“There is a constant feeling of something pushing down into my vagina, almost like my vagina is falling out. I always have to rush to the bathroom to pee and sometimes I do not make it. I have resorted to wearing an adult diaper every time I leave the house, I simply could not deal with the embarrassment of having an accident on the road. I never imagined that my old age would come down to this.”

I looked down at her patient card, she was 68 years old, I would not have guessed. “But that is not the worst part,” she continued, “Every time I walk there is this pain, it feels like something is rubbing down there. I have been to many doctors, I have done many tests; they are saying surgery is my last hope. But one gynaecologist referred me to you as a last resort before surgery. Do you think you can help me?” she asked with her voice cracking and her eyes filled with tears.

I looked at her with as much reassurance as I could muster through a masked face and said, “I will certainly try. Let’s take a look.”

What is pelvic organ prolapse?

Pelvic organ prolapse, often referred to locally as “body come down”, occurs when the tissues and muscles of the pelvic floor can no longer support the pelvic organs. This results in a drop (come down) or prolapse of one or more of the pelvic organs. The pelvic organs include the vagina, cervix, uterus, urethra, bladder and rectum. The bladder is the most common organ involved in a pelvic organ prolapse and is usually associated with urinary incontinence, another disorder of the pelvic floor.

Stages of pelvic organ prolapse

Stage 1: Very mild prolapse – organs are still fairly well supported by the pelvic floor.

Stage 2: Pelvic floor organs have begun to fall, but are still contained inside the vagina.

Stage 3: Pelvic floor organs have fallen to, or beyond the opening of the vagina.

Stage 4: Pelvic floor organs have fallen completely through the vaginal opening.

What causes a pelvic organ prolapse?

The pelvic organs are kept in place by a supportive ‘hammock’ of tissues, muscles, ligaments and fibres connected to the pelvic bones known as the pelvic floor. When the pelvic floor weakens or is damaged it loses its ability to support the pelvic organs resulting in a pelvic organ prolapse. The weakening and damaging of the pelvic floor is primarily related to pregnancy and vaginal delivery, however, hysterectomy, pelvic surgery, and conditions associated with sustained episodes of increased intra-abdominal pressure — including obesity, chronic cough, asthma, constipation, and repeated heavy lifting — also contribute to prolapse.

Who is at risk for pelvic organ prolapse?

Pelvic organ prolapse affects approximately 50 per cent of women over 50 at varying degrees. Women who have multiple children are at an increased risk. Other risk factors are age, obesity, history of pelvic cancer, genetics, hysterectomy, hypertension and diabetes combined increases the risk of pelvic organ prolapse by almost two times.

What is the relevance of pelvic organ prolapse to the Jamaican population?

According to the latest official data from the Planning Institute of Jamaica the Jamaican population is ageing, with some 280,000 Jamaicans now at the age of 60 years and over. Furthermore, the fastest growing segment of the country’s population is the age cohort of 65 years and over. Therefore any condition that affects the elderly population is relevant to the Jamaican population. We should also consider the rate of non-communicable diseases such as hypertension and diabetes in our population, the Ministry of Health has reported that 1 in 3 Jamaican has hypertension with a higher percentage being women. Similarly, 11.9 per cent of the Jamaican population has diabetes with an increasing incidence in women and the elderly. As stated before, diabetes and hypertension combined increase the risk of pelvic organ prolapse by two times. Another important factor is the prevalence of hysterectomy in low-income populations such as Jamaica, which is often done without pre or post-rehabilitation of the pelvic floor to help reduce the chances of a pelvic organ prolapse specifically a vagina vault prolapse that is a risk associated with hysterectomy.

What symptoms should you look out for?

If you could relate to my 68-year-old patient then you should consult your gynaecologist or primary care physician to see whether you may have pelvic organ prolapse. Additional symptoms may include;

• A bulge in the vagina or rectum,

• A bearing down sensation in the vagina or rectum

• Pain during sex, constipation

• Faecal incontinence (inability to control bowel movements)

• Incomplete defecation

• Constantly feeling the urge to pass stool

• Feeling like you can’t fully empty your bladder

It must be noted that it is not uncommon for pelvic organ prolapse to go unnoticed in the earlier stages, symptoms usually become more bothersome when the bulge protrudes through the opening of the vagina.

What are the treatment options for pelvic organ prolapse?

Treatment for pelvic organ prolapse is categorised as conservative versus non-conservative management. Conservative management includes: Training the pelvic floor muscles through physical therapy. The use of pessaries, pessaries are devices that are placed in the vagina to help support the pelvic organs and decrease prolapse symptoms. They are primarily made from medical-grade silicone. Two-thirds of patients with pelvic organ prolapse initially choose management with a pessary, and up to 77 per cent will continue pessary use after one year. Pessaries are an option for all stages of prolapse, and they may prevent the progression of prolapse and avert or delay the need for surgery.

Non-conservative management would involve surgery which is sometimes the only viable option in the later stages of pelvic organ prolapse.

How do I manage my pelvic organ prolapse patients?

My goal as a physiotherapist when treating any patient regardless of their diagnosis is to make sure they feel heard and to find out how the condition affects their quality of life and their identity as a woman. Once I have effectively gathered the appropriate information I can set realistic goals based on their findings that are aligned with their values. It is very important to take the time out to educate each patient on the complexity of women’s health issues and give them a safe space to talk about it. Having tissue close by has been very useful as our talks usually begin with tears of frustration, because they have been living with the condition for so long and end with tears of relief because finally, they feel heard and hopeful.

Further physical therapy management includes a thorough assessment and a detailed examination of the pelvic floor, which usually reveals the cause of the pelvic floor dysfunction. This can range from poor breathing patterns, muscular imbalance, poor posture, general weakness, tightness in the pelvic floor muscles, and what usually comes as a surprise is that most patients are unable to adequately relax the pelvic floor muscles to allow for the proper functioning of the muscles.

These findings are usually addressed with individualised therapeutic interventions. These may include; internal soft tissue manipulations, pelvic traction, retraining the core, improving breathing patterns, pelvic floor strengthening exercises, posture retraining, core strengthening, electric stimulation of the pelvic floor muscles. Biofeedback intervention (for example, rehabilitative ultrasound) assists patients to localise and train areas of weakness.

Physical therapy is a viable option for the prevention and management of pelvic organ prolapse, especially in mild-moderate cases. It is supported by numerous research and I have seen it work time and time again. Doctors and patients alike can benefit from collaborating with pelvic health physiotherapists to prevent and manage pelvic organ prolapse. My 68-year-old patient is doing much better since doing physiotherapy. The rubbing sensation in her vagina has decreased, she no longer runs tirelessly to the bathroom. More importantly, she understands what is happening with her body and feels empowered.

Kimberly Hoffman is a pelvic health physiotherapist and the director of InSync Health Wellness Beauty. She has offices at Ace Total Heath Care, 4 Hillcrest Avenue, Kingston 6; Skyline Medical Services, 13 Duhaney Drive Kingston 20 and Doc’s House Surgeon and Physician, 3 West Henderson Boulevard, Portmore, St Catherine. She may be contacted by email at Kimberly@themummytummyguide.com or 876-358-8701. Follow her on Instagram @thewomenshealthphysio