I have a prolapse and I don’t know how to treat it ? Everything to know how to treat a prolapse, explanations, symptoms and treatments.
What is a prolapse ?
At first sight, if you feel discomfort in the perineal area, you may be suffering from a prolapse. First of all, the patients who consult us most often complain of a discomfort. The patients have a sensation of a ball in the vagina, like a heaviness. Other women can also feel it when they insert their fingers into the vagina. This discomfort worsens when standing or at the end of the day, and decreases when lying down or resting.
There are three types of prolapse:
- Hysterocele or prolapse of the vagina: this is the descent of the uterus into the vagina
- Rectocele or prolapse of the rectum: this is the descent of the rectum into the vagina
- Prolapse of the bladder or Cystocele: this is the descent of the bladder into the vagina
There are 4 grades/degrees of prolapse.
In fact, a prolapse occurs when there is an imbalance in the pelvic structure. It is an “anatomical and mechanical imbalance between abdominal pressure and perineal resistance forces”.
What is the perineum and what is it used for ?
A little anatomy and myology
The perineum is the part that closes our pelvis. Thus, it has a function of support of the organs (bladder, vagina and rectum) and of shock absorption (running, dancing, jumping…). Therefore, it plays an important role in sexual relations, childbirth and the closing of the sphincters allowing us to control urination, defecation and continence.
Our perineum is a set of articulated bones where various muscles are inserted. More precisely, for the articular part, we find the iliac bones, the sacrum and the coccyx. The perineum is therefore delimited between the pubis, the coccyx and the two ischial tuberosities.
For the muscular part, there are three planes:
The deep plane or pelvic diaphragm : its function is to support the bladder, the uterus and the rectum. It separates the pelvic cavity from the perineum. It is formed by the elevator of the anus muscle (pubo-vaginal, pubo-rectal, pubo-coccygeal, ilio-coccygeal bundles) and the coccygeal muscle.
The middle plane : it exists only in the anterior part of the perineum. It is made up of the deep transverse muscle and the external sphincter of the urethra which form the urogenital diaphragm.
The superficial plane : participates in the sexual function as well as the support of the organs. It forms a rhombus divided into two parts (anterior and posterior):
The anterior part or urogenital :
Consists of the ischio-cevernous, bulbospongiosus, superficial transverse and constrictor muscles of the vulva
the posterior or anal part:
Consists of tje external sphincter of the anus
All about prolapse
What are the symptoms ?
- Dysuria: difficulty urinating, need to push to get urine out with a weak urine stream.
- Recurrent urinary tract infections: burning sensation when urinating, need to go to the bathroom often.
- Urinary incontinence: uncontrollable and involuntary loss of urine, which occurs during the day or night. Firstly, there is stress urinary incontinence, which is the loss of urine when making an effort such as coughing, laughing, exercising or walking. Secondly, there is urge urinary incontinence, which is the loss of urine associated with a strong urge to urinate, accompanied by fear of urinating or pain to hold back urination. Finally, there is mixed urinary incontinence, which includes the two previous incontinences combined.
- Gas or anal incontinence: it is the emission of gas and/or stool
- Fecal incontinence: loss of stool without gas emission
- Lower constipation: this is the accumulation of stool in the rectum. The risk of gas production increases.
- Pain during sexual intercourse: this is pain during penetration, during or after sexual intercourse. It is important to consult your doctor to determine the cause of the pain (infectious, dermatological, anatomical, gynecological disease, post-operation…).
What are the causes ?
Firstly, the causes are diverse and specific to each person. Indeed, they can arise from a post-partum (relaxation of the perineal muscles, episiotomy, abdominal hyperpressures during downward pushes in apnea…), a chronic constipation, a sports practice, a bad push of the stools to the toilets, a high BMI, or a genetic factor (hormonal, menopause) or anatomical factor (wide pelvis).
Secondly, most people have movements and/or activities that produce abdominal hyperpressure. As a result, this pushes the organs down towards the perineal diaphragm, thus increasing the risk of prolapse.
Clinical examination
Initially, it is the clinical examination that will allow us to determine the existence of a prolapse. It will inform us about the type of prolapse, the grade or the degree. But also on the existence of hidden urinary or fecal incontinence. Moreover, he will detail if the patient suffers from urethral or bladder hypermobility and dissynergy of the perineal muscles. Finally, he will note the existence of adherent and painful scars as well as the absence of neurological pathology. Generally, it is performed by a specialized doctor assisted by a nurse or midwife. During this examination, full and empty bladder tests will be performed, as well as a questionnaire filled out by the patient.
Sometimes additional examinations may be requested to confirm the diagnosis of a prolapse (dynamic MRI, ultrasound, cystography or rectal opacification).
How to treat a prolapse : treatments
Surgical treatment
Historically, prolapse was treated by hysterectomy (removal of the uterus). But now, how to treat a prolapse ? Nowadays, the surgical treatment of prolapse is mainly promontofixation instead of hysterectomy. This operation consists of fixing the pelvic organs to pull them upwards and is often performed by laparoscopy. Moreover, this widely used surgical method allows the surgeon to intervene with the help of a camera. This makes the operation much less invasive for the patient, who will recover more quickly, but beware of the risk of venting after the operation. Finally, this method is perfectly suitable for young women because of its effectiveness, but it is advisable not to have any pregnancy plans before performing this procedure.
Other women use a pessary. This is a cube that is placed higher in the vagina with the aim of raising the uterus. It requires a learning phase for women to become self-sufficient in knowing how to use it, install it and remove it. According to S. Martin Lasnet, the use of the pessary is globally satisfactory for women with a prolapse.
Drug treatments
There are hormone-based treatments that can improve the vaginal connective tissue. These improvements can be seen after about 6 months of treatment.
Conservative treatment with physiotherapy
The treatment is mainly based on the last 9 points:
- Exercises to increase awareness of the perineum
- Strengthening of the perineal muscles
- Electro-stimulation and biofeedback
- Postural rehabilitation for urination and defecation as well as postures in daily life
- Respiratory rehabilitation
- Education in the use of perineal cones/pessaries (if needed)
- Re-education of sports practice
- Hypopressive exercises.
In order to know the duration, the intensity and the frequency of a treatment, consult a state-qualified physiotherapist, if possible specialized in urogynecology.
Bibliographic references
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- Dr Bernadette de Gasquet. Périnée, arrêtez le massacre. Disponible sur: https://www.marabout.com/perinee-arretons-le-massacre-9782501070140.
- Comité éditorial pédagogique de l’UVMaF. Anatomie du périnée féminin. 2011.
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- Aitsakel A. Traitement du prolapsus genital par voie tranobturatrice : prolift | Elsevier Enhanced Reader [Internet]. [cité 2 déc 2020].
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- Martin Lasnel M, Mourgues J, Fauvet R, Renouf S, Villot A, Pizzoferrato AC. Satisfaction des patientes et efficacité du pessaire en cas de prolapsus des organes pelviens. Progrès en Urologie. juin 2020;30(7):381‑9.