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Prolapse and Exercise - so what is to know?

Prolapse and Exercise - so what is to know?

What is Vaginal Prolapse?

Usually our pelvic organs (bladder, uterus and bowel) are supported by a hammock of connective tissue and muscles. If this support system isn’t working as it should, it can lead to one or more of these organs descending into the vagina, which is called a ‘vaginal prolapse’. 

A prolapse can be categorized into different types – a front (or anterior) wall prolapse, which is the bladder or urethra coming down, a back (or posterior) wall prolapse, which is the rectum or small bowel coming down, or a uterine prolapse, which is the womb dropping down. It is still possible for the top of the vagina to drop down if someone has had a hysterectomy. 

It often seems to be assumed that it’s the uterus that most commonly drops down, but actually the front wall of the vagina is the most common type of prolapse to occur. 

Prolapses can also be divided into ‘stages’, depending on how far down the lowest part descends when you do a maximal downward strain:

  • A stage 1 prolapse means that the lowest part of the wall/organ is still more than 1cm inside the vagina 
  • A stage 2 prolapse means that the lowest part of the wall/organ is between 1cm inside and 1cm outside the vaginal opening. This stage of prolapse, when the organ descends to the opening, is often when women become aware of their prolapse for the first time. 
  • A stage 3 prolapse means that the lowest part of the wall/organ is more than 1cm outside the vaginal opening
  • A stage 4 prolapse means that essentially the whole organ has come outside the body – this is relatively rare. 

 

How do I know if I have a Vaginal Prolapse?

The symptoms of a vaginal prolapse are different in everyone, and it’s important to note that sometimes people with mild to moderate prolapses don’t have any symptoms. 

The most common symptoms are:

  • A bulging sensation (or being able to see a bulge) or a feeling of ‘something being there’ in the vagina
  • A feeling of not being able to completely empty the bladder or the bowel (usually because the prolapse is causing a sort of ‘pocketing’ making it difficult to evacuate).
  • Lower back or lower abdominal ‘dragging’ pain

Sometimes women can complain of a ‘heaviness’ or ‘pressure’, but this needs to be confirmed on diagnosis as this can also be a symptom of over-worked, tired pelvic floor muscles. 

Sometimes prolapse can be associated with discomfort with sex, and sometimes with bladder or bowel leakage, but again – this isn’t always the case and should be confirmed on a physical examination, because there are many people who have these symptoms without having a prolapse. 

The health professionals who work specifically in the area of Women’s Health are best placed to make this diagnosis – gynaecologists, Women’s Health & Continence Physiotherapists, or Continence Nurses. However, your GP is a good place to start and many GP’s will have a vast degree of experience in diagnosing and staging prolapses, and can then refer on to one of the aforementioned professionals for further management. 

 

How common is a Vaginal Prolapse?

Unfortunately, it’s very common for women to experience vaginal prolapse, mainly due to our anatomy. We are animals that stand upright, and have a large proportion of our body weight going through our pelvis, but we also need a wide pelvic opening to be able to birth very large offspring through!

That mix of a large pelvic opening with a heavy load on top of it is unfortunately not ideal for supporting pelvic organs.

Studies have shown that up to 50% of women who have given birth will have some degree of prolapse, with other research showing that 1 in 3 women will have a prolapse that extends at or beyond the vaginal entrance (ie a stage 2 or more prolapse). 

Unfortunately, there is a high proportion of women who will require surgery for either prolapse or stress urinary incontinence. Statistics show that 1 in 9 women will undergo one of these surgeries, which are not without risks and have relatively high recurrence rates. 

 

What factors increase your risk of Vaginal Prolapse?

The main risk factor for prolapse is having had one or more vaginal births, with specific risk factors including:

  • Forceps deliveries
  • Giving birth to a baby over 4kg (9 pounds)

Prolapse is not limited to only those who have delivered babies vaginally, however, with other risk factors including:

  • Pregnancy
  • Family history of prolapse
  • Increasing age
  • Increasing BMI
  • Constipation
  • Chronic Cough
  • Heavy lifting

The main reason that pregnancy and vaginal childbirth are risk factors is because of their effect on what is called the ‘levator hiatus’. This is the name for the space in the pelvis between the two sides of the pelvic floor, and is essentially ‘the gap into which things can fall’. 

Studies on women who have recently given birth show that this ‘gap’ in usually increased from normal for up to 4-12 months after having a baby. This is one of the main things that Women’s Health Physiotherapists will assess for when doing a vaginal examination at a postnatal assessment, because it helps to determine your individual risk for prolapse occurring or worsening with return to higher load or impact activities. 

This ‘gap’ would be increased more significantly, and more permanently, if the woman experienced a birth injury called a ‘levator avulsion’. This means one or both sides of the pelvic floor muscle having a partial or full tear away from the pelvis bone. This can also be assessed for with a vaginal examination. 

 

How is Vaginal Prolapse managed without surgery?

Pelvic Floor Muscle training, under the guidance of a physiotherapist with post graduate qualifications, is recommended as the first line of treatment for vaginal prolapse. 

We probably assume that this training is all about improving the strength of the pelvic floor muscles (measured out of 5), but studies have shown only a minimal link between a woman’s maximal squeeze pressure improving and prolapse improving. 

This makes sense, because a vaginal prolapse needs to be supported all throughout the day while you’re in an upright position, but we probably only maximally squeeze our pelvic floor muscles for 1% of the day – at times like in response to a big sneeze or lifting something that’s heavy. 

Instead, it is more likely that pelvic floor muscle training helps to decrease prolapse signs and symptoms because it improves the ‘stiffness’ and support of the area, and it decreases the ‘gap into which things can fall’ (the levator hiatus) both at rest and under load. 

Other management strategies would include:

  • Teaching women how to empty their bladder and bowels effectively and without straining
  • Determining if symptoms can be improved by incorporating rest periods in ‘anti-gravity’ positions throughout the day
  • Weight loss 
  • Exercise modification
  • Use of support pessaries

 

What is a Vaginal Support Pessary?

Vaginal pessaries are devices worn inside the vagina that help to give support to the vaginal walls. If fit properly, they should give symptom relief, be comfortable and should stop a prolapse from descending. 

They can be a huge help for women with prolapse who wish to remain active or become more active. Pelvic Floor Muscle Training, while essential in the overall management of prolapse, can take a long time for symptoms to improve. Pessaries could be used in a ‘stop gap’ role to prevent further descent, and possibly give feedback on what types of things cause descent to occur, while concurrently working on pelvic floor training.

 

 

What exercise should I avoid if I have a Vaginal Prolapse?

Now this is an interesting one… and if you’re after a list of Do’s and Do Not’s, I’m sorry… it’s not coming from me!

Let’s start with what the recommendations are for exercise for general health. The Australian Government’s “Physical Activity Guidelines for Adults” states that we should participate in:

Cardio exercise:

  • >150 minutes of moderate intensity activity/week
  • OR 75 minutes of vigorous activity/week (or a mixture)

Resistance exercise:

  • >2 days/week 
  • >1 set of 8-12 reps per area
  • Maximum health benefits are gained when you would struggle to do another set

And recommendations for Bone Density and prevention/management of Osteoporosis:

  • Regularly doing a combination of resistance training and moderate to high impact weight-bearing activities

But historically (and I’m not talking that far in the past either) the recommendations for anyone diagnosed with, or at risk of, vaginal prolapse were:

  • Minimise weights
  • Keep all exercise low impact

But although well-intentioned, how evidence-based was this blanket recommendation?  And by giving this advice, are we compromising overall health (in particular our heart and bones) for the health of the vagina? 

Recent studies have looked a lot more into the pressures created in the abdomen, and more specifically in the vagina, during different types of exercise and although we can extrapolate some general information, the main message that comes out is “It’s not what you do, it’s how you do it”. 

If you give the same exercise to a variety of different women, then their individual anatomy, injuries, technique etc will mean that the way they perform that exercise results in a wide variety of different effects to their pelvic floor muscles and vaginal walls. 

It’s highly recommended that in order to tell a woman what exercise they should and shouldn’t do, we should understand:

  1. Their individual risk profile for prolapse occurring or worsening
  2. Whether a certain exercise is likely to be on the higher or lower end of the ‘risk’ spectrum

 

How do I know which risk category I fall into for Vaginal Prolapse?

A Pelvic Health Physiotherapist is a physio who has done a huge amount of extra training in Women’s Health and Pelvic Floor Health. They can do vaginal examinations to check a number of things such as:

  • The Pelvic Floor Muscle function
  • The structural support of the vaginal walls both at rest and on straining (and very important to assess this in standing too!)

There’s a specific test that we can do called ‘GH+PB’, which measures the amount of movement of the tissues at the opening of the vagina when you strain. This measurement, taken externally, has been proven to be a good indicator of what’s happening internally to the size of the space into which our organs could potentially descend. The larger the GH+PB measurement is (in cm) the higher the risk is that a prolapse could occur or worsen when the area is put under strain. 

Some important points to note:

  • It’s important to check if you currently have a prolapse (it’s not always symptomatic) but it’s just as important to pick up those who don’t currently have a prolapse but are at high risk of it developing
  • Pelvic floor muscle exercises are important but there’s a lot more to it than just getting the best maximal squeeze possible, especially for endurance activities like running and playing a game of sport (because when you think about it… how much help is a grade 5/5 squeeze going to be during a run if you’re not squeezing maximally while you’re running?)

 

Which exercises are likely to be higher risk?

There are lots of unknowns here, and we don’t know what the ‘safe’ level of intra-abdominal pressure is for preventing prolapse. We also don’t know, without individual assessment, how different women respond to the same exercise. 

But we can understand generally which exercises tend to come out as creating higher intra-abdominal pressure and perhaps these can be the ones that are more closely tested and monitored. 

Things we can assume about strength and resistance exercise:

 

  • Standing exercises have higher pressure than sitting, and both of these have higher pressures than lying down. On this note – abdominal crunches and lying down abdominal exercises usually come out as one of the ‘lowest risk’ exercises in the studies that have been done, although traditionally these have been amongst those that were the most highly cautioned against. 
  • Increasing weights and resistance increases intra-abdominal or intra-vaginal pressure

Things we can assume about aerobic exercise (note that this is probably the hardest type of exercise to investigate, but there is some exciting current research happening in this area):

 

  • Running, jogging, skipping etc are likely to be high risk due to the fact that they have an endurance nature to them, they’re always done in upright positions, and there are ground reaction forces involved.

Things we can assume about Crossfit-style exercise:

 

  • In low risk women (those who are young and have never had children), there is unlikely to be a negative impact on prolapse between those who choose to do Crossfit compared to those who choose to do ‘gentle’ exercise (but there are likely to be many benefits in other areas of health)
  • There is limited/no research on prolapse risk in women who are considered ‘high risk’

Things we can assume about pilates exercise:

 

  • Most pilates mat and reformer exercises are considered low risk and are unlikely to increase intra-abdominal or intra-vaginal pressures significantly (many are performed in lying down and with relatively low resistance)
  • There are lots of benefits to pilates but in isolation it doesn’t meet the guidelines mentioned previously about Disease Control and Prevention and needs to be considered in conjunction with other forms of exercise. 

 

How can a Women’s Health Physio give you individualized information about the type of exercise you should consider?

A Women’s Health Physio should be able to put all of this together and come up with a plan that suits you regarding an exercise regime. 

They might assess you and find that you’re very low risk for prolapse occurrence or worsening, and then you can work out together whether any monitoring needs to occur as you increase your load and intensity in your workouts. 

They might assess you and find that you’re currently in a high risk category and they can help you to work on a pelvic floor program (and possibly a pessary fitting) to allow you to gradually return to the exercise you love with close monitoring. 

They might assess you and find that you fit somewhere in the middle. Perhaps there are certain things that either make your prolapse symptomatic, or that cause vaginal wall descent without you realizing. Rather than advising you to stop exercising completely, they should be able to help you to come up with regressions or variations of these movements, and perhaps supplement them with other forms of exercise that you enjoy to allow you to still meet the health guidelines. 

 

Some final points to remember about Prolapse and Exercise…

  • Exercise is vital to overall health, and women unfortunately often decrease exercise due to fear of worsening a prolapse. 
  • Remember that a large number of exercises that were previously suggested to be ‘not pelvic floor safe’ don’t actually have much evidence to back that up (and might be really good for overall health)
  • Individual assessment and reassessment is key – and remember that you can’t assess prolapse or risk of prolapse with only an external examination. So if you’ve only had a real time ultrasound screening assessment on your abdomen, this isn’t able to be used to determine your risk profile. 

If you’d like to see a specialist physiotherapist in Western Australia, there’s online Directory for both private and public referrals:

Also, if you live in Perth or Mandurah, we have compiled a list of post-graduate trained physiotherapists who are particularly good with pregnancy, postpartum and exercise – see the FitRight website!

And remember – the whole aim of FitRight is to keep you moving, even if you do have a vaginal prolapse. Chances are that multiple women if every one of our classes are managing a prolapse and the instructors will be aware of this and know how to modify the classes to suit individual needs. 

Whether you’re pregnant, early postnatal, a Mum of young children or heading into peri-menopause, we have classes to suit you!

 

Article was written by Taryn Watson owner of FIT Right. She holds a 

Do I really need Maternity leggings?

Do I really need Maternity leggings?

Comfort and support are the most important features when it comes to maternity clothing and leggings are no different. All of our pregnancy leggings have been specially designed to allow for the growth of the bump and belly while providing absolute support and comfort. Featuring a high waistband that can be worn during pregnancy, or folded down for extra support postpartum

Many woman experience different disorders while they are pregnant, but some of the symptoms are the same such as pelvic pain, swelling, stiff hips and the added strain on the lower back. Therefore finding the right maternity leggings to help relieve and minimise these types of symptoms is essential for comfort during and after pregnancy. Our specially designed maternity leggings have been constructed to support you in all the right places. By keeping the weight off your pelvis and reducing the pressure on your muscles and ligaments around the bottom half of your body that is growing so much!

So what do they do?

They offer:

  • Light compression to the legs, hips and if they are over the bump; the belly and lower back as well.
  • Support under the belly to take some weight off your hips and pelvis by providing a layer of support, they can help to lift up and alleviate the pressure on the pelvis.
  • Help to assist in keeping your weight in the right spots to put your body back into natural alignment.

 

You can wear them under the bump in early pregnancy, then over the bump later in pregnancy. MUMMACTIV pregnancy and postpartum leggings can be worn under or over because: 
  • Over-the-bump leggings have a light compression panel above the waistline that stretches and pulls up over the bump.
  • Under-the-bump leggings have a vee at the front of the waistline so the bump can sit in the middle.

With over the bump leggings when the compression panel is folded over (doubling the layer) and you wear it under the belly they give you even more bump support so the weight of your organs and bump isn't sitting on top of your hips as much.

They are essentially a belly band attached to pants. Many woman buy a belly band during pregnancy or for postpartum. Whereas, maternity leggings already have the belly band attached as a panel above the waist. Because the band is longit can be folded over during pregnancy to really provide support like a belly band, then after-baby, fold it down to help push your tummy in and support it.

 

Had or having a C-section?

 

When maternity leggings are for you...The compression panel scoops low at the front to provide the ultimate in comfort for any c-section scars. After a c section you don’t want to wear any clothing with seams that sit on the scar simply because they will irritate you. We've had customers regularly commenting that our leggings are the only pants they could wear post-baby after a c-section because of the way the seam cuts down and doesn't aggravate or irritate the scar.



Exercise and the clinging baby stage...

Exercise and the clinging baby stage...

Many of us have experienced days, weeks and months whereby the baby, toddler does not want to be put down. This may be the result of new teeth coming in, separation, a leap, fussiness from tummy upset/gas/reflux/colic etc. Many then chuck the baby on the hip and try to carry on with the normal household duties etc because we all know that the jobs just dont get done by themselves!

This way of carrying puts pressure on one side and eventually tilts/unbalances the pelvis region like below:

One of the ways that can help this issue is baby wearing. Purchasing a good quality carrier and getting it fitted for to you. Carrying a baby in a sling or snuggled in a wrap has more benefits than simply being a hands-free carrier – it can aid colic relief, bonding, physical development and more.

When selecting a carrier it is important to remember the following:

  • Head and neck support for babies and sleeping infants/children
  • Wide base of support that supports the thighs and flexes the knees
  • Postural curves support
  • Wide or cushioned adjustable shoulder straps
  • Ability to distribute the baby’s weight evenly across the parents body
  • Ease of loading/unloading, so that the parent can keep their spine in a neutral position

When it comes to exercise you can still get it done and we have found an uplifting fun and motivating class that is for you. It is called Kangatraining.

Kangatraining is a babywearing fitness class for mum and babies. One of the biggest positives of Kangatraining, is that not only do you bring your baby to class, they are an active and important part of the workout! 

PreKanga is the best activity program during pregnancy. KangaOnWheel, KangaTrail, NordicKanga, ReactivKanga and KangaMix are our outdoor classes. KangaBurn is the most efficient workout without your baby. Each of our workout concepts is based on sports science and created with experts such as gynecologists, sport scientists and physiotherapist. The best bit is you can take part with a small bub or even with a toddler. 

Kanga-Classes are being offered in over 25 countries. Here in Australia they have over 100 Kangatrainers running sessions across Australia in both regional and metropolitan areas. Their programs include-: PreKanga (the prenatal program)KangaTrail, KangaOnWheel and KangaMix.

You can get more info HERE

 

 

 

Why This Mum Is Not Rushing Back Into Fitness After Pregnancy....

Why This Mum Is Not Rushing Back Into Fitness After Pregnancy....

Nadine is a Brisbane Mum of two, a personal trainer, Emergency Military Nurse, blogger and a health and fitness enthusiast. Nadine has lived and breathed fitness for many years and was motivating the troops at F45 until she went on maternity leave.

 

During both pregnancies Nadine suffered from severe HG (Hyperemesis Gravidarum) or extreme morning sickness where she had to be hospitalised a number of times due to dehydration/monitoring. For those of you who know Nadine would appreciate that she gives everything 110% and will train anywhere/anytime. Due to unforeseen circumstances Nadine went into labour 6 weeks early and underwent an emergency caesarian. She then spent the next few weeks going back and forth to the special care nursery-pumping around the clock to nourish her little one.

 

For Nadine, exercise is like brushing her teeth, it is part of her day so when she made the conscious decision to NOT return to exercise postpartum it was a big thing. Listening to her inner dialogue and body is an important message for all Mums. Some tend to rush back into a regime which they may not be ready for mentally or physically- the fourth trimester is just as important as the first three…

 

“As you guys know I made the very conscious decision to NOT return to ‘Training’ at 6 weeks when I was cleared to begin ‘light’ exercise. Hear me out tho!! It’s interesting seeing me talk about my birth because birth trauma is REAL and what we experienced to bring Beckham here safely was incredibly scary for all involved but that is a story for another day perhaps, this is something I deal with everyday…. Anyhow this isn’t just about my birth experience….because….I hadn’t felt ready and I had to listen to that internal dialogue. I knew my recovery was going to be longer in duration due to what occurred physically and mentally for me and I know that i have had to be very meticulous, careful and very structured and progressive with my recovery. Slow and steady is absolutely what is needed for me and my body. Physically and mentally my mind and body have been through the wars. And my body has needed REST and a chance to do some internal repair on its own.-mind, body and soul without the additional stressors….Irrespective of my birth experience, I also DECIDED that the 4th trimester was something again that I wanted to immerse into, to truly soak in the time with my newborn and my family…time I’ll never get back, time to bond, time to find our groove. And without the added pressure or ‘postpartum bounce back’ that seems to be on the trend which I refuse to enter into….

 

Project ‘get my body back’, and some rapid postpartum mum bod has been so far out of my priorities it is not funny. That may seem interesting for someone whose life is revolved so heavily around health and fitness…(if your new to my page you may not know that I have a background in personal training, group coaching, have my online coaching and mentoring business, published fitness modelling and heavily involved in this industry) BUT  and that’s not to say others that return sooner are doing the wrong thing, I would hope we are all guided by the professional advice and pave our own path unique to our journey, but what I am saying is this is MY journey and my decision making and  SLOW RETURN is and has been my PRIORITY.

 

But THIS to me is HEALTH! Its looking after ME in all life pillars- the physical sense, the emotional sense etc etc. I have had times where I’ve wanted to get back into it. Let’s not lie. BUT it was in those moments I reminded myself of THIS. Newborn life is fleeting and Ive focused my time and energy into my baby, my family and my WELLBEING OVERALL and gentle walks with Beckham a couple of days a week and that is it, focusing on nutrition especially when a prep baby is exclusively breastfed and that is my HEALTH, my body right now is still an extension to someone else aka BABY BECKS and will be for a while. These decisions have been easy to make-especially when it involves a MIRACLE baby that was born prematurely after a traumatic birth and him being in hospital in special care for the first few weeks of his life and heck a whirlwind pregnancy with trials along the way from the get-go, trust me when I say that we were a bees dick away from our birth being the catastrophic WORST day of our lives with the outcome being potentially VERY different…now as a result; my core and abdominals have needed and will be needing progressive rehab work just like anyone would need to; but perhaps on a grander scale due to what occurred that day. Which i too have been and will continue to be working on. My c-section fortunately and unfortunately had to be rapid, had to be severe, had to be rough and was complicated to say the VERY least. What happened had to happen in order to BRING our baby out alive.

 

Someone doesn’t recover from birth trauma overnight. Im a resiliant  person but Im not immune from that- it rocked me and Dane too- because our birthing partners experience it too lets not forget them. And it still does. It takes time. And I work on that in various ways everyday. We are appreciative and grateful with what eventuated in the end but it was a harrowing experience that perhaps I’ll share one day.

 

In a nutshell, taking this time slow but smart, meticulous and planned, progressive in nature and ensuring reassessment on all fonts along the way, but more importantly being discerning of where I focus my time and energy while I recover has been my priority.  I know where my body ‘can go’, what it ‘can’ look like, what it is ‘capable’ of doing and achieving. But doing that in record time would be foolish and detrimental long term. Pregnancy and birth is short term, my postpartum is FOREVER. AND I choose to honour and look after that!!!!!

 

I’m 4 months postpartum this weekend. I now move into a new phase of my rehab. Take note, in my opinion I started rehab day 1- it just looks different which is MY VARIATION OF NORMAL. And being in a ‘gym’ hasn’t been part of it until now. 4 months postpartum now involves a progressive program that I have taken time to develop with so much intention and will be assessing as I go, and with the necessary health professional checks and advice along the way with a women’s health physiology which also will be ongoing! This new phase isn’t some crazy step up, its simply simply the next part of my progressive step in my current rehab and restrengthening this mind and body. The bi-product of all of this of course will be some aesthetic change but again the focus isn’t that solely!! Im excited to be entering this phase and Ill be sharing it with you and I hope my journey will and can inspire others to also LOOK AFTER AND TAKE MUCH CARE IN THEIR POSTPARTUM JOURNEY……”

 

*Nadine has released her birth story on Dear Mama Project Podcast if you are interested in hearing more.