By Jillian Giannini, DPT, PHRC Los Angeles
Did you know that Pelvic Organ Prolapse (POP)is more common than you think and that the severity or stage of the prolapse does not always correlate with symptoms?
One review found that 41 – 50% of women had POP on examination, though only 3 – 5% of women report symptoms.
Many people understand that POP can happen after vaginal delivery, but POP can occur for other reasons too, including global pelvic floor dysfunction. The risk factors for developing POP include:
- Vaginal delivery
- Parity
- Age
- Obesity
- Menopausal status
- Chronic constipation
- Connective tissue disorders
Some of the symptoms related to pelvic organ prolapse include:
- A feeling of heaviness in the vagina
- A feeling of “something is coming out”
- Urinary incontinence
- Incomplete emptying with urinating and bowel movements
These symptoms can occur with any stage of prolapse, so the severity of your prolapse does not determine your complaints. To learn more about the various types of pelvic organ prolapse check out our blog Taking a Closer Look at Pelvic Organ Prolapse.
Treatment options for POP can range from conservative to surgical. Like so many other pelvic health syndromes, pelvic floor physical therapy should be offered to all women with prolapse concerns! Even if someone eventually needs surgery, pelvic floor physical therapy can help optimize the pelvic floor and girdle muscles which will only improve surgical outcomes. Pelvic floor physical therapy for POP can include the following:
- Training for proper bladder and bowel habits/techniques. This will help reduce strain on the pelvic floor muscles and the connective tissue support to our pelvic organs.
- Lifestyle changes (i.e. proper lifting mechanics, avoiding constipation, etc.)
- Neuromuscular re-education to the pelvic floor muscles. Your PT will help you regain control of your muscles so you can contract them at the right times (when exercising), and relax them at others (to have a bowel movement without straining
- Manual therapy to the pelvic floor and girdle muscles when appropriate,ie tight/short muscles
- Therapeutic exercise to help improve pelvic floor and core strength, endurance, and control
- We may suggest that you speak to your healthcare provider to determine if a pessary is right for you
Donut Fear , Pessaries Are Here!
If you are interested in seeing in more detail how pelvic health physical therapy can help with pelvic organ prolapse check out our blog The Case of Pelvic Organ Prolapse . Outside of pelvic health physical therapy, one of the treatments that seem to be overlooked or under recommended are pessaries. It’s a silicone device that can help support the descent of the uterus, bladder, or rectum into the vagina. A pessary fitting can be done by your doctor or nurse practitioner.
Up to 92% of women can be fitted for a vaginal pessary successfully, which is amazing because it is an effective nonsurgical treatment option. There are a plethora of vaginal pessary options and may require multiple trials/fittings to see what is the best fit for the individual, along with finding one that suits your lifestyle. There are ones that you can remove and re-insert yourself daily, and for individuals unable to remove and insert, there are pessaries for longer duration and they go to the office for cleaning and examination every ~three months per provider’s request.
It’s also important to note that Hanson et al. (2006) found that estrogen therapy was important to successful pessary fittings. Women who used vaginal estrogen had higher fitting success. This is to help keep the vaginal tissue healthy and plump. Especially when women in menopause are more susceptible to POP.
So what are some pessary indications?
- To relieve prolapse symptoms
- Avoid surgery
- Diagnostic tool, to identify occult stress incontinence
- Prediction tool to see likely surgical outcomes
- Prevention of increasing prolapse and related morbidity
They come in all shapes and sizes. A few include:
- Ring pessaries
- Cube pessaries
- Gehrung pessaries
- Gellhorn pessaries
- Inflatable pessaries
With the various stages of prolapse one study showed that women with a stage II, a ring pessary were 100% successfully fitted, 71% for a stage III, and with a stage IV the Gelhorn was more frequently used and 64% successful.
Some symptoms that pessaries can help with include:
- Improve bladder emptying
- Sensations of bulge, heaviness, and pressure
- Urinary incontinence
- Urinary urgency and frequency
- Fecal incontinence and urgency
- Difficult or incomplete emptying of bladder and bowels
Common Pessary Care Instructions:
- Three to four month follow ups with MD
- Local devascularization or erosion: remove pessary two to four weeks and have local estrogen therapy
Just like any treatment there are some complications and precautions when using pessaries. Some of these include vaginal infection, persisting vaginal erosion or ulceration, new symptoms of discomfort and pressure and/or pain. If these occur you can discuss with the provider who fitted you.
With now knowing that up to 92% of women can be successfully fitted for a pessary, a conservative form of treatment, you DONUT have to fear POP because pessaries are here! If you or know someone with pelvic organ prolapse share our post! It’s so important to know all the various treatments and options. Knowledge is power!
References:
The American College of Obstetricians and Gynecologists and the American Urogynecologic Society INTERIM UPDATE: This Practice Bulletin is updated as highlighted to reflect the US Food and Drug Administration order to stop the sale of transvaginal synthetic mesh products for the repair of pelvic organ prolapse. Pelvic Organ Prolapse, Female Pelvic Medicine & Reconstructive Surgery: 11/12 2019 – Volume 25 – Issue 6 – p 397-408 doi: 10.1097/SPV.0000000000000794
Atnip, S., & O’Dell, K. (2012). Vaginal support pessaries: Indications for use and fitting strategies. Urologic Nursing, 32(3), 114-125.
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Are you unable to come see us in person? We offer virtual physical therapy appointments too!
Due to COVID-19, we understand people may prefer to utilize our services from their homes. We also understand that many people do not have access to pelvic floor physical therapy and we are here to help! The Pelvic Health and Rehabilitation Center is a multi-city company of highly trained and specialized pelvic floor physical therapists committed to helping people optimize their pelvic health and eliminate pelvic pain and dysfunction. We are here for you and ready to help, whether it is in-person or online.
Virtual sessions are available with PHRC pelvic floor physical therapists via our video platform, Zoom, or via phone. For more information and to schedule, please visit our digital healthcare page.
In addition to virtual consultation with our physical therapists, we also offer integrative health services with Jandra Mueller, DPT, MS. Jandra is a pelvic floor physical therapist who also has her Master’s degree in Integrative Health and Nutrition. She offers services such as hormone testing via the DUTCH test, comprehensive stool testing for gastrointestinal health concerns, and integrative health coaching and meal planning. For more information about her services and to schedule, please visit our Integrative Health website page.
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FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical therapy?
Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.