Pelvic Organ Prolapse & Pelvic Pain

a displacement of an organ from its normal position, usually downward or outward, often resulting in it protruding from an orifice

prolapse

mechanisms of pelivi organ prolapse

defect in a complex tension system that suspends pelvic organs that includes: Suspensory ligaments, Fascial planes, Pelvic floor muscles

prolapse into/against vaginal wall

cele

Cystocele (anterior wall) =

Rectocele (posterior wall) =

Enterocele (small bowel) =

bladder prolapse into vagina
rectum prolapse into vagina
small intestine into vagina

Pelvic Organ Prolapse risk factors

Obesity

Multiparity

Hysterectomy

Chronic cough

Chronic constipation

Connective tissue disorders

Estrogen deficiency (postpartum, menopause)

Pelvic Organ Prolapse sxs

Visualized or perceived “bulge” at vaginal opening

Heaviness or pressure

Urinary: incontinence, urgency, frequency, incomplete emptying

Bowel: constipation and/or incontinence

Pelvic &/or LBP

pevlic organ prolapse Clinical exam:

Digital palpation intra-vaginally w/ bear down

POP-Q= intravaginal measurement system

Pelvic floor physical therapy = 1st line tx involves

PFM strengthening

Functional training: STS, squat, lunge, lift, carry, etc

Pelvic brace w/ these mvmts

Pelvic girdle strengthening: progressively add load & intensity

Long-term lifting precautions are not realistic or effective. Limit fear/avoidance behaviors thru progressive exercise & activity tolerance

what tx of POP can be worn intermittently or constantly?

Can be used in conjunction w/ PFM training

pessary

what tx is for severe POP, or if PT does not improve symptoms sufficiently

Bladder sling, Hysterectomy, Sacrocolpopexy, Rectopexy

surgery

where is pelvic pain typically located?

Lower abdomen, external genitalia, vagina, anus, pelvis, back, tailbone

what is the nature of pelvic pain?

Sharp, dull, cramping, burning

Intermittent or constant

Cyclical vs activity dependent

Mechanical vs non-mechanical

what is the etiology of pelvic pain?

Multifactorial

MSK, nervous system, organs, psychoemotional

May receive a pathoanatomic diagnosis:

Chronic UTIs (but with negative cultures!)

Interstitial cystitis/painful bladder syndrome (females)

Vulvodynia (females)

Chronic non-bacterial prostatitis (males)

female pelvic pain is located in

Abdominal, vaginal, buttock, or groin pain

female pelvic pain Often co-occurs with or is caused by

Bowel dysfunction (constipation)

Gynecologic dysfunction (endometriosis, polycystic ovarian syndrome, dysmenorrhea, pelvic organ prolapse, hormone dysfunction)

Surgery or trauma to abdomen/pelvis

Sexual trauma/abuse

Gynecologic surgery

Obstetric surgery, trauma, or injury

Recurrent UTIs

Menopausal hormone changes

female pelvic pain Typical presentation of MSK dysfunction:

pelvic floor muscle overactivity

male pelvic pain is located in

groin, testicular/scrotal, penile, rectal, tailbone

Consider referral patterns to groin and external genitalia from T12-L2 (manips here can help)

male pelvic pain often occurs w/

Chronic prostatitis not improved by antibiotic treatment

Urinary dysfunction (hesitancy, weak stream, urgency, post-void UI)

Constipation

Erectile dysfunction

Typical presentation of MSK dysfunction in male pelvic pain

Pelvic floor muscle overactivity

Lumbar dysfunction: hypomobility, or hypermobility with motor control impairments

male pelvic pain pt exam involves

Neuro screen

Posture and movement patterns

Mobility and strength of: lumbar spine, hip, pelvic girdle, pelvic floor muscles

Voiding behaviors

Lifestyle factors

MSK Patterns you may see w/ pelvic pain

Hypermobile individual w/ poor lumbopelvic motor coordination, hip/pelvic girdle weakness, pelvic floor muscle overactivity

Hypomobile lumbar spine or hip with pelvic girdle weakness and pelvic floor incoordination or overactivity

Central sensitization/nociplastic pain pattern: widespread hypersensitivity to palpation/stretch/activation of adductors, abdominal wall, pelvic floor; guarding behaviors; poor bladder/bowel habits; poor sleep and stress mgmt

tx of pelvic pain Medical mgmt of visceral disorders

Physical therapy

Treat underlying lumbar/hip dysfunction:

Lumbopelvic strengthening/motor control

Joint mobilization

Postures and body mechanics

Pelvic floor muscle retraining: usually downtraining

Optimize bowel/bladder habits

Pain neuroscience education

Scar manual therapy

Modalities- maybe

other Treatment of pelvic pain

Pharmacologic: NSAIDs, antidepressants, opioids

Injections

Botox

Lidocaine

Psych and trauma therapy