Q and A: What is the Goal of Prolapse Rehab?

Q: OK, here’s my question that I have been thinking about for a while. Is the goal to make the prolapse go away, is that possible or are we aiming to have no symptoms. Without a doubt these principles have alleviated symptoms ( many years past delivery) but I still have a stage 2 prolapse. What’s my goal if I’m not having symptoms? Thanks! -Susan

A: Susan! I LOVE this question. This is something I have been musing about, too. I think it deserves some conversation within the pelvic health community, so here goes. I think the goal is no symptoms with a return to function and fitness (patient determined level). So if you are asymptomatic and fulfilling all your life duties (work, home, carpool, etc), you are able to exercise in a satisfactory way, sex is good, control and passage of urine and feces all good…then I say rehab has achieved its goal. I do think this may come in the presence of a continued prolapsed position of your organs. However, you have been able to restore the forces and structures that support the pelvic organs in a way that has rebalanced the system and no longer triggers your symptoms or reduces your function. The body is incredibly adaptable, and this new balance may be achieved through a more compliant abdomen above, a different breathing pattern, the elimination of motor patterns or breath holding that were exacerbating the issue, postures that changed the trajectory of forces, strengthening, etc. It makes me think of a certain balloon example I love, we are trying to balance the balloon through the marriage of muscular work and pressures. Likely this balance will change the position of the prolapse to a more elevated position, but does it go back to zero in everyone who eliminates symptoms? We would need some studies for sure, but I think it is reasonable to think that no, not everyone goes back to baseline.

 Some of my reasoning, my musings, relate to the role of the brain in this. If we could extrapolate the new pain science to the realm of pelvic health, not just pelvic pain, it may be that the level of prolapse has returned to a position that the brain no longer perceives as dangerous. The change of inputs, via the re-balancing of factors such as those given as examples above, may have reduced the threat in such a way as to result in a change in the brains output. An example that comes to mind is a participant in a one of my courses. With some simple changes in her alignment and breathing she noted her constant prolapse pressure was almost eliminated in about 15-20 minutes of practice (I have witnesses!!). Did her prolapse instantly lift from a level 3 to a zero? No, I don’t think so. Did we change and balance all her inputs to reduce the pressure from a held abdomen, a tucked bum, and a faulty breath pattern? Did those inputs influence her brains output? I think this is not a huge leap in reasoning in light of all we are learning from the new pain science research. Something changed…and nothing works faster than your brain.

 This also fits with our understanding that some women have a significant prolapse, but minimal symptoms. And some have a minor prolapse, with significant symptoms. Is there a central sensitization issue here too? Similar to an X-ray that shows lots of arthritis in a joint, but the patient reports minimal issues. Or the patient has a relatively clear X-ray, and significant symptoms. This makes me wonder how hearing your prolapse grade may impact your situation (emotion, fear, etc.) given that some have no symptoms and a prolapse may be an incidental finding in an exam. Similar to the impact of an MRI result that shows an incidental disc bulge in the absence of symptoms. Just a thought….and worthy of conversation (not hate mail, please). 

 This must lead us to consider the demand on the system though, too. Your activity or fitness level, may be low impact, you may have lots of time to maintain your physical balance, finances to have a maid instead of having to deep clean the tile in the bathroom yourself, or your kids are old enough to no longer need to be carried. You may be someone who has low demand on the system. So your brain/system may be able to tolerate a prolapse at a level 2. Contrast this with a young mom with three little ones, no maids, no sleep, no time, and the desire to run a marathon….that’s a different demand on the system. So our job as rehab providers is to train the system to meet each individual’s functional demand. And if young mom cannot run without symptoms, then her prolapse at any level cannot tolerate the demand being placed on it. Symptoms and restored function are our big guides to functional and fitness progression.

 Lots to ponder. Please weigh in with your own musings below.

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24 thoughts on “Q and A: What is the Goal of Prolapse Rehab?”

  1. susan pollack says:

    This completely makes sense to me and fits with the experiences I have had in retraining my body–not just the pelvic floor but in other areas too like back and hamstring injuries. One of the reasons I asked the question is that I am considering a return to running and know that running can contribute to POP. I feel like my awareness of pressures, body positioning and usage is good enough that I can start a running program and monitor for symptoms, continuing my exercise program that enhances the performance of my abdominal and thoracic pressure systems. I feel like I have the tools to be successful 🙂 I’ll keep you posted!

    1. Julie Wiebe says:

      Thanks again for your question Susan. Running will certainly be your litmus test! You should work toward it wisely- single leg work, single leg squats with good control, some gentle plyometrics. Get your system ready for single leg impact! Let me know how it goes! And thanks again.


  2. Tracy Gilbert says:

    Excellent response to am excellent question. Thanks for some great insight.

    1. Julie Wiebe says:

      Thanks Tracy! It is such a great question…and leads to others like how do we make surgical decisions? Or pessary recommendations? Is it based on grade? Lots and lots to ponder….Julie

  3. Michelle says:

    Totally agree about the brain connection. I have a small prolapse but found out that my discomfort is due to tight scar tissue from a tear during childbirth, not from the prolapse. Somehow that comforted me to know that it wasn’t prolapse sensations, and I have been able to better “ignore” it (along with internal work that helped to release the contracture). When I do feel it, knowing it is tight skin rather than my organs falling out helps me to carry on.

    1. Julie Wiebe says:

      That is comforting! Prolapse is such a scary to think that your organs might be falling out. So we really do need to consider the WHOLE patient in our care. I wonder too, how does hearing that you have a 1/5 (really weak) pelvic floor in an exam impact women? I kind of explored that here: http://www.juliewiebept.com/individual/q-and-a-isnt-the-piston-approach-just-a-kegel-plus-breath/. Lots for us to keep in mind. Thanks for sharing your experience.

      Take care Julie

  4. Joanie Lehman, MPT, NASM-CES says:

    Great post Julie. I agree – symptoms will guide us.

    1. Julie Wiebe says:

      Thanks for commenting, Joanie!

  5. Fiona says:

    Totally agree with you Julie and well written. I believe it is an individual thing and based on function and comfort. Many women can have a POP-Q grade 2-3 and have no real issues whilst another may have grade 1-2 and be in great discomfort that affects many aspects of her life. There is currently much discussion in the urogynae world as to the validity of the POP-Q system in determining “cure” as there are studies of nullips who by POP-Q definition are a grade 1

    1. Julie Wiebe says:

      Thanks for the added info Fiona! Fascinating, but totally fits with a more global understanding of how POP happens and is maintained by more global/systemic issues vs just a pelvic floor issue if women without children (nulliparous) also have small POPs. Thanks for reading and contributing. Take care-Julie

      1. Fiona says:

        True but that is also one of the misconceptions about POP . It is not all about the pelvic floor – the fascial components play a huge part and you can ,in fact, have an excellent pelvic floor by definition of strength and lift but still have a large POP due to fascial failure. You also do not need to have had a pregnancy. Clinically we see many women who have sizeable POP and they have never been pregnant. Any pressure increasing activity – poor defecatory technique , years of constipation , high levels of lifting in work life, repetitive high impact sport…..of course some people can do all of the above and have 5 kids and remain intact . One of the largest and often ignored factors is genetics – quality of elastic/fascial tissue and its ability to withstand load…of course a supportive and reactive pelvic floor helps!

        1. Julie Wiebe says:

          Agree! Stupid fascia! This is also why I think POP surgeries have high re-occurance rates. Just doing surgery on the pelvic floor doesn’t treat all the reasons the situation arose, was maintained or worsened. Continued unmanaged pressure (from various and patient dependent sources) will gradually impact the repair. Lots to consider. Thanks for the insights! Julie

        2. Lisa Gillispie says:

          I’m also really interested in the impact of stress on fascia. If a nervous system is dysregulated and “stuck” in a more sympathetic dominant pattern, how does the hormone cocktail of adrenaline, cortisol, etc. impact the health of the fascia and the ability for the body to heal from a pelvic floor “injury” so to speak.

          1. Julie Wiebe says:

            Hi Lisa,

            This is a great question, and one I simply do not have a good answer for. I recently heard Ramona Horton speak on fascial issues and visceral manipulation. She did note that the fascia was susceptible (my word, not hers) to sympathetic tone. But I am not exactly sure the specifics, except I imagine it isn’t positive 🙂 if maintained for the long haul. I am going to pass the question to Ramona and ask her to add her reply. She is super busy answering her own emails and questions. You can also follow her on twitter @pelvicviscera and learn more from her.

            Thanks for weighing in-Julie

  6. Shan rogers says:

    Great discussion- thanks for all important aspects to consider for various clinical scenarios. It is frequently a multi-facet management approach.

    I agree that we need to assess & address the neuromuscular system & client injury-recovery belief system to optimise return of function &/or compensating for dysfunction. However there is often an element of facial-connective tissue dysfunction (over stretching) that cannot be corrected via neuromuscular retraining – hence POP gr 2/3 at rest – with strain but functionally relatively as symptomatic if sting, functionally adaptive PFM function. rebalancing the system to compensate for connective tissue dysfunction is imperative (maybe like an ACL deficient knee in a sports person pre surgery or deferring surgery).
    Functionally, I think the symptom bother often depends on on the intensity/ impact /frequency/ load/nature of the activities the person is
    participating in. This coupled with the individuals expectations of their physical performance & body awareness.
    Thanks again for all great comments.

    1. Julie Wiebe says:

      Agreed that the structural components cannot be ignored, but historically our approach has only been structural, so I hope to bring attention to these other contributing factors. I liked your point of the ability of a “functionally adaptive” pelvic floor, and agree that we use this combination of structure and functional adaptation (neuromuscular) in sports med all the time. This is my background and the perspective I was “raised in” as a therapist.

      Thanks for weighing in! Julie

  7. bb bex says:

    I find this post fascinating. I’m currently 16 weeks and have a slight prolapse of the urethra, my bladder and back wall are fine. I have terrible bubbley feeling after peeing, previously I had this feeling all the time. But what interests me is that my pelvic floor strength is 5/5 having been tested twice. Seems mad but also interesting as I believe if I hadn’t done so much Internet research on this myself and scared myself silly that my symptoms would be far far less noticeable, I was shocked when my physio told me it was just my urethra and was hugely common whereas I had diagnosed myself with all kinds and worked myself up. Since being formerly diagnosed I’ve noticed an improvement, I wonder if that is partly due to the relief of it not being as serious as I had thought. The mind is a very complex thing!

    1. Julie Wiebe says:

      Agreed! The brain is complex and fascinating! I am really grateful that you shared your experience here. You are not alone in your experience both in the resulting emotional piece after reading lots of blogs, etc. And the relief of that with some good info and an exam to put that piece to rest.

      Thanks for weighing in! Julie

  8. Kay Crotty says:

    Great blog! Great question! The POPPY trial here in the UK (a large multicentre trial published in The Lancet), showed that women in the intervention group were significantly more likely to report improvement in prolapse symptoms (after 16 weeks of pelvic floor training including up to 5 visits to the physiotherapist)than women in the control group. Improvement in the staging scale of the prolapse (POP-Q) however did not show similar improvements. So we are probably going for improvements in symptoms rather than improvements in the staging. These women did pelvic floor exercises without the adjunct of core training or stretching, so it proved the power of pelvic floor exercises alone. However, it means we still don’t know if a more global exercise approach is better than pelvic floor exercises alone. In any case, we are going for improvements in symptoms! SO important, as all on here know, to keep up the good work even when symptoms improve. Happy training!

    1. Julie Wiebe says:

      Thanks for chiming in Kay! I would love to see that article, it lends support to my clinical experience. Can you give me the citation so I can access. Much appreciated! Julie

  9. Brenda says:

    Very interesting article and comments. I have a grade 2.5 rectocele. I had prolapse surgery in 2013 for bladder, grade 3 rectocele, fully herniated enterocele, and partial hysterectomy. I’ve been in pelvic floor therapy since a few months after surgery and more recently prescribed therapy for my spine. My core “shut down” and I’m dealing with pudendal neuropathy, hip instability, loss of balance, knees and ankles that collapse and roll, and pudendal entrapment. I had 4 vaginal deliveries 30 plus years ago. I also have Crohns disease and IC. The doctors believe the auto immune diseases have aggravated the pelvic floor weakened by the births of my children. I’ve advised my 3 daughters to talk with their doctor about how to keep their pelvic floor healthy so that 30 years from now they don’t go through what I’m going through. Doctors, especially OB-GYNs, should proactively be educating their patients about PFD and how to keep the pelvic floor healthy. The last 4 years have been years of misdiagnosis, surgeries, falls for no reason, PAIN, numerous lifestyle accommodations, etc. It’s no way to live and could have been prevented with pelvic floor education. Thank you for educating.

    1. Julie Wiebe says:

      Thanks for sharing your story. The tide is turning, but it is SLOW. Hoping to really change how pelvic health is delivered to my 12 year old daughter and her generation. And their is still help to be had for those of us in “older” generations, we are learning so much. I hope you have found the care you need. Take care and thanks for weighing in. Julie

  10. Tara says:

    Such a great post and answer to one of the most difficult questions a therapist can get! Thanks Julie for your insight!

    1. Julie Wiebe says:

      Thank you, I appreciate your kind words!! Julie

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