Recently I was blown away by the results of tailored prolapse management for a delightful woman who came to see me 3 weeks after her 2nd baby was born.
She actually came primarily for management of her “ab separation” also commonly called tummy separation, or more officially: rectus abdominis diastasis or diastasis recti. We assessed and treated the diastasis.
Pelvic floor assessment is an important part of abdominal rehab to ensure the abdominal exercises aren’t causing or worsening any problems such as prolapse and incontinence. See https://www.alchemyinmotion.com.au/pelvic-floor-assessment/ for information about assessments. It was especially important in this case because she mentioned a long history of urinary urgency that worsened after her firstborn and a sensation of her insides trying to fall out of her vagina by the end of the day since her 2nd born.
Pelvic floor assessments with abdominal ultrasound (in the first appointment) and vaginal examinations (after her 6-week check-up with the obstetrician) showed:
- Very lax muscles at the entrance and internally
- Strength: zero at the back or the right side. Weak at the front on the left
- Endurance: 4 seconds lying down. Only momentary standing up
- It felt like her right pelvic floor muscle was significantly injured near the front of the pelvis
- Significant stage 2 anterior wall prolapse, also known as a cystocele. This means the front wall of the vagina was stretchy, allowing the bladder to move back into the vagina and protrude nearly 1cm through the pelvic floor and the vaginal entrance. Lying down kept it inside, but straining or standing up pushed the prolapse out.
When the anatomy is in this position standing up, it prevents the pelvic floor muscles from working effectively because the prolapse is blocking them from tightening. If she had done only pelvic floor exercises, it is highly unlikely that much improvement would occur. Especially because she has 2 kids to look after! Some prolapses are sturdy enough that you can make small modifications to prevent them from worsening with motherhood activities. This one was below the muscles as soon as she stood up. You can’t and shouldn’t lie down all day with 2 kids to raise! It was virtually guaranteed to worsen over time, and with the poor pelvic floor anatomy/function, she is someone who is likely to have a poor result if she had surgery in the future.
Luckily, we can combine the usual pelvic floor training and educational information with pessaries to improve results. See https://www.alchemyinmotion.com.au/womens-health-services/ for more information about pessaries.
Initially, a cube pessary was required. It held the prolapse above the muscles which allowed her to progress her pelvic floor training and tone up the muscles. After a few months, the tone improved enough that the cube started feeling funny. We progressed to a ring pessary, which is even easier to use.
By the time she was 7 months postnatal, she told me:
- She had no prolapse symptoms and was easily using the ring pessary
- She was doing slightly modified high-intensity interval training with no issues
- Her bladder symptoms had resolved to pre-children status
Re-assessing her tummy and pelvic floor showed:
- Diastasis had more than halved and reached postnatal goals
- Pelvic floor tone had improved dramatically, indicating that it had never been significantly injured near the front of the pelvis… it was just thin and stretched around the prolapse before. Once the prolapse was out of the way, it could tone up to normal dimensions.
- Pelvic floor strength improvement was so dramatic that I was shocked. There is now moderate to good strength throughout all of her muscles!!
Sometimes a little helping hand after having a baby goes a long way! There is virtually always room for improvement with management, but pregnancy and early postnatal are two of the opportunities for the most prevention and improvement.
This lady was aware/brave enough to seek help, lucky enough to stumble upon a physio with experience in pessary prescription, and she was great at the following advice, and doing her exercises. I feel honored to have been a helping hand to her because I have no shadow of a doubt that it changed the course of her life. With poor management, that prolapse would have led to the increasingly bothersome bladder and sexual issues and prevented her from getting back to her beloved exercise. Improvements aren’t usually so dramatic because prolapses are often much smaller, or muscles don’t have much room for improvement, or there are too many barriers that prevent women from playing their part in management. This case highlights the potential that exists for some women.
New mums are so often tired, feeling physical and/or mentally unfit, and desperate to return to exercise without causing harm, but confused about how to do that. Pelvic health physios with extra training are well-positioned to provide individually tailored guidance. Sometimes assessment clarifies that a pessary is completely unnecessary. Other times a pessary helps rehab faster and more safely. Sometimes mums only need pessaries for a period of months, sometimes longer term.
I wrote up this case study because I want everyone to know that
Pessaries are not just for grannies!!
GPs and patients often have this stereotype because in the past prolapses were taboo/hidden/ignored. They, therefore, progressed over the years until they were too bad to ignore, so almost only older women received treatment. Let’s prevent pelvic floor issues worsening, help mums feel comfortable again, and get back to exercising!