After the birth of her first child, Nadia Garofalo* was up all night, every night feeding her newborn daughter—and peeing. But even in the half-consciousness of baby fog, Garofalo sensed a disturbance in her nether regions. “I honestly didn’t even want to look down there,” says the 39-year-old Torontonian. “But when I took a mirror and stood over it, I saw what looked like a little pinkish bubble protruding out of me.” After her GP mistook the protrusion for her clitoris (really), Garofalo visited her gynecologist, who then referred her to a pelvic physiotherapist. “It was minor, and only visible when I was standing,” says Garofalo. “But I was still paranoid about it.”
Physiotherapist Kathleen Shortt conducted a brief internal examination on Garofalo, and later concluded she had suffered a mild, stage 1 uterine prolapse, where muscles and ligaments in her pelvis had overstretched during pregnancy and delivery, allowing the organs inside her pelvis to be pushed downward. “I was devastated,” she says. “I felt like my body was falling apart. I went online and saw all these Cronenberg-esque photos of women with prolapse and read forums about these poor women who are incontinent because of it, or who can’t have sex. I thought the absolute worst.”
The “absolute worst” is what most of us can’t help but fear when the very concept of pelvic organ prolapse is such a mystery. This invisible—yet crucial—network of muscles and ligaments supports our bladder, bowel, uterus, vagina, pelvic bones and back, and is engaged with virtually every step we take. Between marathon labours, C-sections and certain ab-crunching workouts that force our insides down and out our vagina in much the same way toothpaste is wrenched from a tube, our pelvic floor takes a frequent pounding, so to speak.
But as horrifying as the whole thing sounds, the pelvic floor is also heroically tough, in most cases built to recover from such insults as babies and boot camps. Injuries can often be prevented, or rehabilitated through consistent physiotherapy and physical training that takes pressure off the pelvic floor. When rehab isn’t possible, supportive devices and surgery are sometimes necessary. However, first you have to know the problem exists at all.
When asked how many Canadian women suffer from prolapse, Magali Robert, head of pelvic health at the University of Calgary, hesitates, then measures her words. “We put in a proposal to study that in Canada,” she says, “but we got rejected—which is part of the problem. Everyone can relate to cancer and heart attacks, but when you get into the health burden associated with prolapse and incontinence, it’s seen as a ‘women’s issue’ and people lose interest.”
Even if precise numbers aren’t known, experts say the reach of prolapse is unsettlingly significant. According to Robert, who also leads the Pelvic Floor Clinic at the Foothills Medical Centre in Calgary, if you’ve given birth, chances are you already have it. “I can almost say that every woman who’s had a vaginal delivery has some degree of prolapse, but they most likely have no symptoms. It’s the women who are bothered by symptoms that we worry about.”
Some of the more extreme symptoms of pelvic organ prolapse, like seeing or feeling your internal organs suddenly become external, can be rather obvious; others, such as the frequent sensation of having to pee, pressure or heaviness in your groin, leaking a drop of urine when you run or strain while working out, discomfort during intercourse and hip and back pain, are not so obvious. “General estimates from other countries suggest that about 40 percent of all women will suffer from both prolapse and incontinence in their lives,” says Magali. “By the time we reach 80, 50 percent of us will have some form of incontinence.”
If you were racing for the washroom or leaking while pregnant, take it as foreshadowing of dribbles to come—Robert points out that incontinence during pregnancy is your biggest risk factor for incontinence later on. But just because symptoms such as incontinence and prolapse worsen with time, it doesn’t mean they’re a normal part of aging. “In most cases, they’re simply the result of injuries to muscles and ligaments that have never healed or been properly rehabilitated,” says Shortt.
Trista Zinn, a 45-year-old fitness trainer and mother, has personal experience with this kind of injury, even though her body doesn’t show it. “No one talked about it,” she says. “No one told me not to work out right away or educated me about all the muscles and connective tissue that push out the equivalent of a bowling ball. At my six-week visit, my doc just asked how my baby was, did a quick internal and that was it.” Then, years after having two kids, Zinn did what she had been recommending to all her training clients: She visited a pelvic physio. “Incontinence and prolapse were so common, I had to practise what I preached.”
Even though Zinn could feel no glaring symptoms besides hip pain and her annual internal exams raised no alarms, she was diagnosed with a stage 2 prolapse, not visible externally like Garofalo’s, but her vaginal wall had collapsed and could no longer support her bladder. She was directed to stop all exercise that was forcing pressure onto her injury, such as running and strength training—basically everything she loved to do. “I cried and cried,” says Zinn. “I was desperately afraid of my organs falling to the point where I’d have to push them back in. I also worried my husband would look at me differently.”
Feeling broken and isolated, she resolved to do something about it. While working with her physio on targeted Kegels and breathing, her training instincts kicked in. “I wanted a routine that would really engage the pelvic floor and work.” She researched a series of yoga-like poses and breathing exercises gaining popularity in Spain—where, like in many European countries, things like pelvic rehab are taken seriously—and was surprised to see how quickly she saw improvement. “After two weeks of doing the breathing and poses, I went back to my physio and found my stage 2 prolapse had become a stage 1,” says Zinn. “I remember walking down the street feeling like I had the vagina of a 16-year-old.”
In 2012, with her prolapse fully resolved, Zinn travelled repeatedly to Europe and received her certification in low pressure fitness/hypopressives in Vigo, Spain. She then began training Canadian clients and physiotherapists in hypopressive technique—a series of flexed postures and movements, breaths, held exhalations and rib cage expansions. Key to the technique are stances formulated to engage the muscles in your pelvic floor you can’t feel, then creating maximum space for those muscles to engage and lift upward by exhaling all the air out of your lungs, and lifting your diaphragm up and off your pelvic floor. Sound complicated? Hell, yeah. But if Kegels are the lady push-ups of pelvic floor strengthening, then think of hypopressives as the boot camp for your whole body.
This is figurative speak, of course. “No boot camp in the first year postpartum!” commands Kathleen Shortt. The physiotherapist is steadfastly against any high-impact activity less than one year after delivery, as well as weights like kettlebells and planking. “It took nine months to gain that weight, it should take nine months or more to take it off. Even during breastfeeding, hormones will cause lax tendons and muscles, including those in the pelvis, that can still be stretched and injured by extreme exercise.” Shortt recommends holding off at least a year and checking with a pelvic floor therapist before starting any high-intensity program, to teach you how to engage your pelvic floor properly with hypopressive training and other targeted exercises.
But even exercise we’ve been led to believe is tailor-made for our core can push us closer to prolapse. “When you see the washboard abs, the rectus abdominis, that has nothing to do with your core stability,” says Robert. “You look good, but the rest of your body could be a mess.” Edmonton pelvic health and orthopaedic physiotherapist Mary Wood sees this phenomenon regularly. “What’s fascinating is not only young boot campers, but even Pilates and yoga instructors who have never had a baby are suffering from slight perineal descent and lower back pain,” says Wood, who has also trained in the hypopressive technique. “I see women doing Pilates, for instance, putting a lot of downward pressure on the pelvis and bulging their abdominals. We use hypopressive training to reset their bodies as a whole, so they can go back to doing their exercise, but doing it correctly.”
There are, however, rare cases when rehabilitation is not enough, as in prolapse, where organs can descend almost completely outside of the body. Lowered estrogen levels in menopause may also weaken muscles and ligaments in the pelvis, as can obesity, chronic cough and chronic constipation. In these cases, supportive devices or pelvic reconstructive surgery can be necessary. “Most of our surgery patients are elderly,” says Robert. “But we’re seeing younger women, from their 40s and up, because they’re more aware and won’t accept prolapse and incontinence anymore.”
Surgery often involves transvaginal mesh, a plastic net-like implant that acts like a sling to support weakened organs and alleviate pain. There are significant risks associated with transvaginal mesh, including chronic pain, but in late 2017, the Society of Obstetricians and Gynaecologists of Canada released guidelines about its use, saying that it is still important for women who are at risk for recurrent prolapse (for example, if you’re stage 3 or 4), but doctors need to more thoroughly weigh the risks and benefits for patients, and offer women counselling on those risk so they can better make informed decisions.
The bottom line: Most symptoms of pelvic floor dysfunction (from incontinence to prolapse) can be treated or prevented. “If we continue to abuse or ignore our pelvic floor as we age, we increase our chances of living with problems,” says Zinn. “Just because something is common doesn’t mean it’s normal. If we had been educated as teens about the importance of maintaining pelvic floor health, many of us wouldn’t be in the situation we’re in now.” Robert echoes the importance of education in preventing our insides from pressing down and out, suggesting yoga and fitness classes might be a great opportunity for instructors to spread the word on pelvic health and how to maintain it.
In the interim, Garofalo is in her fourth month of physio, slowly trying out hypopressive training, and performing “super Kegels.” “My muscles are starting to engage all on their own. And I’ve noticed I don’t have to pee all the time anymore.” Now she can hopefully find another middle-of-the-night pastime. Like sleep.
* Name has been changed