Pelvic Organ Prolapse After Childbirth: What to Know

Pelvic organ prolapse is an umbrella term for the downward descent of pelvic organs (bladder, rectum, and/or uterus). Pelvic organ prolapse occurs when there is a weakness in the supporting structures of the vaginal walls. The bulge a person with a prolapse might feel is the bladder, rectum, or uterus putting pressure on a weakened or thinned vaginal wall. When you add the impact of gravity in standing, those weakened structures move down and into the vaginal canal.

The internet is full of scary information about pelvic organ prolapse, which often leaves new moms feeling defeated and anxious. Given how extremely common this condition is, it is worth discussing the action steps you can take to feel better now and keep your body healthy as you age. 

By the time you’re done reading this article, I want you to know these three things: 

1. You’re not alone.
2. You’re not broken. 
3. What steps you can take to start feeling better right now and to prevent issues from arising down the road. 

Mild loss of vaginal or uterine support is extremely common in women as we age, especially for women who have had a vaginal childbirth. Some reports show that 25% of women have some form of pelvic floor disorder in the United States. Of the women with measurable, diagnosed pelvic organ prolapse, most report no symptoms whatsoever. 

Vaginal childbirth is the biggest risk factor for developing pelvic organ prolapse, as the baby passes through the vaginal canal and can contribute to weakness along the supportive structures. Forcep or vacuum delivery can further increase risk, as can each subsequent childbirth. A c-section is not necessarily protective, as pregnancy alone can have quite an impact on the pelvic structures, but it does offer some protection against severe pelvic organ prolapse into old age. 

Other reasons for prolapse may include constipation, pelvic surgery, genetic factors, generalized connective tissue disorders, obesity, and heavy manual work. Many of these risk factors involve heavy pressure moving down, also referred to as an increase in intra-abdominal pressure. If you hold your breath and push, you might be able to feel pressure moving down into your abdomen and pelvic floor - this is what increased intra-abdominal pressure feels like.  

We can’t control all of these situations, but taking steps to be mindful of increases in intra-abdominal pressure in your daily life can help prevent issues from worsening, and can reduce pelvic organ descent and symptoms for the long term. 

The most commonly reported symptoms are: 

• heaviness or pressure in the pelvic floor or vaginal area
• a sensation of a bulge, or "something falling out"
• difficulty voiding urine or stool
• urinary incontinence

Many women do not report any symptoms at all. For instance, one study reported that at one year postpartum, the majority of women in the study had some degree of prolapse when their pelvic structures were measured (89% uterine, 90% bladder, 70% rectum), but of these, 80% had no symptoms at all. 

We can all take steps to keep our pelvic floors healthy and happy, regardless of whether we are having symptoms or not. If you’ve been told you have a prolapse but do not have symptoms, you may still benefit from seeing a pelvic physical therapist to be sure you’re moving in the right direction.

If you were to use a mirror and take a look at your pelvic floor, you might see a bulge coming down toward the vaginal opening. Depending on the severity, that bulge may be very obvious, or it might be hard to see. If you hold your breath and push, you might see the bulge move down toward the opening slightly. 

Though this visual can seem scary, it gives you a good idea of why we want to limit that kind of downward pressure wherever we can throughout the day. For example, try these common movements and notice if you’re holding your breath or putting pressure downward on your pelvic floor: 

• Stand up out of a chair
• Bend over to pick something up off the floor
• Straining or pushing hard as you pass a bowel movement
• Holding your breath or straining while exercising

If you notice that you’re holding your breath or straining with any of these, try a gentle exhale next time you do these things to relieve pressure on the structures of the pelvic floor. 

Pelvic floor muscle exercise is the first treatment recommendation for mild to moderate pelvic organ prolapse. Establishing solid pelvic floor strength, coordination, and mobility will keep your pelvic structures strong and can play a role in preventing a prolapse from worsening as you age. 

Pelvic floor muscle strength is absolutely about more than just "doing your Kegel's". Pelvic floor muscles need strength, but they also need to be able to release completely. There is research that shows 50% of women don’t perform Kegel exercises correctly if they have never had guidance, so it’s always a good idea to check in with your healthcare provider and/or a pelvic physical therapist to make sure you’re on the right track with pelvic floor exercises. 

Other things you can do to reduce your symptoms and prevent a prolapse from worsening include:

• Manage pressure in your body to prevent overworking your pelvic structures. For instance, exhale and engage your pelvic floor before you lift something heavy to avoid putting pressure downward. You can use a similar "exhale on exertion" strategy with exercise, as well.
• Improving toileting habits can make a difference, too. Avoid constipation, exhale as you push (rather than straining), and try to avoid sitting on the toilet too long. Putting a stool under your feet can help, too!
• Pessaries can offer some structural support. These devices come in all shapes and sizes, and are inserted into the vaginal canal almost like a tampon to provide structural support to the tissues. Talk to your OB/GYN or pelvic physical therapist about the pros and cons of this option for you.
• Topical estrogen is a common and effective tool that can help the tissues in your vaginal area be stronger and more flexible. This is most commonly prescribed for peri and postmenopausal women who have had a significant decrease in local estrogen supply, and it can also be beneficial for breastfeeding parents who are in a similar hormonal state. Topical estrogen is available by prescription, so talk to your healthcare provider to see if this is an appropriate tool for you. 
• Surgery to restore anatomic structure can be helpful, though it always comes with its own set of risks and limitations. Physical therapy can help you prepare for surgery so that you can be sure you're moving well and are set up for a successful recovery.

The process of delivering a baby can take many twists and turns, and we are often not able to control exactly how things turn out. A baby traveling through the vaginal canal will certainly have an impact on the strength of those tissues, but there are a few things you can consider when preparing for a vaginal delivery. 

• Exhale as you push, if possible. Holding your breath increases intra-abdominal pressure, which can force your pelvic structures down with the baby. 
• Take steps to reduce the severity of perineal tears. Perineal tearing is extremely common during childbirth, and often can’t be prevented. There is some research that shows that perineal massage starting at 36 weeks through the end of pregnancy can help reduce the severity of tears, which may help with the big picture of pelvic floor support as it relates to prolapse. 
• Support your body as you recover. Consider using postpartum support garments, compression shorts or leggings that cover your abdomen, and taking it easy for the first few weeks as you recover from birth. Taking pressure off the area with compression will help you feel less heavy as you heal during those early weeks.
• Be intentional about how you move your postpartum body. Taking the time to build up your pelvic floor and abdominal strength after birth can make a big difference in how your body moves and the day-to-day stresses that your pelvic floor has to manage. Support your body now and it will pay off in the decades to come. 

In summary, pelvic organ prolapse is not a sentence to lifelong discomfort. It is a structural change that is a natural consequence of vaginal birth, but that doesn’t mean you have to live with the symptoms. There are plenty of tools out there that can make a big difference in your life. Reach out to your healthcare provider and find a pelvic floor physical therapist near you to determine the best next steps for you.