Approximately 30 per cent of women aged between 20 and 59 and more than half of women over 50 suffer from pelvic organ prolapse.
Composed of muscles, ligaments and other tissues, the pelvic floor acts as a kind of hammock, holding the organs in the pelvis in place. Prolapse occurs when these organs – the bladder, rectum, uterus or bowel – ‘drop’ or protrude into the vagina as a result of a weakening in the pelvic floor. Symptoms of pelvic organ prolapse can include the sensation of a lump in the vagina, urinary or faecal incontinence, and problems with sexual intercourse.
Pregnancy and childbirth are the most common causes of pelvic organ prolapse because carrying the weight of a growing fetus, combined with the trauma of labor, can cause the muscles in the pelvic floor to weaken, making sufferers vulnerable to herniation.
Sarah Sheppard was pregnant when she first discovered that something was amiss.
“There was a little bit of urinary leakage when I coughed or sneezed. But I knew that was really common in pregnancy and not a cause for concern. I just assumed it would go away after the birth,” she said.
But the problem didn’t go away. In fact, it worsened.
Some months after a particularly difficult labor, Sarah says she made a disturbing discovery.
“I was showering and I found there was something ‘sticking out’. It went away for a while but, after that, I had a constant feeling of pressure in the vagina. It was uncomfortable, but not painful – a kind of heaviness, like there was something… falling. Again, I thought it would fix itself once I’d recovered.”
Besides pregnancy and vaginal delivery, the other greatest risk factor for prolapse is menopause. The decline in estrogen levels that comes with menopause reduces the elasticity of the pelvic floor. Obesity and smoking are also associated with the development of a prolapse. And, Sarah once discovered, high-impact sports such as running, can further weaken the pelvic floor and cause urinary incontinence.
Prevention and treatment
The good news, however, is that, for the most part, pelvic organ prolapse and its symptoms can be treated. Most women have heard about Kegel exercises; the repeated contraction and relaxation of the muscles of the pelvic floor. Such exercises are encouraged for women of all ages, regardless of whether they have had or are planning to have children, and can aid in the recovery from the demands of pregnancy. Biofeedback and electrical stimulation therapy are also possibilities, especially for those with milder conditions or after childbirth.
For those with an existing prolapse that cannot be rectified by training or physiotherapy, the insertion of a custom-fitted silicone pessary, which sits high in the vagina and holds the pelvic organs up, may be helpful. In the most severe cases, surgery may be appropriate, though the long-term success of surgical repair is not guaranteed.
In fact, women have hardly felt reassured in recent years as information emerged that a common surgical intervention for severe cases of prolapse had resulted in the disability of thousands of women and the death of at least one. The so-called vaginal mesh scandal revealed that the plastic sling introduced in 1998 had caused complications in as many as 10 per cent of women who had received it. Complications included debilitating pain, nerve damage, recurrent urinary tract infections and, in the case of a Canadian woman, fatal sepsis.
The mesh scandal illustrates the apparent disregard with which sufferers of pelvic organ prolapse have been treated in the past. However it should not discourage women from approaching their physicians, given that there are now less invasive and less potentially damaging treatments available.
Why don’t we talk about it?
So if prolapse and its symptoms are treatable, how can we explain the fact that so many women continue to endure it?
Recent studies show that just over half of women who report urinary incontinence actually seek treatment, and less than a fifth receive a specialty intervention. Embarrassment and a belief in being able to treat symptoms without medical assistance are frequently cited as reasons for women’s reluctance to approach their physicians.
But Sarah believes there is something else at play.
“There’s this idea that it’s ‘normal’ or just part of life,” she said. “You have a child and suddenly your body is different.”
Indeed, women often view pelvic organ prolapse as part of the burden of becoming a mother, or of aging.
“There’s a code of silence, almost,” Sarah added. “Even if your closest friends have problems, you wouldn’t necessarily know it.”
Furthermore, Sarah believes that even medical professionals aren’t always inclined to take women’s concerns seriously.
“‘Just do your exercises,’ was the standard response I received when I spoke to my doctors. I think, like me, they just thought it would sort itself out eventually.”
The psychological burden of POP
For Sarah, many of the physical symptoms of her prolapse have now been mitigated. But she still suffers from residual stress incontinence and this has had an effect that is not solely physical.
Prior to having her daughter, Sarah ran the London and Boston marathons, as well as countless half-marathons. She was also instrumental in setting up the southern German branch of parkrun, a movement that encourages people to regularly walk or run in their local park as part of a community.
“I’d always been a runner,” said Sarah.
“That was part of how I defined myself. Becoming a mother already raises a lot of issues around identity. When I discovered that I couldn’t continue to enjoy something that had previously been such a big part of my life, it was absolutely devastating.
“It’s important to raise awareness about prolapse because its effects on quality of life can be really harmful.” Women living with prolapse who have been surveyed, talk of feelings of loneliness, isolation and shame, as well as anxiety and depression.
“Before I got pregnant I knew nothing about prolapse,” Sarah admitted. “You hear talk of pelvic floor exercises in Pilates or yoga classes, but I didn’t know why I should be working on my pelvic floor.
“In hindsight, I know that there are certain things I could’ve done, decisions I could’ve made, that might have made a difference. I would recommend that pregnant women, especially, inform themselves about pelvic organ prolapse, just as they would any aspect of pregnancy. Be aware of all your options so you can make informed decisions about your care.”