In order to understand what pelvic organ prolapse is, we must first understand female pelvic anatomy. At the front (anterior) of the pelvis, there is the bladder and urethra, in the middle there is the vagina, and in the back (posterior) there is the rectum. The vagina has two main walls, the anterior wall and the posterior wall. What supports these structures is a muscular sling known as the pelvic floor.

Causes

When the pelvic floor and ligaments supporting the pelvic organs weaken, the pelvic organs can descend causing a bulge, or prolapse, of one or more walls of the vagina. This can be caused by any condition that increases pressure on the pelvic floor such as pregnancy and vaginal delivery, chronic cough, chronic constipation, obesity, or repetitive heavy lifting. Prolapse can also occur after hysterectomy or pelvic surgery.

Symptoms

A person with pelvic organ prolapse may experience incontinence, difficulty having a bowel movement, pain or numbness during intercourse, and/or the sensation of heaviness around their vaginal opening.

Management

Many conservative treatments can be used to manage the symptoms of pelvic organ prolapse, such as:

• Breathing correctly to manage pressure placed on the pelvic floor
• Performing pelvic floor exercises to improve the strength of slow and fast twitch muscles of the pelvic floor
• Improving body mechanics while lifting heavy objects
• Treating constipation by increasing fiber/water intake, correcting toileting body mechanics, and using breath to decrease straining during bowel movements
• Strengthening core and hip muscles to support the pelvic girdle
• Using a pessary, a device inserted into the vagina to support the vaginal walls

Hormone therapy and surgery are also options used to treat pelvic organ prolapse if conservative measures do not improve symptoms. If you suspect you may have prolapse, you should consult with your primary care doctor, gynecologist, or pelvic floor physical therapist for treatment.

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So you were recently diagnosed with pelvic floor dysfunction, but what does that mean? Let’s talk about what the pelvic floor is, what it does, and what happens when it is not working correctly. 

What does your pelvic floor do? 

Your pelvic floor is a group of muscles that runs from your pubic bone to your tailbone and acts as a muscular sling. It is responsible for the 3 S’s: Support, Sphincter, and Sexual Function. The pelvic floor acts as support because it works in conjunction with your abdominal muscles and diaphragm to provide stability to your pelvis and support your internal organs. Your pelvic floor also surrounds your urethra and anus and is responsible for sphincter function. Lastly, your pelvic floor plays an intimate role in your ability to have pleasurable intercourse, reach orgasm, and, for men, maintain an erection.  

What is pelvic floor dysfunction? 

Pelvic floor dysfunction is an umbrella term for any issue that may cause the pelvic floor to not function properly. Usually, pelvic floor dysfunction falls into two categories: tension or weakness. 

What happens if your pelvic floor is too tight? 

Tension occurs when the pelvic floor muscles and surrounding musculature are too tight and have trouble relaxing. Risk factors include frequent yeast and urinary tract infections, endometriosis, interstitial cystitis, nerve entrapments, constipation, urge urinary incontinence, abdominal surgeries, and fibromyalgia. Symptoms can include pain around your abdomen, vaginal opening, inner thighs, rectum, back, and buttocks. You may notice that it is uncomfortable to urinate, insert a tampon, have intercourse, or have a gynecological exam.  Orgasms can be painful because your muscles are tight and stay contracted after climax. 

Pelvic floor tension can also cause urinary and bowel issues. Muscular tension around your anus can cause constipation because it is hard for stool to pass through the sphincter. Similarly, if the muscles that surround your urethra are tight, you may experience urinary hesitancy and have difficulty starting the flow of urine. Another common urinary symptom of pelvic floor tension is frequency. You may find that you have the sensation to urinate every 30 minutes to an hour or wake up multiple times a night to pee.   

What happens if your pelvic floor is too weak? 

Pelvic floor weakness occurs when your pelvic floor lacks the strength and endurance to perform its regular function. Risk factors include older age, pregnancy and childbirth, abdominal surgery, obesity, and activities that involve high impact or heavy lifting.  

Like pelvic floor tension, pelvic floor weakness can also cause urinary and bowel issues. Because the muscles that hold back urine are weak, you may have stress incontinence and notice leaking during activities such as lifting, jumping, or sneezing. After you urinate, you may also notice slight dribbling because your pelvic floor muscles that surround your urethra do not close it completely.  

A weak pelvic floor can also cause issues with support of your pelvis and torso. You may experience a sensation of heaviness or falling out around your vaginal opening that can be a symptom of pelvic organ prolapse. Additionally, pelvic floor weakness can also contribute to a separation of your abdominal muscles called diastasis recti.  

What can you do if you think you have pelvic floor dysfunction? 

See a women’s health physical therapist! An evaluation with a trained women’s health physical therapist can help you determine the type of pelvic floor dysfunction you have and begin to work towards correcting those issues.  

– Dr. Fei Zang, PT, DPT

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Your rectus abdominis, commonly referred to as your “6-pack muscles,” is attached to either side of your linea alba, a band of connective tissue that runs from the bottom of your sternum to your pubic bone. These muscles play a key role in protecting your internal organs, maintaining posture, and supporting your pelvis and back. In pregnancy, the added pressure of a growing baby and hormones that cause laxity in your connective tissue, causes the linea alba to stretch and separate.    

After giving birth, DRA may naturally resolve when your hormone levels return to normal. However, some studies have shown that even at 6 months postpartum, up to 40% of women continue to have DRA.  

Who is at risk? 

DRA can occur in both genders and across all age groups. Risk factors include pregnancy, having a caesarean section or any other abdominal surgery, or losing a significant amount of body mass over a relatively short amount of time. There are, however, no increased instances of DRA among people who perform heavy lifting, pregnant women with large babies, and people who experience significant weight gain.   

How do I know if I have DRA? 

At MOTI, we screen every postpartum woman for diastasis rectus abdominis, even if they are being treated for something unrelated. This screening can also be performed at home or at your doctor’s office.  

To check if you have DRA, start by lying on your back with your knees bent and feet on the floor. You or a partner can place their hand palm down on your belly with their fingers gently pressing into your navel area. Then, perform a small crunch by lifting your head off the ground and bringing your chin towards your chest. You will notice your rectus abdominis contracting under your fingers as you lift your head. If you feel the muscles separate and  form a gap of at least two finger widths, then you have DRA.   

What do I do if I have DRA? 

If you have DRA, it is best to have the condition treated because it can lead to other issues such as lower back pain, hip pain, and pelvic floor dysfunction. Physical therapy and exercise are the only conservative measures that have been shown to decrease the separation of the rectus abdominis. Returning to traditional core exercises may make the condition worse because as your muscles contract, they tug on the linea alba causing further separation. It is recommended to find a physical therapist trained in postpartum conditions to provide guidance to safely treat your DRA.    

– Dr. Fei Zang, PT, DPT

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If you answered yes to any of the above questions, you may be training your bladder to signal to your brain that it is time to urinate when it is not actually full.  

 
A healthy bladder can hold between 300 and 500 milliliters of urine, and even more at night (for reference, a standard can of soda holds 355 ml). When the bladder is about halfway full, stretch receptors located in the smooth muscle of the bladder walls will become active and stimulate the micturition reflex. This reflex causes the detrusor muscle in the bladder to contract and the internal urethral sphincter to relax. The bladder also transmits a signal to the brain which is interpreted as an urge to urinate. In addition to the internal sphincter, we have an external sphincter that we can voluntarily control. Relaxing or contracting this sphincter determines whether urine is allowed to exit the body. Contraction of the external sphincter will calm the detrusor muscle and the urge to urinate will dissipate as a result.  

 
When you habitually urinate “just in case,” you may be emptying your bladder when it is less than half full. Constantly doing this will train your bladder to think it is full when it is not. The stretch receptors will begin to send signals to your brain at lower and lower thresholds, thus creating the urge to urinate more and more frequently. 

 
In my practice as a pelvic floor therapist, I see the habit of “just in case” voids all too often. Usually it starts as a behavior learned early in life or during pregnancy. If you find that you are going to the bathroom frequently, routinely urinating less than fifteen seconds in duration, or waking up multiple times a night to urinate, I would recommend that you see a pelvic floor therapist to address these issues. Just as the bladder can be trained to hold less urine, with physical therapy, the bladder can also be trained to comfortably hold more! 

– Dr. Fei Zang, PT, DPT

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