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.
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
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!
It’s fair to say that most people never give their pelvic floor muscles any thought at all until they have a problem. The pelvic floor group of muscles work like every other muscle in the body, but because they are inside the body, they are easily ignored.
Of course both men and women have the same pelvic floor
muscles—mostly. The superficial layer is a little different, but the deeper
layers of muscles, bladder and rectum are all the same, and men can have the
same issues with urinary incontinence or pelvic pain as women.
Recent studies show that many men undergoing a radical
prostatectomy (having the prostate removed due to cancer)will be incontinent as
a result of the surgery, and having a pre-operative program of Kegels (pelvic
floor muscle exercises) can help after surgery for men to use fewer pads for a
shorter period of time. These studies
demonstrated that men who work to strengthen their pelvic floor muscles prior
to surgery do better than the “controls”—the group who does Kegels leak less
urine, and score better on the Incontinence Assessment Scale (ICIQ-SF).
At Elevation Physiotherapy & Wellness, we have physiotherapists
who specialize in pelvic health, and can ensure that any man is performing
Kegels properly, start a program of exercises to be done daily, and progress
through more difficult variations of exercises as each man is able. Studies
show that these treatments are inexpensive, and have zero side effects. Don’t buy pads forever—get to work
strengthening the pelvic floor. It can help you get better, faster.
Aylin Aydın Sayılan and Ayfer
Özbaş. The Effect of Pelvic Floor Muscle Training On Incontinence Problems After
Radical Prostatectomy. 2018: American Journal of Men’s Health, Vol.
12(4): 1007-1015
Li-Hui Pan et al. Improvement
of Urinary Incontinence, Life Impact, and Depression and Anxiety With Modified
Pelvic Floor Muscle Training After Radical Prostatectomy. 2019: American Journal of Men’s Health, Vol.
13(2): 1-10
Prostate cancer is often diagnosed in men in their 50s and
60s, but younger men can experience this as well. About 40% of men diagnosed with cancer are
low-risk, and will have “active surveillance” over time, but it should start
with a blood test to see the PSA (prostate-specific antigen) level. If this is at all concerning, then it can be
followed up with an MRI to see if a biopsy is even needed.
Often men will first have their PSA tested at age 50, but it
is now recommended that a man has his first test in his mid-40s. If the PSA level is low, then it needs to be
repeated only every 5 years until about age 60.
Doctors are suggesting that healthy lifestyle choices might help to lessen
the chance of developing prostate cancer—regular exercise, maintain a healthy
weight and eating less animal fat.
For those who develop prostate cancer, it needs to be
treated aggressively. If a man has to
have the prostate removed, better surgical techniques have been developed that
allow sparing of the nerves that control the bladder for urination, as well as
erection and ejaculation. For several
months after the surgery, almost every man will experience urinary incontinence
and erectile dysfunction, but pelvic floor physiotherapy can be helpful to
return to a much better quality of life.
The pelvic floor is a group of muscles that sling under the
pelvis, and act as support and stability, as well as assisting as a
sphincter. These muscles work collectively,
and are generally ignored by all until there is a problem with leaking
urine. Your pelvic physiotherapist can
help you to make sure that you are engaging these muscles correctly and
effectively, as well as teaching you how to manage the abdominal pressure
changes that come with coughing, sneezing laughing or moving around.
There is much that can be done, and seeing a physiotherapist
who practices pelvic health can get you back on the road to full function
quickly.
It is really common for women to have some descent in their bladder, uterus or bowel, and it is not just women who have had babies—this condition can be an issue for women who have never had kids as well. Research supports physiotherapy as a first-line treatment for pelvic organ prolapse (POP). A 2016 Cochrane review of the physiotherapy studies for POP found that pelvic floor muscle training significantly decreased symptoms and improved the stage of prolapse when compared to control groups (Dumoulin et al., 2016).
Many women diagnosed with POP had no idea it was even
possible for prolapse of the pelvic structures to occur, had no idea where to
seek treatment (or that treatment even existed!), and were scared to discuss
their concerns with their friends or healthcare providers. Additionally, many
people’s concerns are written off as a “normal” part of aging by their
practitioners; this leads to people living with potentially modifiable symptoms
because they simply don’t know where to go or who to see.
Sometimes the advice given to a woman to help a prolapse is
not very practical. For example, a young mother being told not to lift anything
heavier than 5 or 10 pounds and to stop all exercise beyond swimming and those
performed in lying down positions. While this might be important in the early
stages of healing, the exercises and movements would have to progress to the
point that this woman could comfortable lift and carry her baby, and get back
to the activities that she finds meaningful and fulfilling. No two pelvic
floors are the same and everyone experiencing POP has different goals and
abilities.
Research has supported that different people manage
intra-abdominal pressure during activity differently, and each woman needs to
understand how their own body will respond to the exercises and activities that
they are interested in returning to. Some women who are looking to resolve or
manage their symptoms tend to do well with the help of physiotherapy and
lifestyle modification/education. A physiotherapist who works in this area will
have advanced training to help pelvic floor issues, and will likely do an
internal assessment to gauge the strength, endurance and control of the pelvic
floor, and address the pelvic floor engagement with proper breathing to manage
pressure changes.
If you’re noticing pressure or heaviness in the vaginal
area, or you can feel a bulge in your vagina in the shower, get checked by your
doctor or a pelvic health physiotherapist—there is much that you can do to help
this problem!
If you’re leaking urine when you cough, sneeze or laugh, it’s no laughing matter—but there is a lot that you can do to help it. It is not normal to leak even if you’ve had kids, nor is it an inevitable part of aging.
The muscles of the pelvic floor work like every other muscle in your body, they are just tucked up inside, so people don’t given them much thought. Due to this weakness, they often don’t work to squeeze effectively around the urethra, and leaking can happen. They also work to hold up organs like the bladder, uterus and colon, and need to be kept strong to keep these organs from sinking down.
It’s not just women who have had kids that have problems with their pelvic floor—it can happen to any woman. A decrease in hormone levels with menopause can cause irritability in the bladder and pelvic floor muscles, and gravity can help things descend if there is poor external support.
The good news is there is so much that can be done before and after you notice any problems. It is important to get to work on strengthening your pelvic floor muscles, and of course, it is necessary to make sure you’re doing them correctly. A proper pelvic floor contraction is a lift—for example, imagine a ping pong ball sitting outside your vagina and you want to lift it inside. Once you have the lift movement down, try to do 10 contractions in a row. Keep practicing—you will get better strength and control as you practice.
It is worth seeing a physiotherapist who works in pelvic health who will do an internal assessment to make sure that you are engaging the muscles properly, and then give feedback on the strength, endurance and control. A pelvic physiotherapist can also give you exercises to work your other core muscles along with your pelvic floor and proper breathing—breath is very important to train with your pelvic floor muscles. Working the pelvic floor regularly –and properly—can help you get to the point where you can cough or laugh without leaking, and that is nothing to sneeze at!
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Could You Have a Pelvic Health Issue?
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Check to download a comprehensive list of bladder, bowel and sexual issues that can be helped with pelvic health physiotherapy.
