Q: OK, here’s my question that I have been thinking about for a while. Is the goal to make the prolapse go away, is that possible or are we aiming to have no symptoms. Without a doubt these principles have alleviated symptoms ( many years past delivery) but I still have a stage 2 prolapse. What’s my goal if I’m not having symptoms? Thanks! -Susan

A: Susan! I LOVE this question. This is something I have been musing about, too. I think it deserves some conversation within the pelvic health community, so here goes. I think the goal is no symptoms with a return to function and fitness (patient determined level). So if you are asymptomatic and fulfilling all your life duties (work, home, carpool, etc), you are able to exercise in a satisfactory way, sex is good, control and passage of urine and feces all good…then I say rehab has achieved its goal. I do think this may come in the presence of a continued prolapsed position of your organs. However, you have been able to restore the forces and structures that support the pelvic organs in a way that has rebalanced the system and no longer triggers your symptoms or reduces your function. The body is incredibly adaptable, and this new balance may be achieved through a more compliant abdomen above, a different breathing pattern, the elimination of motor patterns or breath holding that were exacerbating the issue, postures that changed the trajectory of forces, strengthening, etc. It makes me think of a certain balloon example I love, we are trying to balance the balloon through the marriage of muscular work and pressures. Likely this balance will change the position of the prolapse to a more elevated position, but does it go back to zero in everyone who eliminates symptoms? We would need some studies for sure, but I think it is reasonable to think that no, not everyone goes back to baseline.

 Some of my reasoning, my musings, relate to the role of the brain in this. If we could extrapolate the new pain science to the realm of pelvic health, not just pelvic pain, it may be that the level of prolapse has returned to a position that the brain no longer perceives as dangerous. The change of inputs, via the re-balancing of factors such as those given as examples above, may have reduced the threat in such a way as to result in a change in the brains output. An example that comes to mind is a participant in a one of my courses. With some simple changes in her alignment and breathing she noted her constant prolapse pressure was almost eliminated in about 15-20 minutes of practice (I have witnesses!!). Did her prolapse instantly lift from a level 3 to a zero? No, I don’t think so. Did we change and balance all her inputs to reduce the pressure from a held abdomen, a tucked bum, and a faulty breath pattern? Did those inputs influence her brains output? I think this is not a huge leap in reasoning in light of all we are learning from the new pain science research. Something changed…and nothing works faster than your brain.

 This also fits with our understanding that some women have a significant prolapse, but minimal symptoms. And some have a minor prolapse, with significant symptoms. Is there a central sensitization issue here too? Similar to an X-ray that shows lots of arthritis in a joint, but the patient reports minimal issues. Or the patient has a relatively clear X-ray, and significant symptoms. This makes me wonder how hearing your prolapse grade may impact your situation (emotion, fear, etc.) given that some have no symptoms and a prolapse may be an incidental finding in an exam. Similar to the impact of an MRI result that shows an incidental disc bulge in the absence of symptoms. Just a thought….and worthy of conversation (not hate mail, please). 

 This must lead us to consider the demand on the system though, too. Your activity or fitness level, may be low impact, you may have lots of time to maintain your physical balance, finances to have a maid instead of having to deep clean the tile in the bathroom yourself, or your kids are old enough to no longer need to be carried. You may be someone who has low demand on the system. So your brain/system may be able to tolerate a prolapse at a level 2. Contrast this with a young mom with three little ones, no maids, no sleep, no time, and the desire to run a marathon….that’s a different demand on the system. So our job as rehab providers is to train the system to meet each individual’s functional demand. And if young mom cannot run without symptoms, then her prolapse at any level cannot tolerate the demand being placed on it. Symptoms and restored function are our big guides to functional and fitness progression.

 Lots to ponder. Please weigh in with your own musings below.