Author: Amy R. Marsh, EdD. DHS, CH, CI, CSC, ABS

Wouldn’t you know, June is almost upon us, and so is Pelvic Organ Prolapse Awareness month. The Association for Pelvic Organ Prolapse Support abbreviates it to “POP Awareness,” giving me uncomfortable nursery rhyme associations like “Pop goes the… ” (let’s leave it at that).

For people with a vagina and a uterus, pelvic organ prolapse can include the displacement of the uterus, bladder (cystocele), and part of the rectum (rectocele) dropping down or pushing into the walls of the vagina. Other prolapses include urethrocele, vaginal vault prolapse, and enterocele. Here’s a POP Symptoms Quicksheet from the above organization.

Earlier this week, my exceptional pelvic floor therapist gently urged me to blog about this topic both as a patient and as a sexologist.

But before I share “TMI” as the saying goes, let me explain that even while I was studying to be a sexologist (2006-2008, and again in 2011), NO ONE EVER TALKED ABOUT ORGAN PROLAPSE and its effect on sexual health and sexual behavior and enjoyment. At the time, I even had this condition myself but didn’t know it, because none of my health care providers, during numerous gynecological exams, ever thought to mention it to me.

The only reason that I now know that I had pelvic organ prolapse as far back as 2006 was because of a drawing I did for one of our sexology classes (I think it was Practical Skills taught by the late Dr. Janice Epp and co-taught by Dr. Hernando Chavez). We were challenged to draw a picture of our own genitals. So, in my best Our Bodies, Ourselves mode (or A New View of a Woman’s Body mode), I took off my clothes, got out a mirror, and drew this picture below. Yep. That’s me, and this drawing shows the mysterious “pillows” that I had begun to detect in my vagina. The ones I never asked my doctor about until, I don’t know, 2010 or 2011? (I mean, I always assumed my medical providers would mention anything anomalous and because they didn’t mention it, I didn’t ask!) So what you see below is a vulva with rectocele (rectal) and cystocele (bladder) prolapses.

My classmates and I tacked our drawings proudly on the classroom wall. We looked at them. I was proud of the artistic merit of mine. BUT NO ONE EVER ASKED ME ABOUT THE DRAWING! There was no “hey, what’s that in your vagina?” from the inquiring minds that formed my cohort. Even the teachers didn’t comment. EVEN THE TEACHERS (yes, I’m shouting). And I didn’t see anything similar in the drawings from other cis-women in class, so, uh, I guess I just, uh, thought that there was nothing significant.

In fact, even during the oh-so-cutting edge Sexological Bodywork class of 2006 (taught by Joseph Kramer, Chris Frawley, and Isa Magdalena), no one ever mentioned my condition either. And, I mean, this was a class where we were all doing genital massage on each other, all the time! Even with the amazing body knowledge that we shared, prolapsed organs were completely missing from the discussion. FYI – back in 2006, Jack Morin’s book, Anal Pleasure & Health, was one of Joseph Kramer’s top recommendations, but I just checked the index – no mention of rectoceles or other types of prolapse.

(Even my husband of nineteen-plus years never mentioned changes either, though I am pretty sure some of the changes date from 1996, when my second child was born.)

Bloody hell.

Once I finally did ask the nurse practitioner at Kaiser Richmond about “the pillows,” she tartly responded, “oh yes, you have a prolapsed uterus and a rectocele. Someday you might want surgery.” And she shoved a brochure in my hands. I took it with a sense of shock. I had already seen the woman several times over the span of a few years and she had never mentioned this!

Fast forward to 2016. I finally had a consultation with a gynecologist in Hilo, who is a specialist in prolapse and who confirmed a diagnosis of rectocele (stage 3), cystocele (stage 2), and uterine prolapse (stage 3). Please note that if the above nurse practitioner had referred me to pelvic floor therapy several years ago, my condition might not be as advanced as it is now. The doctor and I discussed surgical prospects, topical estrogen (to thicken tissues in the vagina for suturing), and pelvic floor therapy to strengthen the muscles of the pelvic floor. I said I wasn’t interested in a pessary. The idea of physical therapy as a preparation for surgery, and as a good in itself, was highly appealing to me.

I am so fortunate the doctor referred me to the estimable Rheam Mansour, PT, DPT, WCS, CLT, at Life Care Center of Hilo. (Her doctorate is in physical therapy, naturally.)

And here is where the story gets interesting.

It took me awhile to catch on to the serious nature of the exercises and daily regimen that Rheam recommended. But once things clicked, here’s how and why they clicked.

1. A few sessions in, Rheam replaced the word “kegel” with “butt squeeze.” This helped because I was really struggling to detect finer muscular sensations of “kegels” and the direction to do “butt squeezes” conveyed easily detectable, “gross” (not in the sense of “icky”) sensations.
2. Rheam explained that muscles need: “nutrition, circulation, hormones, education (in the form of exercise), and repitition (also exercise).” So I began to see what I was doing in terms of over-all health.
3. I had an epiphany about the time an assistant hula teacher called me “duck feet” in class, and realized how painful it was to stand or sit with my feet straight out. A different hula teacher sent me an article called “Feet and the Pelvic Floor” from The Alignment Rescue, written by Carol Robbins RES-CPT(note: the website is undergoing some renovation at the time this blog is written). The article explained so much. Here’s an excerpt:

   “Now the muscles of the pelvic floor are connected to the hip joint (both literally and figuratively) in that the po- sition of the femur in the acetabulum (thigh bone in the hip socket) will change the resting tension of the pelvic floor. Add to that a chronic tail tucking position (which does NOT allow normal hip extension, which would en- gage the posterior butt muscles and create normal tensile loads on the sacrum – which is a heavy duty pelvic floor attachment site) and we’ve got some major mechanical flaws that will inevitably end up affecting the func- tion of the pelvic floor.”

   Rheam confirmed that outwardly turned feet weaken the pelvic floor. I began to pay conscious attention to how I was sitting, standing, and doing my exercises.

4. I incorporated my Ipsalu Tantra “Rishi Isometrics” and “Immortals Wand” exercises into my regimen, and included (a) butt squeezes and (b) awareness of foot alignment. I showed these to Rheam and she was enthusiastic. (Jump-starting my lapsed tantra practice has also granted many benefits.) Note: unlike the Rishi Isometrics video link above, I tighten the perineum when I lift up and inhale. I am not saying he’s wrong, it’s just how I’m doing it. With the Immortals Wand, the butt squeezes happen when I have to reach out or lift up.
5. Work with a “pelvic floor electrical muscle stimulation system,” both vaginally and rectally. Renting the STM-1o will soon allow me to continue this treatment at home.
6. Logging my daily practice.

Oddly, I began to realize that the process of strengthening my pelvic floor muscles was also helping to lift my depression and hone my will power. Rheam says it’s because I am learning that I can transform my body. I do agree.

Now, in my last consultation with the gynecologist he explained that I am strengthening what is still intact, but that “one suspension of the bridge” (as it were) still needs surgical repair and he doesn’t expect that I can reverse the prolapses through exercise – just keep them from worsening.

I would like to see if there are other options as I continue to work with Rheam. I also am working on losing weight. For one thing, if I do have surgery, I want a lighter body to move around during the three months of recovery. Losing abdominal weight will also ease the pressure on the prolapsing uterus and bladder – that in itself may contribute to some reversal in the condition.

This is only the first of several blogs on this topic. I realize I have left much unsaid. The point I’d like readers to consider is that “even” a relatively well-educated person can be lost when it comes to assessing the meaning of physical changes that form the “mysteries” of organ prolapse. Until 2016, every single medical provider I had ever seen let me down with regard to this issue, and even my sexology instructors were clueless about this topic.

This should tell you something. Anyone with a uterus and a vagina (including some trans men who still possess both) should be given preventative information about prolapses. This condition is not just confined to women who have given vaginal birth. Anyone with weakened pelvic floor muscles can experience a rectocele or cystocele. [2020 update: trans women who have a vaginoplasty and trans men who have had a hysterectomy may also experience prolapses.] Here’s a page for cis-gender men.

Thanks for reading. Stay tuned for more. In the meantime, here are some unnerving pictures of uterine prolapse (more advanced that I am dealing with).

####