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Pelvic Organ Prolapse And Pelvic Pain With Maureen Mason, PT, DPT, WCSMaureen, welcome to the show. It’s great to have you here. It’s great to meet you, Joe. Thanks for having me on. You’re welcome. I’m excited to speak with you. It’s a new topic this week. We’ve spoken about pelvic pain, men’s health, and women’s health. I know we’re going to go deep into a certain topic that you have some expertise around. You talk about it in a new book that you have coming out, and that’s a topic of pelvic organ prolapse, which can be painful, as you know and as we all know, but there’s a lot to this topic. I think a good place to begin, because it sounds scary to people, is what is pelvic organ prolapse and what’s the cause of it? Pelvic organ prolapse is a lowering of the pelvic organs towards the base of the pelvis, the vaginal opening, and it’s experienced by women. What is lowered in pelvic organ prolapse can be the bladder, the uterus, the bowel, or it can be all three organs descending down. Pelvic organ prolapse is also a hidden condition that it’s still not talked about and people aren’t aware of it in terms of preparation for childbirth and also the menopause transition. When pelvic organ prolapse is experienced, people are typically in shock, fear, and worry. There’s a very high emotional impact as well as them feeling the shame and not wanting to see a provider so it goes untreated and undiagnosed. What are the common symptoms that a woman would experience when this occurs? What would drive them to start seeking help from a pelvic health physical therapist or maybe another provider? What would drive them to see a provider for help would be an uncomfortable odd sensation typically of a bulge or pressure. It might be a general sense down there where people aren’t aware of what’s going on and where it is. A lot of people are disconnected from their pelvis due to a sense of privacy down there and they might not even know what’s going on and live with this pressure and a bulge sensation for years. What would drive them to see someone is more discomfort, heaviness, and pressure. It’s not typically described as pain, but it can become painful when someone feels like they just need to get off their feet, and then finally, their bladder might not empty. The bladder can tip to where the urethra comes out of the bladder. It’s the straw of the bladder that empties. It can get a little kinked up and they can’t empty their bladder. Also, they may have the ability to feel like they need to use the restroom and push but nothing happens. They’re like, “What the heck is going on?” This is very distressing and it can be dangerous too because the bladder is retaining and the bowel, etc. As the uterus descends, it can be very uncomfortable. Intimacy functions are affected. Intimacy may start. There may be a desire for penetration and there’s what’s called Obstructive Intercourse. Intimate relations, sexual relations, and then we have the effect on the relationships if people are unable to have intimate relationships. There’s a broad spectrum of what pelvic organ prolapse can create in terms of discomfort driving people to want to or need to see a provider. You mentioned that there are these typical signs and symptoms, but that some people are “disconnected” from their pelvis, which sounds funny because we’re all anatomically disconnected. I’m wondering if you can give us an idea of what you mean by being disconnected from their pelvis and how that impacts their care. Typically, when pelvic organ prolapse might start it can happen postpartum. If a woman is nursing a child, she’s sleep deprived and she may have some thyroid problems where she’s feeling off. She could be in postpartum depression and suffering from a little bit of perinatal trauma if the birth didn’t go as she wanted it to. We know that women can have a birth plan and think, “I’m going to do it this way. I’m going to have a natural birth.” Maybe, if they need intervention of different nature, they can be in a numb state and that’s trauma. We have perinatal trauma and also the busyness of our lives. If someone is in the menopause transition, let’s say they’re a grandmother and they’re caring for their elderly parents who are almost needing a nursing home. I’ve certainly worked with many women whose prolapse came on while they were caring for their elderly parents and lifting them while they were going through this themselves. They didn’t have time to think about it. It’s similar to the arch that is hurting. People are walking far. They have to walk and they think, “My arch hurts and that’s just the way I am,” or the neck hurts. “My neck hurts because of my work and all my demands. I don’t have time to deal with it.” Like many health conditions, people can ignore it for a while, but then it can go from a chronic problem to something that becomes critical that the body will start to give the person signals that they must see a provider. It becomes pain, alert, and danger. I have to pay attention. What’s going on? What do I do? Typically, younger women and younger generations are more empowered to take a mirror and examine. They look and say, “I’ve heard about this. My friend is talking about it. I know what this is,” and so on and so forth. There is a generational difference historically that the older an individual, the more they might feel a sense of shame and disempowerment due to religion, cultural influences, and things like that. That’s been my experience. People will say, “I don’t want to go down there. It’s down there.” They’re disconnected and that can start with an OB-GYN exam where typically, they were even putting a drape up when they’re examining the woman for the Pap smear and things like that. The woman is relying on the doctor to tell her what’s going on down there. “Am I okay? Am I damaged? What’s going on?” There is disempowerment when one receives a pelvic exam. Those are some of the very important biopsychosocial considerations that providers have to be aware of as well as anyone from the general public tuning into this that it is normal for many women to feel disconnected. It’s normal to not know what’s going on and it can be normal to ignore health conditions for a while too. That can lead to even more trouble when they think, “Why didn’t I come in before? Why didn’t I see someone? I’ve been dealing with this for years.” That’s a great explanation. In there, you’ve already started to touch on a little bit of the potential causes of this. I’ve been listening to them as you’re speaking, but maybe you can guide us to the more common causes that might lead to pelvic organ prolapse. The most common cause is childbirth, and that can be vaginal childbirth, but also cesarean birth. A mother has endured ten months of increasing pressure on the pelvic bowl and the pelvic floor muscles can have some elasticity. The uterus is an amazing organ that can increase so many times in size and then shrink back down but the pressures of the pregnancy and the direct aspects of the birth, whether or not the intervention was needed. A larger baby over 8 pounds tends to put more pressure. We certainly have women that have 9 to 10-pound babies and multiple births. Birth is number 1, 2, and 3, and we celebrate resilience and recovery in the pelvic floor that things can heal and move back up. Pelvic floor muscles can get stronger with time so pregnancy is the actual aspect of the birth and delivery or the birth weight. Also, when a woman is postpartum, if she’s nursing, her estrogen cycle does not return until she ceases nursing. There are target receptors in the pelvic floor muscles and the pelvic floor for estrogen that help the strength. Women have testosterone like men. Testosterone, progesterone, and normal hormone cycling, when it’s temporarily or permanently ceased in the case of menopause, the pelvic floor gets weaker. Another cause is hormone changes. We have mechanical effects and we also have hormone effects. Another fascinating concept is the pressure systems or intraabdominal pressure. Some people are always clearing their throat or even when they talk, they’re pushing down into their pelvis. Women are lifting babies. Older women are lifting suitcases. For life, we need to lift, push, pull, and carry objects. Some people, when they lift things, push down and firm their abdominals, but they create pressure downward. This is called Intraabdominal Pressure. Intraabdominal pressure regulation is very important. If we consider someone with asthma and a chronic cough, chronic bronchitis, or even something like food allergies where they have a lot of phlegm and they are clearing their throat all the time throughout the day, it can cause a little aggravation of a prolapse over time. That’s another thing to consider. In the past, and still, at this current time, we have told women, “Do not squat. Do not lift.” A woman’s got to lift a toddler in a car seat and the toddler might be 30 pounds and so on and so forth. It’s like, “A woman has to be a CrossFit-trained person and lift a baby and carry them and this and that,” and even carry two toddlers sometimes. We know with biomechanics that optimally, when we lift, push, pull, or carry, the pelvic floor engages. The abdominals, the back, and the whole fascial body engage. We’re not only lifting with our pelvic floor and our biceps. Personal training, having people learn to use all their muscle units in synchrony for lifting, pushing, pulling, or carrying. Maybe they went into pregnancy and all they were doing was a little bit of abdominal tightening when they lifted, and then their pelvic floor can be turned off postpartum. It stops working and so they might need to retrain it. Intraabdominal pressure regulation is a big factor to consider, which is fascinating because if someone strengthens their pelvic floor with exercise and they get stronger, that can help the prolapse. However, if several times a day or all day, they’re coughing or clearing their throat, etc., that’s a problem. Also, constipation. Bloating puts pressure on the pelvic floor. Many times in the world of pelvic therapy, people can have prolapse and no one has talked to them about their nutrition, fluid and fiber management, and basic things. Busy moms sometimes might not have time to poop. They might be so busy running around that they might ignore their own signal. For example, you’ve got two kids, you’re going out the door, and you might need to go, but elementary school starts in 10 minutes and you’re 8 minutes from school. Your child says, “Mom, I need to poop.” “Hurry up kid.” At work also. People in business climates where they can’t use a restroom, it’s very common. Medical providers are notorious for not using the restroom because of our busy schedules. A full bladder, if the bladder is being kept too full and then the menstrual cycle affects prolapse too. When a woman goes through ovulation, let’s say she’s postpartum and starts her cycle again. She’s ovulating and having a normal cycle. There are two points in the menstrual cycle where women can experience prolapse or it can come back a little bit and then it goes away. We celebrate a resiliency model on prolapse, and when someone can find out and be a detective with a therapist what is causing this and look at all the drivers, then they’re on the road to empowerment, self-control, and having some control over it. One other thing, Joe, for your question on what causes it, obesity has been linked to prolapse, but we don’t want to have people consider that they need to lose weight and it’ll go away. There are certainly underweight individuals with prolapse as well as individuals with more lax or loose connective tissue. Those individuals, even in a study of twins, with one who went through a pregnancy and the other was a nullipara. She hadn’t had kids and these twins were examined and they both had the same degree of prolapse. Not only pregnancy and menopause transitions, but connective tissue differences can be part of the picture too. Let’s talk about diagnosis and then we’ll venture into the treatment. I’m assuming the diagnosis will be a little bit shorter. Let’s do a diagnosis first. How is this condition diagnosed by various professionals out there? The diagnosis for pelvic organ prolapse is via a urologist, a gynecologist, or a urogynecologist. It could be an internal medicine doctor as well if they’re doing a Pap check or that type of thing. It’s any medical provider. It could show up in the emergency room. A nurse practitioner, a nurse, a community health clinic, or a physical therapist make a musculoskeletal impairment diagnosis. There’s a visual inspection. Is anything bulging beyond the vaginal opening? Also, if the woman does a beardown maneuver, the so-called Valsalva breath holds and beardown, some feel that’s somewhat of a false test to only have someone bear down and do a visual inspection because people are so used to clenching. If they have prolapse, they might not bear it down. They’re on their back and doing something for a provider to check something that they feel shameful about and what might happen later in the day when they’ve been up all day. We wonder what happens in standing. It’s all about standing and function. If we get into more specific details of a diagnosis, there are grades of prolapse and those are based on how many centimeters the organs are moving down towards the vaginal opening. It’s technically called the hymen area, which is a vestigial area of tissue inside the vaginal opening. It can be one centimeter from it or it can be one centimeter up to it. It’s stage one. In stage two, it is starting to come out a little bit. In stage three, things are out, and in stage four, it’s completely out. We can think of this too like a hernia. Hernia can be someone who can lift something heavy. A male might feel it in their groin and it might come and go or it could be the GI system cramping and they need to get in and see someone. It’s diagnosed by a POP-Q. It’s the Pelvic Organ Prolapse Quantification scale. It’s called the POP-Q. Those are done by urogynecologists and that’s a staging technique to determine or make a decision on what type of care would be needed from there on. What does treatment look like for those various stages? There’s a big wheel of treatment that can be done. Surgery is sometimes necessary, but we might consider surgeries not considered actually until a woman’s done breastfeeding for a year. We might have someone in postpartum and think, “I got this diagnosis. I’m in for therapy, but I think I’m going to need surgery.” If they’re nursing and what about a woman that decides, “I’m going to nurse my child for two years?” Education on how long the cessation of estrogen is going to be present and how that might affect the pelvic floor is something an individual needs to consider. However, according to the International Urogynecology Consensus that was published by Kari Bo and others in 2022, the first line of treatment should be pelvic floor muscle training. It’s the number one thing that’s helpful. According to the International Urogynecology Consensus, the first line of treatment for pelvic organ prolapse should be pelvic floor muscle training. Click To Tweet There is a lower grade of prolapse in those that have stronger pelvic floor muscles. With that being said, pelvic floor muscle training is not so easy to do. Forty percent of individuals cannot correctly engage their pelvic floor. They might bear down and make it worse. If someone tries at home to do a whole bunch of workout things for their pelvic floor, they might be aggravating it. They might think, “Pelvic exercise didn’t help.” If possible, see a pelvic specialist and physical therapist for training in this. We have the biggest studies done in the Scandinavian countries because they have socialized medicine and there they see them for at least eight visits making sure they do them correctly. Why? It’s because sometimes people do them correctly. Pelvic floor muscle exercise is also called Kegels, but I prefer to say pelvic floor muscle exercise. They can do them correctly and then they can get off track. It’s similar to physical therapists working with someone with engaging their rotator cuff. They might be engaging it correctly, but the next thing you know, the trapezius is pulling the shoulder up and they’re doing it incorrectly. Exercise is conservative care. We also have estrogen therapy or hormone replacement therapy. It’s lovely. I was naive as a young physical therapist thinking, “Hoorah. Kegels. I’m going to fix this prolapse for this patient.” We boot-camped them with the pelvic floor exercise and they got somewhat better, but they were nursing and still having problems. Years ago, this was for me in my practice, there came hormone therapy, and there went prolapse healing. The woman returned to powder puff football, which she wanted to do. Women playing football and lifting their babies and things. We don’t want providers to put themselves in a box and say, “I’ve got the only thing,” which happens in the medical field. Also, the allied health and fitness trainers said, “You have to do my program.” We need the doctor to prescribe estrogen and dose it. Sometimes, it’s as simple as twice a week of estrogen uses topically. The other thing is pressure management, as I discussed. Some people might be consuming too much dairy and have a sensitivity. Once they taper down on that or maybe go to some hard cheeses, they stop all the throat-clearing, asthma, and allergies. There are many things that can be done. Sometimes there are environmental influences on that. Some people are sensitive to wheat and again, throat clearing and things like that. Fluid and fiber management is huge for optimizing function. People say, “I eat an apple and I have a salad.” Maybe they’re consuming 8 grams of fiber a day. We need to know the guidelines are 20 to 30 grams. I went through this myself as a healthcare provider. I thought, “I’m having salads,” and it’s simple to add one new healthy thing a week to help the GI system as well as maybe some elimination. This is because aside from constipation, there is bloating. People say, “This is how I am.” Bloating is a lot of pressure. If one observes how much their stomach, their lower abdomen can distend, this is happening on the pelvic floor as well. At the base, we have the uterus, the bladder, and the bowel. Another conservative care aspect is pessaries. A pessary is like an orthotic in a shoe. If someone is going to go out for a run, they’re not going to wear their sandals. They’re going to get their best shoes. A pessary is typically a silicone device. It’s like a little disc that is custom-fit. It is inserted in the vaginal canal. It’s placed high up enough to support the bladder to help the uterus to not fall down and the same thing to the bowel. The pessaries tend to work best for bladder prolapse and the uterus is a little more difficult for the person with a back wall coming down. What people need to know about pessaries for conservative management, typically, it takes a fitting and trial of 2 to 3 different types. These are to be prescribed and monitored by a urogynecologist. Some pelvic health therapists in training with urogynecology are fitting pessaries. There can be an aggravation and irritation of the tissues. The pessary, interestingly, has to be big enough to keep things in, but not so big that one can’t remove it. It’s like the orthotic that goes in the shoe that doesn’t fit and you can’t get it in your shoe and it’s pushing your foot out of the shoe. It’s nice to think of as an orthotic. Also, women with comfort with self-palpation, examining and putting the pessary in and out. There are pessary removal tools. A woman might take a pessary in and out on her own every couple of days or leave in. We do know from research, a year’s worth of pessary use can reduce the stage of prolapse by one stage. That’s long-term use. Women that have difficulties with the insertion of a pessary and removal might keep it in for a month and they go into their urogyn once a month and have the pessary checked and observation of the tissue to make sure there’s no irritation of any of the tissue and so on. Those work, usually, they can help in conjunction with estrogen therapy for some people. There’s perhaps 20%, maybe even 30% that don’t tolerate them. Before we get to surgery, there’s one more thing that could be helpful for people and that’s manual therapy. Manual therapy is a hands-on technique to assist externally. Let’s say someone has a cesarean scar and there’s a little stiffness inside where the bladder sits. The front wall of the pelvis where the bladder sits, the bladder can’t move up and down. Manual therapy combined with visceral therapy, internal can help the bladder glide upward. It’s the same thing with the uterus and the bowel. Now if there’s scar tissue from let’s say an episiotomy, which is an incision that is made to assist with the birth, we could consider that episiotomy could be a stiffness spot that’s holding things down and pulling down on the back wall. Manual therapy can glide, have the person contract and relax, help the stiffness of the tissue, and allow things to glide upwards. Someone is trying to contract their pelvic floor. Imagine they have a cesarean scar and maybe they had an episiotomy from another birth. These things are all a little bit like anchors dragging down. We have wonderful research that’s new on this approach called Biotensegrity which looks at the geodesic dome by Buckminster Fuller, but that’s throughout the whole body, our myofascial networks. The bladder is not only suspended by one thread, like a piece of yarn. It’s the same thing with the uterus and with the bowel. Biotensegrity looks at the ribcage and how everything is working in the abdominal wall. It’s the same thing with manual therapy. These are specialty treatments and then we have surgery for pelvic organ prolapse. The surgery can be successful. We know some people might be, for example, a triathlete and they might not want to deal with conservative care. Maybe they have their strength. They don’t have constipation or anything like that. They have surgery and it can be successful. However, there is, unfortunately, a repeat surgery rate between 20% and 30% and that can be within a few years. I do want to mention mesh because mesh has been in the literature here in America. We see ads, “Did you have mesh?” The wrong type of mesh was used for several years. It was an experimental type of mesh and it didn’t allow the myofascial fibers to engage in it. The body made a big scar out of it. That is something that people hear about. They’re still going to hear about, “I can’t have mesh.” Our pelvic floor organs and the myofascial tissue are somewhat delicate tissues and in many cases, mesh has to be used. The American Urogynecology Association, a few years ago, made a statement that mesh is safe to use in the hands of an experienced provider that’s an expert with it. I want people reading this to know that if you’re going to have surgery and hopefully, you’ve experienced conservative care that can help set you up for an excellent surgery, a mesh can be part of the surgery and it can be helpful. The American Urogynecology Association made a statement that mesh is safe to use in the hands of an experienced provider that's an expert with it. Click To Tweet Maureen, it’s been great speaking to you about pelvic organ prolapse and the way to diagnose and treat it. Also, all the education and learning around it. I know a lot of this you have wrapped up in a new book. If you can tell us the name of the new book and how people can learn more about you. Thanks for asking that, Joe. I had a calling to write a book and therapists over the years kept asking me to write one. Finally, a publisher approached me, Handspring Publishing. It’s a wonderful publishing house and they’re now a Singing Dragon also. Pelvic Rehabilitation: The Manual Therapy and Exercise Guide Across the Lifespan is now available at major booksellers. There’s a Kindle version as well. That book goes through the basics of how our pelvic floor muscles work and what we need to do for how the bladder works, how the bowel works, and how the muscles work together. There’s a chapter specifically on pelvic organ prolapse in the postpartum challenges. People can look up the book and it’s a great read. People are loving it. It’s for the public as well as healthcare providers are buying it for themselves in their departments. I have CentralStationWell.com as my website. I will have some information on prolapse up for people for more detail. There are wonderful exercises too that some women can do some decompression with Cat Camel and then Down Dog and these types of things. Also, they can elevate their hips and build up to weightlifting. I have an outline of an exercise series that can be in there as well as hypopressive exercise. That is a different way of breathing and engaging the pelvic floor that takes some training. I recommend for everyone check out the book. It’s called Pelvic Rehab: The Manual Therapy and Exercise Guide Across the Lifespan. You can find it at most major booksellers such as Amazon. You can also check out Maureen on her website. At the end of every episode, I ask you to share this information with your friends and family on Facebook, LinkedIn, or Twitter. I’m on Instagram the most. You can find me @DrJoeTatta. I’d love to see you there and connect with you and with Maureen. I thank you all for being here and we’ll see you next episode.
- Maureen Mason
- Pelvic Rehabilitation: The Manual Therapy and Exercise Guide Across the Lifespan
- @DrJoeTatta – Instagram