Shame and silence: Why are we still ignoring pelvic organ prolapse?

It was a shock for the then 30-year-old when that didn’t happen.

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Despite an uncomplicated delivery, daughter Allegra weighed 4.3 kilograms, and Smith gave birth to her while lying on her back, something that she now knows puts more load on the pelvic floor.

Within a week or two of giving birth, Smith suspected that “something was severely wrong”.

“I just felt this really uncomfortable bulging, heavy sensation. And I like looked in the mirror at my vagina, and I was like ‘Oh my God’.”

Smith returned to hospital, where she was told everything was fine and then, at her six-week checkup, was given the all-clear to start exercising again. She dove straight back in, but when the symptoms became more intense, she sought a second opinion.

“Like a lot of women who get diagnosed with prolapse, the first time you hear about it is when you are being diagnosed with it,” Smith says.

What is pelvic organ prolapse?

Prolapse is when the pelvic organs – either the bowel, the bladder or both – start to “sag into the vagina”, explains Pecoraro. But people’s experiences are wide-ranging.

In some very mild cases, women don’t experience any symptoms. However, they may be at a higher risk of it growing worse with age. These cases – referred to as stage one prolapse – are now considered by many experts as normal anatomical changes, says Lyz Evans, a women’s health physiotherapist.

“The vagina is not concrete,” adds Evans, the owner of Women in Focus physiotherapy. “It’s meant to have movement in it, but it can be an early sign to take a more proactive approach.”

For women who do have symptoms, Pecoraro says, “it can give them discomfort, pain, problems emptying their bowel or bladder, it can give them difficulty with intercourse”.

Some women with prolapse don’t experience symptoms until menopause, when the connective tissue becomes weaker because of the loss of oestrogen. In the worst cases of prolapse, the pelvic organs start to herniate out of the vagina.

Being pregnant is the biggest risk factor for prolapse. “The progesterone makes the connective tissue more stretchy and weaker,” Pecoraro says, adding that the weight of carrying the baby also stretches the supports that hold up the bladder.

A family history of prolapse; carrying excess body weight; having a large baby; the use of forceps during delivery; and a protracted labour all increase the risk. “In the bad cases, you can actually tear the muscle off the bone,” Pecoraro says.

But Pecoraro insists that full recovery is often possible. For instance, when symptoms show up in perimenopause or menopause, “sometimes just giving some oestrogen is all you need”.

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The first port of call for prolapse is typically physiotherapy. A six-month structured program of pelvic floor physiotherapy can lead to “significant improvements” in people who have given birth and have less severe prolapse, says Evans.

Another option is pessaries (soft removable devices that come in different shapes and sizes and which help to reduce the gravitational load on the pelvic tissues), which Evans refers to as “sports bras for the vagina”.

Up to 20 per cent of women with a prolapse require surgery which, Pecoraro says, has an 80 to 85 per cent success rate.

Though rates and outcomes can be improved, a proper diagnosis is essential, says Pecoraro. “If you have problems with continence – urine, bowel or gas – you should see your gynaecologist. Don’t suffer in silence.”

Living with prolapse

The afternoon I speak with Evans, she has already seen five prolapse patients that day. Two of those patients were in tears because “they cannot look at their own vagina”.

The heartbreaking side effects of living with prolapse are not limited to unpleasant symptoms and altering the way some women see themselves. “Their feeling of who they are and their own kind of femininity and sexuality changes,” says Evans, a mum of three. “And they avoid intimacy. So, then the run-on effect to a woman’s relationship and potentially family unit is huge.”

Many patients she sees also become fearful of exercise, though avoiding exercise only makes the tissues weaker and the prolapse symptoms worse. It also puts them at greater risk of developing other health conditions. “The impacts run deep, and they seep through into almost every crevice of their life,” she says.

It is a sad truth when many cases may be prevented from happening. Improved prenatal education, pelvic floor exercises, knowing their inherited risk and being taught how to push in a “more biomechanically optimal way” to reduce the strain, can also help women reduce their risk of prolapse.

Smith was ultimately referred to Evans and the pair now run pre- and post-natal education courses called the Empowered Motherhood Program.

But Smith’s prolapse became worse before it improved.

During her second pregnancy, simple activities like walking to the park became hard. “I felt like I couldn’t do any activity without feeling symptomatic, which I think just slowly eroded my confidence in myself and not only physical capabilities, but my general capabilities in life,” she says.

The physical and emotional toll continued into her third pregnancy. Smith admits feeling anxious throughout the entire pregnancy as she battled incontinence.

In the five years since she gave birth to her youngest daughter, Smith has worked hard to heal. She started out with basic pelvic floor exercises and core activation, was fitted with a pessary and has gradually built her body and confidence back up. Today, she attends several Pilates or yoga sessions each week, walks and does prolapse-specific workouts.

Though she still has fear around high-impact activities like running, she says her symptoms have mostly subsided. “I’m in a really good place,” says Smith, who talks openly about prolapse with her daughters.

“We don’t want to put [people] into a fear spiral … But I think every woman is capable of making bold decisions about her body if she has all the information available to her. And I definitely want that for my daughters.”

June is Pelvic Organ Prolapse Awareness Month.

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