to notice that their muscles tone up and that their prolapse improves.
So again, prevention where possible is better than cure!
What can I do if I have a prolapse?
If you develop a prolapse during pregnancy or after the birth of your baby, there is a good chance that it can be temporary, due to your pelvic floor muscles being weakened, and the effects of the relaxin hormone from pregnancy. As the effects of the relaxin leave your body, and your pelvic floor muscles strengthen, the support for your pelvic organs can continue to improve over the months following the birth.
You can follow the advice given to Alicia by her Physiotherapist, which can help the prolapse to reduce or go away, or prevent it from getting any worse. Do everything possible initially to reduce the strain on and improve your pelvic floor muscles, otherwise the longer the prolapse stays there, the more likely it is to become permanent.
Follow the advice below, even if you do not notice a bulge or feel like everything is going to fall out. Heaviness, aching or dragging feelings can also be a warning sign that your muscles are weak, and can be felt before a prolapse develops. These should not be ignored if experienced.
Regular pelvic floor exercises. Work regularly throughout the day on your pelvic floor muscle exercises. If your muscles get tired quickly, it is better to do shorter sessions, but more often through the day. If you do too many exercises at one time, you can make your muscles really tired, and then the prolapse may feel worse.
When possible, lying down is better than sitting or standing. Even 5 - 10 minutes throughout the day when you get the opportunity can help to take the weight of your pelvic organs off your pelvic floor and give it a rest so it doesn't get so heavy and drop down. Learning to feed your baby lying down can be helpful, rather than having to sit every time. As you feed your baby regularly, this can provide a good opportunity for that rest. Often heaviness and achiness from a prolapse can be worse at the end of the day, particularly if you have been on your feet a lot. Frequent rests throughout the day can prevent or reduce this.
Space out your activities. If you have housework, washing or ironing to do for example, try not to do it all in one hit. Spread what you can throughout the day, or try to space housework over different days when possible. Make the most of any help that you do have available, so that you can avoid some of these activities until you are feeling better.
Don't push through warning signs or the feelings of a prolapse. It is best not to push through the feeling of heaviness in your pelvic floor or vaginal area. This usually happens when your muscles are quite tired and the organs are dropping down more. Take the time to rest, to help this feeling to go away more quickly.
Brace your pelvic floor muscles during daily activities.Brace (lift and tighten) your pelvic floor muscles when you lift your baby, hang out washing, are standing at the sink, or if you have to squat down to pick something up or out of a low cupboard.
Minimize lifting. Try to avoid lifting anything heavier than your baby. If you have a toddler, try to encourage your toddler to climb up to you while you are sitting on the lounge or a chair. Wherever possible, try not to lift them. This will reduce the strain downwards on your pelvic floor muscles.
Avoid straining to use your bowels.Try to keep your motion soft by drinking plenty of water and looking at your fibre intake if your motion is hard. Refer also to "How do you go to the loo" in As Your Shape Changes for further tips on how to make it easier to go to the toilet.
Do your pelvic floor exercises lying down. Try your pelvic floor exercises lying down with a cushion or pillow underneath your bottom. Women who do this may feel “everything lift back up”, compared to when standing, and this position allows you to really feel your pelvic floor muscles drawing up inside. Even resting in this position during the day can be helpful. If you are still bleeding a lot after having your baby, you may prefer just to lie flat, rather than lifting your bottom up while resting or exercising, until the blood flow has reduced. If you are pregnant, just lying on your side can be helpful, but not flat on your back to exercise (after 16 weeks of pregnancy).
Minimize squatting down. Avoid squatting down when possible, if you feel like "everything is going to fall out" in this position. As your muscles get stronger, you can tighten them as you squat down, and this feeling should lessen.
Be careful when exercising. Try not to do any bouncy type of exercises, or to walk for long periods at one time. If you feel any heaviness, achiness or bulging after you have exercised, this means that you have done too much at this stage. Reduce the amount of exercise you do, so that you do not feel any worse after you have finished, or the next day.
Avoid abdominal curls ups, sit ups and crunches. Avoid doing abdominal curl ups, sit ups or crunches as these can place pressure downwards on your pelvic floor muscles and further weaken the muscles.
Start postnatal abdominal bracing exercises. Focus on lifting your pelvic floor muscles first when you do your postnatal abdominal bracing exercises, so that you don’t any strain or pressure on the prolapse (provided you do them correctly). When you focus on lifting the pelvic floor muscles first and then drawing in your lower abdominal muscles, don't hold your breath.
NOTE: It is OK to gently push a bulge back into your vagina, when you notice it has dropped down. Obviously make sure you do this with clean hands, and try to follow this with bracing your pelvic floor muscles, or lying down for a while. Check with your doctor, or Midwife if you are not sure about doing this.
It is also OK to have intercourse if you have a prolapse. It is not likely to make it worse, however you may need to lie down for a while afterwards if your pelvic floor muscles feel tired, or you feel any heaviness or achiness due to the extra blood flow to the area during intercourse.
Click here to download a free factsheet called "What is a prolapse"
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