Feeling of Heaviness in Vaginal Area? Pressure in Your Pelvis?
Do you experience an annoying feeling of “heaviness or bulge” in the vaginal area or a “pressure” between vagina and anus or pelvis?
It is usually a part of a range of clinical conditions caused by Pelvic Floor Dysfunction, the vaginal bulging, a symptom of Pelvic Organ Prolapse.
This week, we will be looking at the pelvic floor problem the – Pelvic Organ Prolapse ( POP)
Pelvic Organ prolapse is related to symptoms from a failure of the supporting structures, the pelvic floor muscles, resulting in collapse, causing protrusion of organs into the vagina.
There may be a descent of the bladder into the anterior vaginal wall, rectum into the posterior vaginal wall and the vaginal vault or uterus into the apex of the vagina
A recent study reported that pelvic organ prolapse is a common condition affecting nearly 30% of women (20–59 years of age) and more than 50% over 50 years of age seeking gynecologic clinic visits. Women with Pelvic organ prolapse often present with a combination of pelvic floor disorders, such as incontinence, bowel, bladder, and sexual dysfunction (Sánchez-Sánchez et al. 2020).
Symptoms of Prolapse:
Symptoms commonly are reported as:
- Feeling of pressure or heaviness in the vaginal area
- Presence of bulge in vaginal space and at the entrance of the vagina
- Stress urinary incontinence – leaking urine with coughing, sneezing, jumping, sit to stand etc.
- Difficulty emptying bladder
- Symptoms worsen through the day of activity
- Symptoms improve with rest and lying down
Factors contributing to Pelvic Organ Prolapse
- Weakness in Pelvic floor muscles and laxity in connective tissue supporting the organs. It can occur during pregnancy and childbirth, having multiple vaginal births, birth trauma from forceps and can influence the pelvic organ prolapse.
- Increase in intra-abdominal pressure above from chronic coughing, chronic constipation, high-level stress with abdominal tension, heavy lifting causing pressure going down to the organs below.
Risks for Pelvic Organ Prolapse
- Older age
- High parity / multiple pregnancies
- Early age at the first delivery
- Forceps delivery
- A prolonged second stage of labour
- Carrying and lifting heavy objects or doing heavy work
- High infant birth weight
Types of Prolapse :
Uterine prolapse – Uterus descending and dropping down into the vaginal space
Vault prolapse – Can Occur after a hysterectomy where the top portion of the vagina sinks into vaginal space
Cystocele – Bladder pushing on the front of the vagina
Rectocele: the rectum bulging from the back of the vaginal wall. A clinical study noted that most women presenting with prolapse complained of obstructed defecation and clinically was noted to have had posterior-compartment prolapse (Dietz et. al. 2018)
*It is not uncommon to have more than one prolapse occurring at the same time*
Sexual dysfunction with Pelvic Organ prolapse is prevalent in women frequently reporting having less sexual desire, arousal, orgasm, and pain, with negative implications on a relationship with their partners ( Lucia La rosa et al. .2019)
Most women do not mention these issues unless specifically asked about them. Although pelvic organ prolapse does not pose any risks, however, women with this problem are known to report a lot of distress, decreased quality of life with reduced physical activity and limitation in social, sexual, and occupational performance.
Management and Treatment for Prolapse:
Surgery for Prolapse:
Surgery usually is opted for patients having severe prolapse, having at least stage II prolapse or are having bothersome symptoms and have failed conservative approach.
It is done to relieve the symptoms, restore normal anatomy, prevent relapses and correct possible intrapelvic defects.
A surgical approach can vary depending on the condition.
- Sacral colpopexy ( for uterine prolapse) and sacrospinous ligament fixation ( for Vault prolapse repair)
- Anterior colporrhaphy ( Cystocele repair )
- Posterior colporrhaphy ( Rectocele repair )
- Perineorrhaphy ( repairs to the perineal body to help relieve the symptoms of vaginal bulge or laxity) to maintain bowel and sexual function.
- Obliterative procedures – is more appropriate and are usually considered in older women with advanced-stage prolapse, cannot tolerate extensive surgery and no longer desire preservation of coital function.
According to some studies, surgical management of POP improves the long-term quality of life and sexual response. However, conversely, other studies describe the worsening of the sexual function in patients and dyspareunia (pain during sexual intercourse or sexual activity ) following surgical treatments. Also, studies have noted complications and risks following surgery, including mesh erosion into the vagina, infection, bowel dysfunction, stress incontinence, revision surgery etc.
Faced with this evidence, the authors noted that a multidisciplinary approach in the treatment of women with POP and cystocele is essential (Lucia La rosa et al. .2019)
Conservative Management and Treatment for Prolapse
Research indicates that Conservative based approaches and interventions help women regain control over the prolapse symptoms and their life. There is an increased need for providing education among women and health care professionals on preventative measures and available conservative multi-professional team-based approach. With prolapse treatment options expanding to include conservative choices, women presenting with this condition or symptoms need to be listened to, given better information about available treatment choices and offer support in making an appropriate decision that is right for them (Abhyankar et al. 2019)
*It is vital to create more awareness of pelvic organ prolapse and its symptoms among women in making an appropriate treatment choices that is right for them.*
Vaginal pessaries are intravaginal support devices used to reduce prolapse or incontinence. They are medical based silicone devices inserted into the vagina to help hold the organs up in place. They are alternative non-invasive treatment options and usually controlled by the patient. It is known to provide symptom relief without surgical complications for women with these conditions. Pessary use is also known to be the most cost-effective treatment alternative for treating pelvic organ prolapse (Radnia et al. .2019)
Some women, although were successfully fitted with a pessary for prolapse, one third was noted to undergo surgery, with approximately 60% of women undergoing surgery within the first year and 90% within two years. ( Patnam et al. 2020)
Pelvic Floor Physiotherapy for Pelvic Organ prolapse:
PFM training and Pessaries can be a valuable therapeutic tool to relieve symptoms of POP and for a conservative approach.
Physiotherapist trained in Pelvic Floor Physiotherapy can help with assessing tissue laxity, muscle strength and provide appropriate management options from pelvic floor muscle training, relaxation training to address the pressure system from above or below. Pessaries management or provide appropriate referrals to address the dysfunction.
Physiotherapy based treatment for POP is identified in research and has given more focus on prevention, early diagnosis, and treatments.
Pelvic floor physiotherapy with exercise prescription and monitoring is useful both in the treatment and prevention of functional disorders of the pelvic floor.
In Conclusion education and awareness is vital among women and professionals in taking conservative approaches for pelvic organ prolapse as a first line of management and preventative measure, with multi-professional team approach in treatment decision making.