When Things Go POP

In a post last week I talked about the very important pelvic floor muscles—that springy base that supports our pelvic organs and controls the orifices that pass through it. While it’s pretty darned important to keep our pelvic floor toned and in good working order, that becomes harder to do as we age and absorb more of the slings and arrows of outrageous fortune. Or just of daily life.

One common side effect of aging on those muscles is pelvic organ prolapse—or POP. This is when one or more of the organs resting on our pelvic floor—the uterus, the bladder, and the bowel—sag into one another, sometimes causing the vagina to protrude. It’s like pebbles on an elastic surface. If the surface is taut, the pebbles stay in place; relax the surface, and the pebbles all roll toward the center.

When we were young, our pelvic floor muscles were taut and nicely toned, and our organs were all held in place by ligaments and the pelvic floor. Over time, those ligaments stretch and sometimes tear. The pelvic floor sags and loses tone, and the organs tend to drop, move around, and squish together.

Factors that cause or exacerbate POP are

• vaginal delivery, especially of large babies
• heavy lifting
• chronic constipation
• chronic cough
• being overweight
• menopause and loss of estrogen

Since virtually all of us have encountered (or will encounter) at least one of those conditions, pelvic organ prolapse is, as you might expect, extremely common. About half of us will experience some degree of prolapse in our lifetime. Not only that, it’s been around for a while, too; it was mentioned in literature as long ago as 2000 B.C.!

Often, the condition is mild and you may not even know you have a prolapse, in which case you don’t need to do anything. On the other hand, you may experience one or more of the following unpleasant symptoms:

• difficulty urinating or having a bowel movement
• leaking urine with any “bearing down” motion, such as running, sneezing, or coughing
• a sudden urge to urinate and not quite making it to the bathroom
• leaking small amounts of stool
• frequent urinary tract infections
• feeling as though something is falling out of the vagina
• tissue emerging from the vagina
• partner’s sensing “something is in the way”; more rarely, painful intercourse

Our organs can prolapse in several creative ways. The bladder can fall into the vaginal wall in front, which is called a cystocele. The bowel can tip into the vaginal wall behind, called a rectocele. Or, the uterus can fall down into the vagina, often squishing it out the vaginal introitus (entry).

Treatment options include lifestyle change, surgery, or using a pessary. Lifestyle changes can prevent further damage to the pelvic floor:

• Maintain a healthy weight to relieve pressure on the pelvic floor
• Don't smoke, which is often associated with a chronic cough
• Avoid heavy lifting
• Avoid constipation and straining with bowel movements
• Do kegels. (Lots of kegels.)

Pessaries are simple silicone devices that are individually fitted and inserted into the vagina to hold it in place. They need to be removed and cleaned every few months, which can be done at home or in a doctor’s office. They’re usually effective, but they can limit the depth of penetration during sex.

Additionally, topical estrogen can help improve tone in the pelvic floor muscles and vaginal walls.

As a last resort, various surgical options can relieve the discomfort and distressing symptoms of prolapse. Sometimes this involves a hysterectomy and/or reconnecting the torn ligaments. Sometimes a synthetic mesh material is used to support the prolapsed organs.

Consider the surgical option carefully, however. According to the National Association for Continence (NAFC), about 11 percent of women have surgery for pelvic organ prolapse, and about 30 percent of those surgeries fail, necessitating yet another surgery. These failure rates have led some experts to consider POP a “chronic” condition. Additionally, a recent notification from the FDA warns against using the surgical mesh because of a high incidence of “serious complications.” Also, it may be impossible to remove the mesh once it’s in place.

Pelvic organ prolapse is common; it can cause embarrassing or annoying symptoms. It can interfere with sex, and it can even interfere with everyday activities. Once a prolapse has become severe, kegel exercises are less effective and treatment options are less reliable.

The best approach is to take care of your pelvic floor before things get out of hand. So, as we said before… start kegeling.