by Sue Croft Physiotherapist
Adapted from author’s blog first published Jan 26, 2022 at SueCroftPhysiotherapy.com.au
What is a prolapse and how are prolapses graded or classified?
Vaginal prolapse (Pelvic Organ Prolapse or POP) occurs when there is a relaxation of the fascia and other ligamentous supports of the vagina and pelvic organs and/or muscle damage causing the organs of the pelvis (the bladder, uterus and bowel) to descend to or beyond the opening of the vagina (the hymen). Rectal prolapse occurs when a mucosal or full-thickness layer of rectal tissue descends in the rectum and may eventually protrude through the anus.
Since 2002, vaginal prolapse has been classified by doctors and pelvic health physiotherapists using the POP-Q system grading prolapse from Grade 0 to 4. In recent years there has been a definite change in the clinical relevance of these prolapse gradings, although they are still important for researchers.
The change is guiding health professionals towards assessing the bother of symptoms for the woman rather than the anatomical positioning of the anterior and posterior walls or cervix/vault. This is because many women can have significant prolapse but are completely unaware of any bothersome symptoms and other women with minimal laxity or bulge can be highly anxious and in a world of distress exacerbated by a diagnosis of Grade 1 or 2 prolapse.
Interesting research (O’Boyle et al 2002, Larsen and Yavorek 2006, Buschbaum et al 2006) has shown a surprising number of young nulliparous women (never had a baby) had Stage 1 prolapse as measured by the POP-Q system and yet they were completely asymptomatic. So, there are variations in what is actually normal and this is what needs amplifying with conversations around prolapse in the clinical setting.
POP following vaginal birth is a very common condition with up to 50% of women who have had a baby demonstrating vaginal prolapse throughout their lifetime. (1) Many prolapses are asymptomatic for years with only 15% of women being symptomatic at 20 years.(2)
With increasing awareness about prolapse, many women are also worried they have prolapse when in fact they don’t. This causes tremendous anxiety, perhaps completely unnecessarily. Get an accurate diagnosis confirmed by your doctor or pelvic health physiotherapist who understands about prolapse stages.
A new definition of clinical pelvic organ prolapse
The International Urogynaecological Consultation for Pelvic Organ Prolapse believes there is a need for improvement and is running a 3-year project with a committee of expert urogynaecologists looking at best practice documents and consensus papers on the management of POP with final conclusions being produced in 2023.
They have released a new definition with Clinical POP being defined as ‘anatomical prolapse with descent of at least one of the vaginal walls to or beyond the hymen with maximal Valsalva effort, with the presence either of vaginal bulge or of functional or medical compromise due to prolapse without symptoms bother’.
What this means is to be clinically defined as having POP requires descent of at least one wall to or beyond the hymen with either bothersome vaginal bulge or functional or medical compromise due to the prolapse (such as obstructed voiding or renal impairment).(3)
Why is this important? The thinking is to try and normalise this variation in positioning of points of assessment and bring the relevance back to how is function compromised for the woman.
Research has shown that prolapse is strongly associated with levator avulsion and while it is important that women know if they have any muscle injury so they can implement the preventative strategies in my book Pelvic Floor Essentials (Edition 4) to stop a prolapse from occurring or prevent worsening of any diagnosed prolapse, it is also important to emphasize what a woman can do with her pelvic floor muscles, not what she can’t do.
The physical impact of prolapse
Common prolapse physical symptoms include:
- the feeling of a lump or bulge in the vagina or dropping below the entrance of the vagina (feeling like a dislodged tampon), discomfort or pressure on the pelvic floor or rubbing of the tissue against underwear causing ulceration of the vaginal tissue.
- a sense of vaginal drag, heaviness, ache and/or unresolving low back pain.
- changes with sexual intercourse (bulky or loose-lax feeling during intercourse, the ‘look’ of the vagina changes making the woman anxious).
- the inability to hold in a tampon.
- a loose feeling when exercising.
- bowel dysfunction including difficulty with complete evacuation of the bowels, some rectal tissue coming out of the rectum during or after defaecation, difficulty getting clean after defaecation.
The psychological impact of prolapse
Women in clinic are often devastated on learning that they have a prolapse regardless of the grading they have and how symptomatic they are. Like everything in life, the language around prolapse has increasingly had a powerful effect on the psyche of many women who have been given a diagnosis of prolapse. Due to the plethora of Facebook groups and internet blogs from non-scientific sources, women are widely read on prolapse and this can have a devastating effect on their mental health and well-being.
Taking a biopsychosocial approach
A biopsychosocial approach to managing prolapse is an important holistic progression in prolapse management.
Understanding prolapse through a biopsychosocial model means recognising that:
- The body (muscles, tissues, hormones) matters.
- The mind (emotions, beliefs, self-confidence) matters.
- The social world (relationships, community, daily activities) matters.
By addressing all three, women are more likely to feel empowered in their recovery.
Treatment and Management Options
The best management plan depends on your symptoms, lifestyle, and goals. Options may include:
- Pelvic floor physiotherapy – guided exercises to strengthen muscles and support organs
- Lifestyle adjustments – managing constipation, reducing heavy lifting, maintaining a healthy weight
- Pessary use – a small device fitted inside the vagina to provide support
- Surgery – in some cases, surgical repair may be recommended
Evidence supports the role of pelvic floor physiotherapy in improving symptoms and function for many women. Our physiotherapists take a holistic approach, working with you to regain strength, confidence, and quality of life.
When to Seek Support
Don’t let the diagnosis of prolapse define who you are or what you can do with your life in the future. It need not be considered a devastating diagnosis.
Knowledge is empowering. It is important not to catastrophise about your prolapse as this will change your life if you become fearful about moving and exercising.
Decreasing your exercise can also affect your mood making you feel depressed and have a significant impact on your quality of life and that of your family.
Seek help early and find yourself a prolapse mentor – a health professional who will calmly give you evidence-based advice and treatment as well as supporting you emotionally should you need it and help you achieve your exercise desires.
If you notice symptoms such as heaviness, bulging, or changes in bladder or bowel control, it’s important to seek assessment early. A women’s health physiotherapist can help you explore treatment options tailored to your needs.
Learn more
You can learn more about our Prolapse services here, and our Active Women’s Health team members here. Alternatively, to find a pelvic health physio near you visit APA Find A Physio website.
References:
- Hagen S, Stark D, Maher C, & Adams E (2006). Conservative management of pelvic organ prolapse in women. Cochrane Database of Systematic Reviews (Online), (4), CD003882. 10.1002/14651858.CD003882.pub3.
- Jelovsek JE, Chagin K, Gyhagen M, Hagen S, Wilson D, Kattan MW, Elders A, Barber MD, Areskoug B, MacArthur C, Milsom I. Predicting risk of pelvic floor disorders 12 and 20 years after delivery. Am J Obstet Gynecol. 2018 Feb;218(2):222.e1-222.e19. doi: 10.1016/j.ajog.2017.10.014.
- Women’s Health Training Associates 2021 Research Update. Taryn Hallum
