Pelvic organ prolapse occurs when a pelvic organ—such as your bladder or uterus—drops (prolapses) from its normal place in your lower belly and pushes against the walls of your vagina. This can happen when the muscles that hold your pelvic organs in place become weak or stretched.
Many women will have some kind of pelvic organ prolapse. It can be uncomfortable or painful, but is not typically a serious health problem. It doesn’t always get worse, and it has been shown that with work it can get better!
More than one pelvic organ can prolapse at the same time. Organs that can be involved when you have pelvic prolapse include the bladder, rectum, uterus, urethra or small intestine.
A bladder prolapse (cystocele) is most common, and occurs when the tissues that hold the bladder in place are stretched or weakened. This causes the bladder to move from its normal position and press against the front wall of the vagina, forming a bulge.
A uterine prolapse occurs when a woman’s pelvic muscles and ligaments become weak, allowing the uterus to drop from its normal position and the cervix to bulge into the vagina.
A rectocele occurs when the tissues and muscles holding the end of the large intestine (rectum) are stretched or weakened, allowing the rectum to move from its regular position and press against the back wall of the vagina.
There is much that can be done to improve your prolapse!
You will need to work with a physiotherapist who works in pelvic health to make a program of exercises and other healthy habits that is specific to you and your situation and lifestyle.
Some things you can do to help:
Pelvic floor strengthening exercises (called Kegel exercises) can help to build support at the bottom of your core
Reach and stay at a healthy weight
Avoid lifting things that are too heavy for you, as it can put stress on your pelvic muscles
Caution with higher impact exercise and activity, and possibly switch to lower impact exercise
Avoid straining with bowel movements, and increase fibre intake
Try “the Knack”, which is a technique of engaging your pelvic floor muscles just before you cough, sneeze or lift in order to better manage the pressure increase
Urinary frequency and urgency are very common issues. If you’re usually going more often than that, or are always needing to know where the toilet is wherever you go, it is possible to train your bladder to be a better reservoir by using your pelvic floor muscles.
What is “overactive” bladder?
The bladder can become irritable or “overactive”, making you pee more often. This could be due to habit, if you often empty the bladder before it is full. If your bladder never fills up, it doesn’t ever expand and can become smaller over time. But this can be reversed! You can use your pelvic floor muscles to train your bladder to hold more urine before you need to pee.
It is important that you first get checked by your family doctor, and assuming there is no infection or other medical reason, you can get some help from a pelvic health physiotherapist, who has advanced training in working with pelvic floor muscles and other structures in that area.
What to do?
If you feel you need to urinate more than every 2 hours, try not to go with the first urge you feel.
When you do feel the urge to pee:
be still (standing or sitting) and tighten up through your pelvic floor muscles
try to distract your brain at the same time with something else
Doing this can help settle down the urge to urinate. If after a minute or two you still need to go, try to walk to the toilet slowly. If the urge to pee has settled down, try to delay going until you feel an urge again. Over time you are trying to lengthen the time between visits to the toilet.
A physiotherapist trained in pelvic health can help to improve these issues further, by listening to your own experience and making a plan forward that is individual to you. If you continue to struggle with urinary frequency or urgency, speak with your physio about this.
It is fair to say that the pelvic floor group of muscles is pretty much ignored by most people until they have an issue like urinary incontinence or urgency. Think of this group as any other mucle in your body, that needs to know how to turn on and off easily, and be coordinated with other parts of the core. This “One Minute Wellness” video explains all about the pelvic floor, and how engaging these muscles can help improve strength and control at the base of your core.
The pelvic floor group of muscles work like every other muscle in your body, but are generally ignored until someone has an issue! Here’s how to make sure you’re engaging (and releasing!) properly.
Kegel Exercises for Men
Post-Prostatectomy May Not Always Be Good
Pelvic floor physiotherapy does not equal Kegels. It also involves
teaching each patient how to manage the increased pressure in the system when
they cough, sneeze or move, and also learning how to appropriately engage their
pelvic floor muscles as they are moving in certain ways. Each patient is different: many men don’t
properly engage their pelvic floor muscles, and other men might keep their
pelvic floor muscles engaged too much of the time and need to learn to relax
them.
A new study in International Urology and Nephrology, suggests
there may be a subset of post-prostatectomy patients who need to learn to relax
their pelvic floor in order to improve incontinence. Many men have significant
incontinence initially following radical prostatectomy—not just stress urinary
incontinence, but a consistent drip requiring the use of many pads through the
day and night. Of course they improve as time goes on, and continence improves
first when the man is not moving (sitting or lying down). Commonly, men continue
to leak with movement for several months.
Many men get in the habit of engaging their pelvic floor consistently in
an effort to prevent any leaking, and over months can lead to them having
difficulty getting those muscles to relax.
Keeping the pelvic floor muscles tight too much of the time can lead to
urinary urgency and frequency. As well,
men often urinate more frequently because they don’t want to leak, so over time
their brain teaches the bladder to become less of a reservoir.
The above retrospective study had136 patients with post-RP SUI who were
treated with pelvic physiotherapy. Of these, 25 had underactive pelvic floor
muscles, 13 had overactive pelvic floor muscles, and 98 had evidence of both.
All men received therapy to either relax or strengthen their pelvic muscles.
The total number of pelvic physical therapy sessions depended on a patient’s
progress. Incontinence improved in 87% of them, with 58% achieving what is
considered the optimal improvement of needing 2 or fewer protective pads per day.
Further, pain was a problem for 27% of the men, but that proportion dropped to
14% by the end of therapy.
The authors concluded that this study was the first to demonstrate that
pelvic health physiotherapy can be a beneficial treatment modality for men who
have pelvic pain after prostatectomy, because the pain for some men may be due
to pelvic floor muscle overactivity.
It appears that men who have surgery often develop pelvic floor
overactivity or muscle tightness postoperatively, and any type of pelvic floor
dysfunction can lead to stress incontinence. Kegel exercises can worsen pelvic
floor overactivity, and are not the best treatment for every patient.
Nearly all men have urinary incontinence immediately after a
prostatectomy, but that percentage drops to about 5% to 20% within 24 months
following RP. Men who have not seen improvement within 2 to 6 months should
seek physiotherapy.
It was also concluded that pelvic floor training engages the patient in
their rehabilitation process, and is a good resource to utilize
postoperatively. It also underscores that personalized treatment of post-RP
incontinence may be warranted, as some patients will benefit from strengthening
work, while others need to learn to relax their pelvic floor muscles.
Reference Scott, KM,
Gosai E, Bradley MH. et al. Individualized pelvic physical therapy for the
treatment of post-prostatectomy stress urinary incontinence and pelvic pain
[published online December 5, 2019]
Pelvic floor physiotherapy does not equal Kegels. It also involves
teaching each patient how to manage the increased pressure in the system when
they cough, sneeze or move, and also learning how to appropriately engage their
pelvic floor muscles as they are moving in certain ways. Each patient is different: many men don’t
properly engage their pelvic floor muscles, and other men might keep their
pelvic floor muscles engaged too much of the time and need to learn to relax
them.
A new study in International Urology and Nephrology, suggests
there may be a subset of post-prostatectomy patients who need to learn to relax
their pelvic floor in order to improve incontinence. Many men have significant
incontinence initially following radical prostatectomy—not just stress urinary
incontinence, but a consistent drip requiring the use of many pads through the
day and night. Of course they improve as time goes on, and continence improves
first when the man is not moving (sitting or lying down). Commonly, men continue
to leak with movement for several months.
Many men get in the habit of engaging their pelvic floor consistently in
an effort to prevent any leaking, and over months can lead to them having
difficulty getting those muscles to relax.
Keeping the pelvic floor muscles tight too much of the time can lead to
urinary urgency and frequency. As well,
men often urinate more frequently because they don’t want to leak, so over time
their brain teaches the bladder to become less of a reservoir.
The above retrospective study had136 patients with post-RP SUI who were
treated with pelvic physiotherapy. Of these, 25 had underactive pelvic floor
muscles, 13 had overactive pelvic floor muscles, and 98 had evidence of both.
All men received therapy to either relax or strengthen their pelvic muscles.
The total number of pelvic physical therapy sessions depended on a patient’s
progress. Incontinence improved in 87% of them, with 58% achieving what is
considered the optimal improvement of needing 2 or fewer protective pads per day.
Further, pain was a problem for 27% of the men, but that proportion dropped to
14% by the end of therapy.
The authors concluded that this study was the first to demonstrate that
pelvic health physiotherapy can be a beneficial treatment modality for men who
have pelvic pain after prostatectomy, because the pain for some men may be due
to pelvic floor muscle overactivity.
It appears that men who have surgery often develop pelvic floor
overactivity or muscle tightness postoperatively, and any type of pelvic floor
dysfunction can lead to stress incontinence. Kegel exercises can worsen pelvic
floor overactivity, and are not the best treatment for every patient.
Nearly all men have urinary incontinence immediately after a
prostatectomy, but that percentage drops to about 5% to 20% within 24 months
following RP. Men who have not seen improvement within 2 to 6 months should
seek physiotherapy.
It was also concluded that pelvic floor training engages the patient in their rehabilitation process, and is a good resource to utilize postoperatively. It also underscores that personalized treatment of post-RP incontinence may be warranted, as some patients will benefit from strengthening work, while others need to learn to relax their pelvic floor muscles. Reference Scott, KM, Gosai E, Bradley MH. et al. Individualized pelvic physical therapy for the treatment of post-prostatectomy stress urinary incontinence and pelvic pain [published online December 5, 2019]. Int Urol Nephrol
Let’s
face it—giving birth is trauma to the body, and it takes time to heal before
returning to anything even remotely athletic.
Several authors established the guidelines below based on the
classifications from the Royal College of Obstetricians and Gynecologists
(Goom, Tom & Donnely, Grainne & Brockwell, Emma. (2019). Returning to
running postnatal – Guidelines for medical, health and fitness professionals
managing this population.)
I
can summarize it all by saying 3-6 months, depending on several factors, and it
is best to start with low impact exercise and progress to running.
0-2 Weeks:
•
Pelvic Floor muscle exercises (Kegels)
•
Basic core exercises (e.g. pelvic tilt, bent knee drop off, side lying
abduction)
•
Walking
2-4 Weeks:
•
Progress walking/pelvic floor muscle/core rehab
•
Consider introduction of squats, lunges, bridges
4 -6
Weeks:
•can
introduce biking, cross trainer or other low impact exercise, if new mother is
comfortable
6-8 Weeks:
•
Scar mobilization (for either C-Section or perineal scar)
•
Power Walking
•
Increased duration/intensity of low impact exercises
•
Deadlift techniques beginning with light weights, no more than the weight of
the baby in a car seat (15kg) with gradual load progression (e.g. barbell with
no weight). This aims to strengthen and restore strategies for carrying out the
normal everyday tasks required when caring for a newborn and/or older sibling
8-12 Weeks:
•
Introduce swimming (if lochia has stopped and there are no issues with wound
healing)
•
Spinning (if comfortable sitting on spinning saddle)
Assessment
of Pelvic Health
•
Return to running is NOT advised if the following is present:
•
Urinary and/or fecal incontinence
•
Pressure/bulge/dragging in the vagina before or during the start of running
•
Ongoing or onset of vaginal bleeding, not related to menstrual cycle, during or
after attempted low impact or high impact exercise
•
Reduced pelvic floor muscle endurance. Recommended baseline in standing:
10 x fast reps, 10x 6-8 second holds,
and 60 seconds submaximal (30-50% contraction) hold
•
strength testing of the pelvic floor muscles by a Physiotherapist should be
> Grade 3/5
Objective
Assessment
Before
returning to running, it is recommended that the new mother needs to be able to
complete the following without pain, heaviness or incontinence:
•
Walking 30 minutes
•
Single leg balance 10 seconds
•
Single leg squat 10 repetitions each side
•
Jog on the spot 1 minute
•
Forward bounds 10 repetitions
•
Hop in place 10 repetitions per leg
Aim
for 20 repetitions of each test:
•
Single leg calf raise
•
Single leg bridge
•
Single leg sit to stand
•
Side lying abduction
And
Other Considerations:
Weight: increased weight
puts greater load on the pelvic floor
Fitness: it is better to
start with lower impact activities, and where you have to start will depend on
your birth experience and symptoms
Breathing
matters!
Diastasis Recti: expert
consensus is that a mother can return to running if the DR is functional (there
are strategies to control intro-abdominal pressure) and not before
Scar Mobilization: Both C-Section
and perineal scars can result in pain and restriction. It is recommended to
assess and implement advice and guidance regarding scar mobilization.
Sleep: Sleep
deprivation (<7-9 hours/night) is associated with increased risk of injury,
increased stress, and may reduce muscle protein synthesis. Education regarding
optimizing sleep, day-time naps and good sleep hygiene may be warranted.
So…
clearly it is more involved than just “3-6 months”. If you are not leaking, feel psychologically
ready, and can perform the above pelvic floor and strength testing, it would
still be smart to return to running using a walk:run program, such as 1 min run
and 1 minute walk (with the run speed being able to hold a conversation, not
faster), with gradual increase to 10:1
The
Physiotherapists at Elevation Physiotherapy & Wellness excel at the proper
and safe return to running after baby. Contact us anytime to make sure your
pelvic floor health is adequate, and we can devise an individual program for
you to improve strength to reach all of your fitness goals!
Symptoms of urinary urgency or frequency are very common
and can be incredibly disruptive to your life. It is not a good feeling to have
to run your life by where your next bathroom is.
A physiotherapist with advanced training to treat pelvic
floor dysfunction can help! There are several factors that you need to look at:
1. Consider your pelvic
floor: the pelvic floor muscles work like every other muscle in the body,
they’re just inside. It is important to make sure you can properly engage those
muscles and also relax the muscles easily. These muscles can be involved with issues with urinary urgency and
frequency or pelvic-area pain.
2. Measure things:
sometimes certain tools can be used to get a big-picture sense of what is going
on, and can help your Physio design the plan that will help you fastest. These
can include tests like:
Bladder
diary- provides a picture of your
bladder and bowel habits, how much and what you drink to figure out any
patterns. Constipation is important to address as it can impact bladder
function as well as pelvic pain.
DASS
(Depression, Anxiety and Stress Scale)
PCS
(Pain Catastrophization Scale)
4. Look at
everything: a thorough physiotherapy
assessment includes looking at how you breathe, your posture, how you move,
your lower back, and overall strength—not just the pelvic floor itself. The
pelvic floor muscles are very important with urinating, having a bowel movement,
and sexual function. There are many
reasons for the onset of overactive pelvic floor muscles, and it is important
to get to the driver or source of this in order to move symptoms forward.
5. Diet modification–
caffeine, alcohol, carbonated beverages, tomato products, citrus fruits and
juices and cranberry juice are several irritants that can contribute to intense
discomfort. Sometimes they need to be stopped for a period of time to help
symptoms.
6. Breathing– HOW
you are breathing matters! Purposeful deep breathing can calm your nervous
system, and can be one of the easiest, yet most effective, interventions to
learn.
7. Help improve
sleep– three out of four people who have ongoing pelvic pain have
difficulty staying asleep, and that is worse if you have to get up in the night
to pee. Going to sleep at the same time every day, staying warm, and no screens
right before bed can all be helpful.
8. Manual therapy–
different treatment techniques will be helpful for different people—one thing
does not work for everyone, of course! Your Physio will likely want to work
with stretching or strengthening different muscles (pelvic floor and others),
and techniques for your nerves and connective tissue With the pelvic floor,
it is possible to be both too tight and too weak, and lengthening must be
addressed first.
9. Exercise:
exercises that are fun, non-irritating and novel will help to change the brain
to look at pain differently.
All of these things can help change pain, frequency or
urgency issues to help get better, faster!
Pelvic organ prolapse (POP) is when the
bladder or the uterus starts to descend in the vagina due to the muscles and
connective tissue in the area not providing enough support. It is not typically
painful per se, but can create a feeling of heaviness and pressure in the
vagina that gets worse the longer a person is on her feet.
Pelvic support changes throughout the day!
The degree of descent can depend on pregnancy, the contents of the bowel and
bladder, hormones, recent physical activity, stage in the menstrual cycle—the
list goes on.
So… there are several factors that could
influence the support of the pelvic floor:
Change in the strength of the
levator ani muscles of the pelvic floor: strengthening means they can better resist
the downward movement of the pelvic organs with pressure changes due to
breathing and movement. If the levator ani muscles are worked regularly, they
show improvement in strength, endurance, coordination and function— and the
nervous system is better able to recruit the muscles.
Connective tissue changes:
pelvic ligaments in those with prolapse are longer than those without prolapse.
The bladder, urethra, vagina and uterus are attached to the pelvic walls through
connective tissue called the endopelvic fascia, and that can be vulnerable due
to childbirth and repetitive straining. It is not likely that the connective
tissue will adapt much to pelvic floor muscle strengthening, but the prevention
of further stretching of the ligaments is positive.
Hormonal influences are huge:
estrogen receptors in the bladder, uterus, vagina and pelvic floor can make
collagen to increase the thickness of the vaginal wall. With decreased estrogen with menopause, the
vaginal walls can become thinner, more acidic and have decreased blood flow. An
estrogen supplement can lead to reproduction of collagen to support the tissues
to withstand downward forces.
Pressure changes: the pelvic
floor responds to what is happening above it, and adjusts the pressure; be sure
to contract the pelvic floor before coughing, sneezing, laughing etc to better
manage the pressure system.
Time of day- people report that
POP seems to worsen as the day goes on, likely due to the amount of time spent
upright, which will increase the demand of the pelvic floor due to gravity
Research shows that 19% of participants in
pelvic floor strengthening program experienced a decrease in grade of POP, but
74% reported a reduction of bothersome symptoms. Instead of thinking about
“reversal” of prolapse, it is maybe better to think about regaining function
and restoring strength through the pelvis. There can be improvement due to
remodeling of tissue and increasing estrogen levels, and it is very important
to control what you can! There is hope to
improve a prolapse through strengthening the area, managing the pressure system,
controlling weight and looking at supplemental estrogen. Symptoms can be significantly improved—work
with the pelvic floor physiotherapists at Elevation Physiotherapy &
Wellness to help you get better, faster!
Exercise is good, right? But how soon is too soon after giving birth?
If you had an uncomplicated vaginal birth,
you can start gentle exercise (walking, stairs, breathing exercises, some
abdominal exercises) almost immediately after giving birth, but clear it with a
medical professional first.
Research on women who begin exercise after
giving birth shows that there can be a disconnect between the pelvis and the
rest of the body when trying to get back to exercise after baby. The muscles
and connective tissue through the abdomen is put on stretch for several months,
and are longer and softer for a period of time after giving birth, and this can
lead to pain in the joints of the pelvis and pubic bone.
It would not be at all typical to
experience severe pain, dizziness, weakness, vision changes, chest tightness,
bleeding or leg pain—be sure to check in with your physician if experiencing
any of these. Otherwise, start back at
up to 30 minutes of walking each day—if you can’t do 30 minutes all in one
shot, then try two 15 minute walks, or even six 5 minute walks spaced through
the day. Just keep moving.
Also, get your pelvic floor moving—it would
be best to be checked by a pelvic floor physiotherapist who can make sure that
you are engaging properly and give you a specific exercise program to start,
and teach you how to breathe on exertion.
The National Academy of Sports Medicine in the U.S. recommends breath
work and easy abdominal exercises with moving your legs to start.
If you’ve had a Cesarean- section, you may
have to wait a bit longer to get back to the exercise game. Walking is good, and do get back to pelvic
floor strengthening, but hold off at least 8 weeks for more vigorous exercises.
If you are wanting to get back to running
post-partum, try the jump test first: have a full bladder, and jump up and down
20 times in a row, followed by coughing four times in a row—if you didn’t leak
urine or feel any heaviness in your pelvis or vagina, you’re likely ready for
that run!
I always hesitate to use the word “normal”, as there are so
many factors that go into how often you pee.
If you typically get up once in the night, then that is probably normal
for you. If your sleep is disrupted
because you’re getting up more frequently, then possibly something needs to
change during the day while you’re awake.
Are you
drinking too much after dinner?
Assuming you’ve been drinking fluids through the day and your kidneys
are working properly, stopping all fluid intake 2-3 hours before bed will
reduce waking up at night.
Are you
drinking alcohol or caffeine? Both
are diuretics, meaning they make the body produce more urine. Enough said.
Are you
pregnant? There is a pregnancy
hormone called human chorionic gonadotropin (hCG), which will increase blood
flow to the kidneys and uterus—this will put pressure on the bladder.
Do you
take medications for high plod pressure, muscle relaxants or sedatives?
Some of these drugs can make you pee more.
Are you over 60? As you age, the bladder tends to not hold
as much, so if you’re drinking the same amount as when you’re younger, then you
may have to pee more often. As well, menopausal women can have changes in the
urethral tissue—the tube from the bladder that urine flows out—that make the
urge to pee more prominent in the brain, so women may want to keep less in the
bladder and empty more often.
Do you have a UTI or prostate issue? If
peeing in the night is also associated with burning or urgency, it could be due
to a UTI or enlarged prostate. A larger
prostate can lead to thickening of the bladder tissue, and the prostate can
make the urethra smaller, so the bladder holds less and is less elastic, and
then has to push against the obstruction of the prostate. This equals more
peeing, day and night.
When should you get
it checked?
If you are up a few times in the night, try to keep a
bladder diary for two 24 hour periods and see if there is a pattern—track how
much you take in, what you are drinking, how often you pee, and how long is the
flow of pee in seconds. If you’re peeing
more than 8 times in any 24 hour period, that is likely too much. If frequent
peeing is also associated with increased thirst, weight loss or increased appetite,
you should get checked by your family doctor. If you notice the frequency of
peeing in the night getting worse, if you see blood in your urine, it is
painful to pee, or if you’re going to pee often but only in small amounts, then
get checked by your doctor.
Really, the pelvic
floor?
If you’re peeing often, or have real urgency to pee through
the day or night, then sometimes the brain and the pelvic floor can be the
cause. If other things, like UTI or prostate issues, have been ruled out,
sometimes having a pelvic floor that is too tight or too weak (or both) can be
an issue. The pelvic floor is often
ignored by most until they have a problem.
At Elevation Physiotherapy & Wellness, we are your pelvic floor
specialists who can help with bladder frequency and urgency due to pelvic floor
issues—there is much that can be done, let’s start now!
