The Pelvic Diagnosis You’ve Never Heard Of
Prevention & Treatment It’s hard to believe that, currently, a condition believed to impact up to half the female population exists without any preventative screening to answer for it.
Sherrie Palm, the founder and executive director of the Association for Pelvic Organ Prolapse Support, opens up about this silently pervasive reality facing women.
Mediaplanet: Certain health conditions and symptoms of POP are often not shared during doctor visits. Why is this case?
Sherrie Palm: Despite nearly 4,000 years on medical record, stigma continues to shroud pelvic organ prolapse (POP) in silence. Urinary incontinence, fecal incontinence, tissues bulging from the vagina and painful intercourse are symptoms few women are comfortable speaking about out loud. I feel all pelvic organ prolapse symptoms need to be talked about out loud, enable women suffering in silence to recognize they are not alone, to increase awareness of POP and to clarify that treatment is available.
MP: What types of symptoms did you experience that told you something was wrong?
SP: The symptom that got my attention is the symptom that gets most women’s attention: vaginal tissue bulge. I noticed the bulge for about three months when I would wipe after urinating before I got curious enough to get a hand-held mirror to see what was going on down below. I had no idea what the bulge was or what it meant; I simply knew it needed to be addressed.
At grade 3, my bulge was pretty pronounced. However I had other indicators for years prior to tissue bulge. Fourteen years prior to my POP diagnosis, I had a hysterectomy. Prior to that procedure, I couldn’t keep a tampon in. I now know that this is a symptom of POP. I also suffered with chronic constipation for decades, as well as difficulty staring my urine stream—also symptoms of pelvic organ prolapse.
MP: Can women self-examine to find any irregularities that may be POP?
SP: All women should perform vaginal self-examination; vaginal tissue bulge is very easy to see. Examine yourself at the end of the day, after gravity and daily activities have pulled and pushed organs downward—especially if you’re on your feet all day while working.
Take a hand-held mirror into a locked, well-lit room and simply take a look at your vagina to see if tissues are bulging out. In lesser grades of severity, the bulge may be a tiny marble sized ball, or only a tiny bit of the cervix may be viewable. As the grade becomes more severe, the size of the bulge increases. Mine appeared to be about the size of a golf ball.
MP: What are the options for treatment, and what type of treatment worked for you?
SP: There are multiple options for treatment, both non-surgical and surgical, and I encourage women to explore non-surgical until they’ve had time to do their homework and know for sure they are ready to move forward to surgery. Physical therapists provide tissue manipulation as well as multiple treatment modalities for POP.
"While types of POP and symptoms are often similar among women, lifestyle, age, employment and fitness level translate to a diverse variety of experiences."
Non-surgical options include kegel exercises, kegel assist devices, pessaries, hormone replacement therapy, electrical stimulation, biofeedback, tibial nerve stimulation, myofascial release therapy, targeted core or pelvic floor exercise regimens, urethral injections and support garments. Women typically utilize multiple non-surgical treatments at the same time. Often, women get tired of time-intensive maintenance and want a more permanent fix, thus moving on to surgery.
MP: What factors should one consider when deciding whether to have surgery?
SP: It is important to explore non-surgical treatments while you evaluate POP, recognize behavior impact, as well as track symptom cause and effect (e.g., If I pick up something heavy, my POP feels worse), and then explore as much information about surgical options as possible prior to making the decision.
POP surgery may be vaginal, abdominal, robotic, laparoscopic or a combination of these; there is no “best type” of surgery for all women. What is most important is locating a qualified POP surgical specialist. Female Pelvic Medicine Reconstructive Surgeons (FPMRS) are the POP surgical specialists and may be either urogynecologists or urologists. It is pivotal women write down their questions, so when they see a specialist they capture as much information as possible.
MP: Can Pelvic Organ Prolapse recur after surgery?
SP: There is always a chance additional POP surgery may be needed; no medical procedure comes with a 100-percent lifetime warranty. By consulting with a reputable FPMRS surgeon, checking references, following doctor’s orders post-surgery regarding lifestyle behaviors that should be modified and evaluating whether utilization of mesh is a proper fit for individual needs, risk of recurrence is radically reduced.
February 2016 marks my eight-year POP surgery anniversary for grade 3 cystocele, rectocele and enterocele repair. Mesh was utilized for the cystocele and rectocele, and a consultation with my urogynecologist a few months ago confirmed I have no granulation, that the mesh is still intact where it was placed, and that POP has not returned.
MP: There are five types of prolapse. Does every case of POP vary with symptoms?
SP: We are as unique on the inside as we are on the outside. While types of POP and symptoms are often similar among women, lifestyle, age, employment and fitness level translate to a diverse variety of experiences. Everyone interprets pain and pressure differently.
Combinations of POP type are impacted by quality of life measures, which cannot be standardized because they vary radically. Physical, emotional, social, sexual and fitness activity, as well as employment, can all have an impact.
MP: What’s the most common misconception about POP?
SP: Narrowing it down to one misconception is very difficult; there are many. I’d say the most common misconception is the prevalence figure currently accepted (3.3 million women in the U.S.). Research frequently indicates half the female population likely experiences POP.
The reality is we simply do not know because POP screening is not a part of routine pelvic exam protocol. Diagnostic clinician curriculum falls far short of need, related to POP. But I’d be doing the women at APOPS a huge injustice if I failed to mention an additional misconception—that POP is asymptomatic in early stages. If women don’t know POP exists, how can they recognize symptoms are POP-related?
We have so much more to learn. It is imperative we shift awareness not only within the lay community, but also within multiple fields of clinical practice that address women’s pelvic health screening. Pelvic organ prolapse is a global women's health pandemic. Since vaginal childbirth and menopause are the two leading causes, nearly every woman has at least one hash mark on her risk factor profile.