Holding It Together
At 42, I have two kids, an ongoing sinus crisis that precipitates coughing and a mountain of heavy groceries that I often lug around. Over the past year, I’ve also been on a barre workout binge, spending my mornings smugly executing hundreds of squats and lunges in step with my twentysomething classmates.
Who knew that this makes me a perfect candidate for pelvic organ prolapse, a condition in which pelvic organs, such as the uterus, bladder and rectum, can “relax” into the vagina, causing symptoms of heaviness, pressure and bowel issues? That’s why, at a recent visit to my OB/GYN, I asked if there were any issues “down there.” “Yup,” she said cheerfully. “I’ll refer you to a specialist.”
I was stunned. I had assumed that pelvic organ prolapse happens to women over 65 – a messy, awful business that can require surgery and complicated gynaecological procedures. Google searches made things worse. Pictures of grade 4 prolapses dominated, featuring desperate women with dislodged uteruses that required immediate surgery.
Luckily, after an anxiety-ridden trip to a surgeon, I discovered that my pelvic organs aren’t on the verge of collapse – though there’s some evidence that I might not be so lucky down the road, when hormone levels decline and may cause the tissues of the vulva and lining of the vagina to become thinner, drier and less elastic. More importantly, I also learned that things aren’t dire for women who do have prolapse.
It’s certainly common: More than 50 percent of women who have delivered a baby – and even those who haven’t – will experience some degree of prolapse in their lives, says Mandy Rempfer-Kuncio, an Edmonton-based pelvic health physiotherapist. “Giving birth is a big risk factor,” she says. “A lot of women don’t realize until later that they have a prolapse.”
Pelvic Organ Prolapse 101
Why? These women, who have prolapsed bladders (cytoceles), rectums (rectoceles), intestines (enteroceles), urethras (urethroceles) or uteruses, may have no symptoms at all – particularly if they’re grade 1 or 2 prolapses. Others may have pain during sex, a bulge at the opening of the vagina, trouble going to the bathroom, incontinence, an urgency to pee or back pain – all symptoms that can be quickly chalked up to carrying children, overexercising or having an overactive imagination.
Plus, there’s little education on prolapse. It isn’t discussed in prenatal classes, and OB/GYNs often don’t mention it during prenatal or postnatal visits. “How come I’ve never heard of this?” is a common refrain among women.
And that’s because it’s not top of mind for many physicians, concedes Heather, a general practitioner based in Toronto who experienced episodes of urinary incontinence with exercise six weeks after the birth of her third child. After heading to her family physician, she was diagnosed with a grade 2 cystocele and referred to a pelvic physiotherapist.
She was shocked that she knew so little about pelvic organ prolapse. “It speaks to the level of training we get with regard to prevention,” she says. Plus, she says, medically, the focus is on the baby, not the mother. “The expectation is that you’re going to take the good, the bad and the ugly as a parent,” she says. “It’s not really kosher to talk about it.”
While pelvic physio exercises have helped her, as has a pessary (a small round or ring-shaped device inserted into the vagina to hold up internal organs), Heather says that she has had to alter her exercise regimen. She forgoes boot camps, which include core exercises that can put pressure on the pelvic organs, along with Pilates and her beloved running. “It certainly has changed my life,” she says.
Like Heather, I didn’t wait to take corrective action. The week after my trip to the OB/GYN, I visited the cheery North Toronto studio of Trista Zinn, the Canadian pioneer of Hypopressives – low-pressure fitness and a postural breathing technique taught to women postnatally across Europe. The technique has just started to take off in Canada (it began here in 2012), with more than 100 Hypopressives trainers across the country. The training uses breathing techniques that involve a series of “rest breaths,” with the final one ending in apnea (cessation of breathing) into a false inhale to create a suction or vacuum, in combination with specific poses to relieve pressure from the pelvic cavity.
“The poses activate the inner muscles, making you better able to recruit the pelvic floor,” says Zinn, who adds that the technique can help improve bowel movements, boost sexual function and restore body confidence shell-shocked women who are concerned about their sexual futures. In addition to teaching in Toronto, Zinn currently flies across Canada and U.S. on a regular basis to teach other instructors about Hypopressives. She also hopes to get more interest from the medical community as a preventative tool rather than only taking action once a problem has occurred. “I would like to see more healthcare providers not be so close-minded,” she says.
Zinn knows all about the feelings of hopelessness that a pelvic organ prolapse diagnosis can elicit. A former personal trainer with two kids, now 15 and 10, she discovered she had a grade 2 cystocele at the age of 40. “It was on Mother’s Day weekend 2012, which was devastating,” she says. “I was also told not to run or do any of my workouts – anything that could have helped me emotionally deal with this news. I remember being in my room, crying.”
Finding A Solution
Scanning the Internet after a friend suggested trying out Hypopressives, Zinn tried the postures. “Within two weeks, my grade 2 prolapse had gone to a grade 1 and I felt totally good,” says Zinn. “I remember walking down the street and everything felt lifted. There was more support in my pelvic floor and abdominals.” Zinn then travelled to Spain and was trained in how exactly it should have been done. “That eliminated any trace of a prolapse – it’s so important to find a qualified instructor so that you know it’s being done right,” she says.
Zinn’s enthusiasm is certainly inspiring. It’s echoed in the words of MaryWood, an Edmonton-based pelvic health physiotherapist and clinical director of CURA Physical Therapies. A big believer in Pelvic Floor Muscle Training (PFMT) – vaginal exercises beyond Kegels that improve muscle tone – and Hypopressives training, she says that prolapse symptoms can improve. “We may see someone go from a grade 2 to a grade 1,” says Wood. “More importantly, I have had significant reports of symptom improvement.”
Wood also believes that exercises like jogging don’t have to be taboo. “You can do that, but it’s beneficial to do your Hypopressives,” she says. “It’s a negotiation of reward versus risk.”
What is non-negotiable is getting information on prolapse risk and how to prevent it to women as soon as possible. “After delivering a baby, leaks should be decreasing at six weeks and be gone by three months,” says Wood. “If not, see a pelvic health physiotherapist.”
Rempfer-Kuncio agrees. She says women should be counselled about prolapse risk before delivering and should start exercises before delivery. “We want to make birth more efficient,” she says, adding that side-lying positions can help reduce tearing and damage to pelvic-floor muscles. She also believes in perineal stretching, PFMT and postural guidance before and after delivery.
“Nursing mothers are likely at more risk because of their hormonal changes due to lactation and the necessary movements of motherhood that include lifting, carrying and holding,” she says. “Postural correction is huge.”
But not everyone is convinced that pelvic organ prolapse prevention is possible. “No matter what anyone does, prolapse prevention isn’t always possible through pelvic physiotherapy,” says Dr. David Quinlan, head of obstetrics and gynaecology at Victoria General Hospital in Victoria, BC, and a board member of The Society of Obstetricians and Gynaecologists of Canada, though he is a big believer in doing pelvic physiotherapy once a problem is identified. He says that factors such as increasingly large babies, high body mass indexes, prolonged second-stage pushing during delivery, forceps deliveries and a “small genetic risk” can cause pelvic floor damage, regardless of what a women does ahead of delivery.
Dr. Quinlan isn’t quick to send women with prolapse off to surgery to pull up the pelvic organs unless it’s absolutely necessary. “Most patients are grades 1 and 2,” he says. “Many of those patients who don’t have bothersome symptoms don’t need treatment; they need support. We do non-surgical management first.”
Rempfer-Kuncio feels that pessaries are an effective tool, also. “One study found that 92 percent of women who were fitted with pessaries were relieved of symptoms,” she says. “It’s a good option.”
Joanne Drew*, a 32-year-old personal trainer based in Toronto, certainly relies on her pessary after being diagnosed with a grade 1 rectocele and grade 2 cystocele after the birth of her son last year. She is quite upset over her diagnosis, which came after she started an aggressive exercise regimen six weeks postpartum. “It’s a depressing diagnosis to get after delivering this beautiful child,” she says.
But having done pelvic physiotherapy and Hypopressives, she is more optimistic about the future, which she hopes will include another child. “I wish someone had said, ‘Take six months and let yourself heal,'” she says. “But I know strength is going to build over time. I used to think about it all the time, but I don’t now.”
Breathing deeply as I hold a Hypopressives pose, I’m on the same page.
*Not her real name