When Pilates isn’t Enough; Do You Know What Pelvic and Genital Prolapses Are?

Making one’s mikveh experience isn’t only about the physical condition of the mikveh itself, or how the balanit does her job. Sexual pleasure and physical comfort impact on a woman’s overall mikveh experience. Not feeling good about your body is going to impact on your desire to go to mikveh.
We are pleased to present (in the first of such articles) a piece by Tali Ginsburg who writes about a health problem many women experience, but few discuss, even with their health-care providers.

Let’s talk about genital prolapse.

Let’s talk about it because hardly anybody ever does. If you have a bulging, uncomfortable sensation in your vagina then know that you are not alone. At least half the mothers in the world have some degree of pelvic prolapse. What you’re feeling is your pelvic organs (either the uterus, bladder or rectum) pushing down into your vaginal canal. Not only is it uncomfortable, it can be downright frightening, and difficult to discuss it with a partner because essentially a very important and sensitive part of you feels broken.

What exactly prolapse is and what you can do about it.

We’ll start with the pelvic floor, a layer of muscles and connective tissue that form a Frisbee® at the bottom of the pelvic cavity. The levator ani is a group of voluntary muscles that support the pelvic organs and assist the urethral and anal sphincters to close completely.

Genital prolapse occurs when the pelvic floor is not providing enough support, the ligaments and connective tissue that anchor the vagina, uterus, bladder or rectum are weak or torn, and there is increased flexibility of the vaginal walls. The leading cause of prolapse is vaginal delivery since there is a great amount of stress on tissues and nerves as the baby exits the vaginal canal. Even during pregnancy, hormone-induced tissue changes can lead to prolapse.

Another cause is repeated stress to the pelvic floor, which gradually weakens pelvic floor muscles and ligaments. Common sources of increased abdominal pressure are chronic cough, jobs that require heaving lifting and years spent straining during defecation. Gravity is no friend to the pelvis, organ descent can just happen with aging as muscle fiber density decreases and nerve conduction slows down.

In most cases prolapse is a permanent condition however, if prolapse occurs during pregnancy or right after birth, the condition can improve markedly. The pelvic organs may even move back into place entirely as tissues heal and hormones get reabsorbed by the body. There are three main categories of prolapse: uterine, rectocele (rectal), and cystocele (bladder), which refers to the organ descending through the vaginal wall. Descent is classified by structure and severity, ranging from Stage I asymptomatic descent to Stage IV the uterus is hanging out between your legs (a complete uterine eversion). A woman’s symptoms depend on the type of prolapse and the grade of descent and may include urinary or fecal incontinence, pain during sexual intercourse, and irritation of the prolapsed area.

I recently saw a 26 year old patient, seven months postpartum with a stage two rectocele prolapse. She came to me because she felt an uncomfortable bulge and she was not able to enjoy sexual relations with her husband. She felt helpless because she believed that surgery was the only treatment option available but she still wanted to have more children. Prolapse isn’t only a physical condition, it affects a woman’s self-image and her relationship with her partner.

On her first visit, I told her that physical therapy and a pessary could ease her symptoms. I talked to her about female anatomy and her condition. We discussed situations that should be avoided (constipation, slouched posture, lifting heavy loads). Then we worked on engaging her pelvic floor muscles and I gave her exercises to do at home. Two weeks later, at our third session, she bounced into the clinic with a huge smile. She told me she only felt the bulge now when having a bowel movement, sex had become pleasant again, and she no longer felt like she just had to grin and bear her situation until surgery. She wanted to try a pessary as well.

What is a pessary?

A pessary is a vaginal ring or plug that mechanically reduces prolapse. Pessaries have been around for ages, dating back to at least 1800 BC when they were documented in the Egyptian Kahun Papyrus. Both the Greeks and Romans used them.

In the past pessaries were made of pretty much everything: ivory, linen and wool scraps, natural sponges, cork, wax, bone, and pomegranate halves soaked in wine. When rubber came along, it replaced cork and brass models. Today, pessaries are made of non-reactive silicon and come in all sizes and shapes.

By Huckfinne (Own work) [Public domain], via Wikimedia Commons

Though surgery has been the first-line treatment for prolapse over the past century, over the last twenty years pessaries have been making a comeback. They are simple to use, inexpensive, have low rates of complications and provide women a more active role in treatment. A woman can insert and remove her pessary according to her needs; she can choose to wear her pessary all the time, during the day or just for strenuous activities.

If you think you might have a prolapse or if you know you do, get yourself checked out. Tell your gynecologist about your symptoms and find a physical therapist specializing in pelvic floor rehabilitation. The earlier you start treatment, the better the results.

Tali Ginsburg is a physical therapist (US and Israel certified) specializing in pelvic floor dysfunction, lymphedema and orthopedics. She runs a private women’s clinic in Jerusalem, providing attentive, timely, individualized care in a comfortable atmosphere. For more information on prolapse or any other women’s health issues visit www.taliginsburgphysio.com or e-mail Tali at tgriffel@gmail.com.