A vaginal birth increases the risk of prolapse, urinary incontinence and faecal leakage compared to a caesarean section. The risk of having a prolapse in conjunction with a vaginal birth is double.

However, according to Sahlgrenska University Hospital in Gothenburg, Sweden: ‘the most important risk factor for pelvic floor disorders after vaginal delivery is being overweight or obese.’ The scientists who conducted the study have already shown that many women suffer from incontinence, even 20 years after giving birth. The final study shows that other problems, such as prolapse and faecal leakage, can also occur.

So what exactly is prolapse and how can it be prevented and treated?

Prolapse is when one or more pelvic organs slip down and move out of their usual position. There are different kinds of prolapses:

  • prolapse of the bladder (the most common type of prolapse)
  • prolapse of the uterus
  • prolapse of the intestine

There are also different degrees of prolapse, the highest being when the uterus ‘protrudes’ from the vagina.

Causes of prolapse

The pelvic floor muscles are located at the base of the pelvis, and usually look like a taught carpet. After giving birth, they become more like a hammock as the pelvic floor stretches during pregnancy and childbirth. Even if you had a caesarean section, the muscles will be stretched as this already happens during pregnancy.

The pelvic floor’s function is to protect the bladder, uterus and rectum. These organs are anchored to various supporting tissues (connective tissue and muscles). If the tissues are already, or become weakened and subjected to various external stresses (e.g. running/jumping), one or more of these organs may drop and possibly protrude through the vagina.

  • The hormone relaxin affects the body during pregnancy and up to 3 months after the end of breastfeeding, weakening tissue. Genes also play an important role in aspects such as collagen quality. Collagen makes our skin firm and holds the connective tissue together, and can prevent stretch marks and wrinkles. It has been suggested that if you get stretch marks during pregnancy, you should pay extra attention to pelvic floor exercises as the quality of collagen affects the supporting tissues.
  • Your collagen type is also an important factor in the relationship between prolapse and incontinence. Collagen decreases with age.
  • If you are hypermobile, you are more likely to suffer from prolapse.

Persistent coughing can also affect the muscles of the pelvic floor, with smoking and asthma among the risk factors. Others include obesity and constipation. And as if that weren’t enough, the older you get, the greater your risk of prolapse. The risk also increases with the number of births and if you suffer injuries during childbirth, such as large vaginal tears.

But what is the main cause of the pelvic floor becoming weak and being unable to hold the organs in place?

Prolapse (and also umbilical hernia and abdominal separation) is a result of too much pressure inside the abdomen and pelvis. The pressure has to go somewhere and so it is pushed forward/downward.

What is abdominal pressure?

Abdominal pressure occurs when you breathe in and activate your core muscles at the same time. The core muscles look like a soda can with the bottom (pelvic floor), the lid (diaphragm) and the wall that goes around the can (the transverse abdominis). There are also the deep back muscles, located at the back of the can. The transverse abdominis is located under the oblique abdominal muscles and the rectus abdominis  (the ‘six-pack’ that sits at the front).

Abdominal pressure is therefore created when the core muscles contract: the diaphragm (when you breathe in and out) and the pelvic floor (when you lift it upwards). When you activate all the core muscles at the same time (important!), you create an internal tension, that is, abdominal pressure.

Pregnancy itself does not cause prolapse or a weak pelvic floor. However, prolonged labour, incorrect birthing technique and the use of a ventouse or forceps can cause it. Sure, pelvic floor exercises are important, but they are not the solution. The pelvic floor is just one part of your core muscles – and you need to learn how to activate all of them at the same time. You should also remember that when you activate the pelvic floor it affects the rest of the core.

When you activate your core in the wrong way (e.g. you clench your stomach), your posture is incorrect (posture also affects abdominal pressure) and if this occurs over a long period of time, there is simply too much pressure for the pelvic floor to handle. Your stomach doesn’t explode of course, but something ‘breaks’ anyway. This occurs in the form of an umbilical hernia, or an abdominal separation (diastasis recti) becoming even wider (forward pressure), or in the form of prolapse (downward pressure).

Prolapse symptoms

There are four types of symptoms:

  • local (a feeling that something is bulging out of the vagina, pressure, pain in the lower abdomen)
  • bowel (a feeling of incomplete evacuation of the bowels, gas and faecal leakage)
  • sexual (sex is painful, uncomfortable)
  • bladder (a feeling of not having emptied the bladder completely, urine leakage)

Other symptoms may include constipation, feeling like something is dropping out of you, pain in your lower back/stomach and difficulty keeping your tampon/menstrual cup in place.

How can prolapse be prevented?

As I already mentioned, pelvic floor exercises alone are not the solution, squeezing and squeezing won’t help – you need to look at the big picture.

First of all, you need to know how to manage and distribute the internal pressure.

Start with your posture. If your bottom is under you, i.e. you ‘pull your tail between your legs’, pressure increases. Think about if you were to squeeze a soda can from one side – what would happen? Of course, the pressure would increase somewhere else, wouldn’t it? So you need to keep the can just as it is, straight and smooth!

When you stand, you should be able to lift your toes up, so you shouldn’t stand on the front of your foot like you do when you walk in heels (which is a big no-no if you want to get your core in order!).

You should learn to be aware of your everyday movements: how do you sit? Look at the picture above, do you see how the pressure pushes against the stomach?

How do you pick up something heavy from the floor? Do you use your legs and activate your core, or do you bend over on straight legs like a crane with your stomach relaxed? How do you stand when you carry your child – is your stomach pressing outwards?

Learn where your pelvic floor is located

A very simple way to find out is by sitting on a chair. Spread your buttocks and place the palm of your hands by your sit bones (the two bumps you sit on) and facing towards you. Cough a couple of times, do you feel light pressure against your palms? This is your pelvic floor. You feel an outward pressure.And as I said before, prolonged coughing can cause prolapse – now you probably understand better and above all you can feel this outward pressure.

How do you learn to activate your pelvic floor?

Lie on your back with your knees bent and your feet on the floor. Breathe in and out a few times. Now try this: breathe in through your nose first, on the out-breath breathe through your mouth (shape your mouth like you’re drinking from a straw) and exhale forcefully. Feel how you lift your pelvic floor upwards as if you were pulling a tampon inwards. Don’t move your bottom or the rest of your body. Try to isolate your pelvic floor. Relax completely as you breathe in and repeat a few more times. Remember – the idea is to pull upwards rather than to clench anything. If you clench your stomach, you increase abdominal pressure and that’s what we’re trying to eliminate.

Illustrations: Trainimal Woman