Evidence  

https://www.racgp.org.au/afp/2015/july/pelvic-organ-prolapse-a-review 

Hans Peter Dietz 

FPOP is a common condition requiring surgery in 10–20% of women. Vaginal childbirth is the main aetiological factor, and major tears of the levator ani muscle (avulsion) seem to be the primary link between childbirth and prolapse of the bladder and uterus. Avulsion can be diagnosed by palpation, which, together with prolapse quantification using the POP-Q system, is well within the scope of general practice. This is also true for conservative treatment with PFMT and pessaries. 

Primary prevention is feasible through modification of obstetric management. The main modifiable risk factor for pelvic floor trauma and later pelvic organ prolapse is forceps, whereas vacuum is not associated with increased risk. Secondary prevention is feasible through pelvic floor physiotherapy, which requires provision of adequate diagnostic and therapeutic postnatal services. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8073097/ 

Elizabeth O Bodunde,  Daire Buckley,  Eimear O'Neill,  Gillian M. Maher,  Karen Matvienko-Sikar,  Karen O'Connor,  Fergus P. McCarthy,  Ali S. Khashan,  

Postpartum complications like pelvic organ prolapse, anal and urinary incontinence are also strongly associated with medium to long-term mental and physical ill-health, poor mother-infant bonding, relationship difficulties and sexual dysfunction. 

Education 

Your pelvic organs are your bladder, uterus (womb), large bowel and rectum (back passage). Support tissues called ‘fascia’ and ‘ligaments’ hold these organs in place. These support tissues help to join your pelvic organs to the bony side walls of the pelvis.  

These support tissues can be torn or stretched. Your pelvic floor muscles support your pelvic organs from below. If your pelvic floor muscles are weak, they may not give your pelvic organs proper support. Without strong support, pelvic organs may bulge down into the vagina (birth canal). This is called a prolapse. 

The biggest cause of prolapse is pregnancy and birth – almost one in two (or 50 per cent of) women who have been pregnant will have some kind of prolapse.  

Your pelvic floor is weakened during pregnancy (by extra weight and hormone changes) and then again when you give birth – particularly if you had more than one baby, your baby was big, or you had to push for a longer time than usual. 

You are also more likely to have a vaginal prolapse if: 

• someone in your family has also had a prolapse 
• you have been through menopause, and you have low levels of the hormone oestrogen  
• you are over overweight 
• you cough a lot or strongly (because you smoke, have bad bronchitis or asthma) 
• you often have constipation and need to push hard or strain to go to the toilet 
• you regularly lift heavy things (like furniture, older children etc.) 
• you have fibroids or a pelvic tumour 
• you have had surgery in the past to treat a vaginal prolapse. 

Nurse Continence Specialist Christine Murray answers common questions about prolapse, and where to go for help and further information. 

Types of Pelvic Organ Prolapse 

• Vaginal prolapse is when the walls of the vagina become overstretched and bulge downwards towards the vaginal entrance. The bulging can be the front vaginal wall with the bladder in front of it or the back vaginal wall with the rectum immediately behind. 
• Uterine prolapse is when the uterus (womb) and cervix (opening to the womb) drop down towards the vaginal entrance and may protrude outside the vagina. 
• Bladder prolapse is when the bladder causes a bulge in the vaginal wall. This usually occurs because of weakened pelvic floor muscles, which support the uterus, bladder and bowel. It can occur by itself, or it may happen alongside other types of prolapse. 
• Bowel prolapse is when the bowel bulges forward into the back vaginal wall.

Signs and symptoms of Prolapse 

In mild cases of prolapse, there are often no symptoms at all. In those cases, it’s more likely for the prolapse to be noticed during your six-week check-up, either with your obstetrician, midwife or GP. This is common in early postpartum to feel as if your vagina is different, as your pelvic organs and pelvic floor are still healing. 

When women do have symptoms, they can range from minor changes known as Stage 1* to completely life-altering consequences (Stage 4) and can include some or all of the following: 

• Feeling or seeing a bulge or lump at the opening of the vagina 
• Feeling a ‘dragging’ sensation, as if something is going to fall out of the vagina 
• Feeling of pressure due to the pelvic organs pressing against the walls of the vagina 
• Difficulty, discomfort or pain with intercourse 
• Lower backache 
• Faecal incontinence 
• Constipation or difficulty having a bowel movement 
• Pain or difficulty having sex 
• Urinary incontinence 
• Difficulty passing urine.

*Stage 1 is the least severe, and means the organ is still well-supported and inside the vagina. Stage 4 is the most severe, and means the organ is coming out of the vagina. 

Birth Trauma Australia says that some women may have a more significant prolapse than others and yet they don’t feel bothered by their symptoms. Whereas other women could have what is described as a stage 1 prolapse and feel completely overwhelmed by their symptoms. One woman’s “normal” will be different from another’s. 

Treatment for Pelvic Organ Prolapse 

If you are experiencing any of the symptoms above immediately after giving birth, speak to your healthcare team in the Maternity ward.  

If you are experiencing any symptoms after being discharged, speak to your GP who may refer you to a women’s physiotherapist or a doctor who specialises in women’s pelvic floor problems (called a urogynaecologist). They may recommend one or more of these treatment options: 

Continence physiotherapist/Women’s health physiotherapist  

Physiotherapy strengthens the pelvic floor that supports your organs. A physiotherapist can design a special pelvic exercise program for you. Physiotherapy aims to fix prolapses. 

A Nurse Continence Specialist  

A registered nurse with extensive education and training in continence care. They are able to assess your condition and work with you to develop a management plan to suit your needs. Nurse Continence Specialists may visit you at home or see you in a continence clinic. Contact the National Continence Helpline on 1800 33 00 66 and speak to a Nurse Continence Specialist.  

Pelvic Floor Exercises  

Pelvic floor muscles, just like any other muscles, can be strengthened with the correct exercises. It is important to have your pelvic floor muscle training technique checked by an expert such as a Pelvic Floor Health Physiotherapist or a Nurse Continence Specialist. 

Lifestyle changes  

This can include losing weight, quitting smoking, eating and drinking differently, and lifting less and keeping good bladder and bowel habits to avoid straining. See the brochure from Continence Foundation Australia ‘Good Bladder Habits for Everyone’  

Pessary 

Physiotherapists commonly fit a pessary in the early postnatal period. It’s a small plastic or silicone support that is placed inside the vagina to decrease the symptoms and discomfort associated with a prolapse. 

Surgery 

If the prolapse is significant your GP will refer you to see a urogynaecologist. (Urogynaecology is a sub-specialty of Gynaecology) 

Surgery can be done to repair torn or stretched support tissues and ligaments. There are several types of prolapse surgery but all of them try to fix the prolapse and make the vaginal wall stronger which helps the tissues support the pelvic organs.  

Psychological or emotional birth trauma 

Birth trauma is any wound or damage that happens as a result of childbirth. Although trauma can be physical, such as a birth-related injury, it can also be psychological or emotional. 

This can present as postnatal depression, postpartum post-traumatic stress disorder, or Obsessive-compulsive disorder. 

Having Pelvic Organ Prolapse can impact the enjoyment of daily life and impact mental health. It's important to seek medical support not only for the treatment of the condition but also for your mental health.  

If you are concerned about your symptoms or are finding it hard to manage you should speak to your GP. In an emergency, you should call 000. 

You can also reach out to organisations such as PANDA. They have highly trained and caring counsellors and peer practitioners who can help you work through and support you in your birth trauma recovery journey. 

Australasian Birth Trauma Association and BirthTalk offer free resources to new parents, including evidence-based information on birth trauma recovery and healing. 

Empowerment 

Pelvic organ prolapse can occur after both vaginal and caesarean birth but is significantly more likely from a vaginal birth because of the increased pressure from pushing during labour.  

It can take up to six months or longer for your pelvic floor to heal from birth. The good news is that postpartum prolapse is not a life-threatening condition and can improve with time, especially with pelvic floor muscle training during the postpartum period with the help of a physical therapist.  

Most importantly, remember that pregnancy and labour change your body. It takes time to recover! Be gentle with yourself and never feel ashamed to seek advice from a professional for help. 

Useful links  

Special thanks to The Continence Foundation of Australia for content sharing and providing support for families.   

Continence Foundation of Australia  

www.continence.org.au  

https://www.continence.org.au/who-it-affects/women/prolapse  

The national peak body for continence awareness, management, education, research and advocacy. Free information and resources are provided to individuals, carers and professionals.   

National Continence Helpline  

1800 33 00 66  

Pelvic Floor First  

www.pelvicfloorfirst.org.au  

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists  

https://ranzcog.edu.au/wp-content/uploads/2022/05/Pelvic-Organ-Prolapse.pdf  

Australian Birth Stories   

https://australianbirthstories.com/postpartum/prolapse-after-birth-understanding-the-causes-symptoms-and-treatment-options/  

The Australasian Birth Trauma Association   

https://birthtrauma.org.au/pelvic-organ-prolapse-pop/  

Centre of Perinatal Excellence (COPE)  

https://www.cope.org.au/  

PANDA – Perinatal Anxiety & Depression Australia  

https://panda.org.au/  

Miracle Babies Foundation  

https://www.miraclebabies.org.au/content/birth-trauma/gmc0l4 

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