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ARE KEGELS ENOUGH?

A mother’s guide to Pelvic Organ Prolapse and how to reduce, address or avoid it

By: Lisa Iacovelli  |   August 12, 2021

Photo credit: Cristen Wright

 
Incontinent sneezes and pelvic organs descending in your vaginal canal—childbirth can be brutal! And healing your body is a journey. We speak to pelvic floor expert Lisa Iacovelli on the stuff no one wants to talk about.

Pelvic Organ Prolapse (POP) in the peripartum period
For all mothers, you and your body have changed and will continue to change as you raise your children. Throughout our lifespan, we must honor and acknowledge and learn how to care for ourselves each step of the way.  

Before we tackle the nuts and bolts of Pelvic Organ Prolapse (POP), let's take a deep breath and honor each of our incredible journeys into motherhood and the amazing miraculous nature of the female body that can grow and nourish a human being in utero and in the postpartum period.  

So many factors are out of our control, despite all of our best efforts for a healthy pregnancy and thoughtful delivery. However, there are many things we can do to reduce our risk and support and hasten our recovery.  

Today, there are incredible resources for women, including experts in pelvic floor dysfunction, certified instructors in yoga/pilates and pre/postnatal exercise programs. A plethora of ever-growing tools are at your disposal to support your recovery and make it a little more fun!

What is POP (Pelvic Organ Prolapse)?
POP is the general term used when one or more of your pelvic organs (uterus, bladder, urethra, rectum) descend and bulge into your vaginal canal, a result of stretch injuries to your pelvic ligaments, fascia, pelvic floor muscles and the nerves that supply them.  

POP affects 41% of women over 60 years old. (Interestingly, it is less common than urinary stress incontinence and fecal incontinence.) Nonetheless, when it occurs, it can be alarming.  

POP can begin in pregnancy and may worsen with delivery and/or occur in the postpartum  period and beyond. Risk factors include: pregnancy and childbirth (both vaginal and C-section deliveries), obesity, size of baby, longer second stage of labor (pushing phase), multiple births, birthing multiples, use of forceps/vacuum during delivery, perineal tears/episiotomy, and our genetics in terms of connective tissue integrity and how they are influenced by our hormones.



How do you know you have it?
POP can: 
● Cause low back pain;
● Cause pain with intercourse as organs get in the way;
● Cause pelvic heaviness making it difficult to stand for long periods or carry the babes;
● Change how well you can empty your bowels and bladder
● Cause incontinence.

In addition, POP may cause no symptoms at all.

Often the prolapse is not low enough for you to actually see it but may cause some symptoms as described above. You may notice it during wiping or showering, when you first see or feel a bulge. At your final postpartum checkup your physician or midwife may let you know you have POP, but not always. It's ok to ask them to check! Otherwise, a thorough examination by a Physical Therapist specializing in pelvic floor rehabilitation will not only answer the question but help you on the road to recovery.

How is a POP different from a cystocele?
Prolapses are named for the particular organ(s) that have descended into your sacred vaginal canal. Then, they are graded on a scale of 1-4,depending on how low they go. A Grade 4 prolapse, the lowest, reaches outside your vaginal canal. For example, your doctor may tell you that you have a “Grade 3 Rectocele” or “Cystocele”. 

So, what’s in a name?

Rectocele — Your rectum descends, bulging into the back of the vaginal canal and causing rectal pressure, possible constipation and difficulty evacuating your bowels.

Cystocele — Your bladder descends and bulges into the front of your vaginal canal, which may cause bladder pressure, urgency/frequency/incontinence, difficulty emptying the bladder and slow urination. 

Uterine prolapse — The uterus descends straight down the middle, causing your cervix to ride low in your vaginal canal which may feel like a golf ball in your vagina (so pleasant…) and cause aching/cramping sensations in the pelvis. 

Does it get better?
A general rule for POP is that a Grade 1 or 2 will often heal with physical therapy. A Grade 3 or 4 POP often requires some longer-term management to eliminate symptoms and prevent worsening. 

There are other factors that influence prognosis and healing. These include the integrity and elasticity of the ligaments of the organ that has prolapsed and the overall condition of your core canister and hip stabilizers. For example, if you had a large tear, a large DRA (Diastasis Recti Abdominis) and/or your pelvic floor muscles are very weak, your POP will take longer to heal.  

The good news is that at every step of the way treatment techniques are available. Also, during the postpartum period, your body is in high gear for healing and these forces improve your prognosis and increase your ability to recover fully. Your high progesterone and relaxin hormone levels during pregnancy cause ligaments to loosen and pelvic joints to be less stable. Postpartum, estrogen levels drop and relaxin continues with breastfeeding.  These hormone changes may make you more vulnerable to POP but will eventually return to normal. I have seen some pretty low prolapses after delivery resolve and become symptom-free by one year postpartum, with supportive treatments and smart exercises. 



How to seek help, and from whom
If you are experiencing any of these symptoms, schedule an evaluation with your OB/Gyn and a Physical Therapist who specializes in pelvic floor rehabilitation. We work as a team to help in your recovery.  

Your OB/Gyn will evaluate the extent of your POP and may prescribe topical estrogen cream if they feel your vaginal tissues and organs would benefit from hormonal support. If your prolapse is very low, they may offer to fit you with a pessary, which is inserted inside your vaginal canal to lift up your organs, reducing pressure and allowing your pelvic floor muscles some much-needed rest. There are also external support garments that provide similar support; these are ideal if your tissues are sensitive or still healing. 

Your Physical Therapist will evaluate your alignment, the function of your core canister and hip stabilizers, and guide you through your recovery with strengthening exercises, correction of any mal-alignments, rehabilitation of perineal tears, DRA and pelvic floor muscles, and symptom management. 

There are times when, despite good efforts in rehabilitation and full recovery from pregnancy and delivery, your POP is still symptomatic and affecting your quality of life. At that time, you should schedule a consultation with a Uro-gynecologist, a surgeon specializing in POP repairs to learn about all your options.

Are Kegels enough to regain strength?
Kegels or pelvic floor muscle exercises are not enough to recover from POP. The pelvic floor muscles are only one part of your core muscle function. The core muscles work as a team to reduce load on your spine, pelvic organs and hips. It's important to rehabilitate your entire core canister which includes the deepest abdominal and back muscles, the respiratory diaphragm, the pelvic floor muscles and the rotator cuff muscles of your hips. Those play an important role in stabilizing your pelvis and act as an anchor point suspending the pelvic floor muscles. Think of this group as the sturdy trees to hang your pelvic floor hammock on! 

If you have a remaining DRA (Diastasis Rectus Abdominus) or split down the middle after eight weeks, you must address it. Otherwise, your core canister just won’t work properly. In addition, if your spine and pelvis are twisted or you have poor posture, even a strong core canister will have a tough time doing its job. 

Good Alignment + Good Posture + Strong Core Canister =  Happy Pelvis



How can I alleviate my symptoms right now?
When your core muscles are not recovered yet and you are symptomatic, it can be helpful to use belly bands and support belts to stabilize your pelvic joints, support your abdomen and lift your bottom to reduce the load on your pelvic organs. There are many available belts online: sacroiliac joint belts, lumbar supports, prolapse and varicosity supports all designed to accommodate pregnancy and also available for postpartum and beyond. Your Physical Therapist can help you choose which option is best for you. 

Incorporate frequent rest periods during your day, using inverted postures such as supported bridge pose, shoulder stands, or placing a wedge/thick pillow under your buttocks so the pelvis is higher than your head. This will help to relocate your organs and give your pelvic floor muscles a chance to rest. 

Additional tips: 
● Be proactive and try to rest before you have symptoms. 
● Keep bowel movements soft and moving daily with no straining. 
● Keep activities low impact and keep lifting light. 
● Sit to comfort your baby or toddler. 
● Use strollers to avoid baby carriers when you are symptomatic. Or, ask your sherpa (i.e. your partner) to do the heavy lifting. 

Stay ahead of the game
If you are not yet pregnant, now is the perfect time to prepare! Prior to pregnancy, address any existing pelvic joint, low back, hip or tailbone issues. Familiarize yourself with kegel and pelvic floor muscle contractions. Address any chronic urinary or bowel issues (i.e. constipation, IBS, urinary frequency or incontinence). These areas all influence the function of your core canister or may be a sign it’s already not functioning well. 

Optimize posture and good body mechanics to protect yourself during your daily activities. 

Pre-pregnancy and during pregnancy, strengthen your core canister with pelvic floor muscle exercises, hip strengthening, breathing exercises coordinated with pelvic floor muscle function, and core canister recruitment strategies incorporated both into exercise and daily activities.

Be savvy about your new hormonal milieu during pregnancy and postpartum. Circulating relaxin which causes ligamentous laxity and can make your joints and pelvic organs more vulnerable to injury. This hormone is most prevalent in the first and third trimesters and up to five months postpartum or longer if you are breastfeeding, so take extra care to protect yourself, focus on core strengthening and keep your exercises low impact and lifting light.  

Knowledge is power
So there you have it, the nuts and bolts of POP. Honor yourself by taking the time to care for your body and get help if you need it. By fully recovering with each pregnancy and delivery, you will optimize your health and protect yourself from unwanted injuries in the years to come. 

To find a physical therapist specialist in your area:

https://aptapelvichealth.org/
https://aptapelvichealth.org/
www.marinpmc.com

References:
1. www.voicesforpfd.org
2. Pregnancy, Labor, Delivery, and Pelvic Organ Prolapse Eddie H. M. Sze, MD, Gordon B. Sherard, III, MD, and Jeanette M. Dolezal, PhDVOL. 100, NO. 5, PART 1, NOVEMBER 2002 0029-7844/02/$22.00 981© 2002 by The American College of Obstetricians and Gynecologists. Published by Elsevier Science Inc.
3. Pelvic Organ Prolapse in Pregnancy Obstet Gynecol Int J 2017, 8(2): 00284
4. Pelvic Organ Prolapse INDUMATHI KUNCHARAPU, MD, BARBARA A. MAJERONI, MD, DALLAS W. JOHNSON, MD, May 1, 2010 ◆ Volume 81, Number 9 www.aafp.org/afp American Family Physician

 

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