It leads to bad sex and incontinence – so why can’t we talk about it?

Pelvic organ prolapse (POP) affects about half of all women and can lead to painful sex and incontinence. A lot of the time it’s preventable and mostly fixable, but our cultural shame around “private parts” is really helping no one. Nats Levi reports.

As they say on social media, if you know you know. And that enigmatic expression definitely relates to POP (which stands for pelvic organ prolapse). Unfortunately, if you’re one of the ones who “knows” in this instance, you’ve probably already experienced it. Why? Because we don’t talk about it. Meaning, those experiencing POP don’t only deal with its often deeply embarrassing consequences, they suffer behind a wall of silence.

Dr Melissa Davidson is a Waikato-based physiotherapist, revered in medical circles for her expertise in in pelvic health. She thinks the taboo around this topic is due to our country’s conservative culture. “People treat anything to do with pelvic organs as a taboo area. If we lose self-consciousness when talking about our anatomy, we can remove the taboo.”

POP stands for a pelvic organ prolapse with the pelvic organs being the bladder, uterus, and rectum (part of the bowel) which are all supported by the pelvic floor muscles.

Vaginal childbirth is the most common cause of POP but it can also be caused by other experiences such as menopause, weight lifting, or a chronic cough. It’s estimated that as many as 50 percent of women will experience POP in their lifetime, and yet the mystery around it remains – possibly because some of its common symptoms (incontinence, constipation, pain during sex) are considered awkward topics in themselves.

Liz Childs, a pelvic health physiotherapist in Wellington, says her clinic averages 100 patients a week, and few of them knew anything about pelvic healthcare before they needed treatment.

Hannah Findlay is a classic example. She experienced something known as a grade 2 bladder prolapse (cystocele) during the birth of her first baby in 2018. “Like any woman, I had heard horror stories about your uterus falling out (after childbirth), or peeing your pants whenever you jump on a trampoline. I still had no idea about our pelvic floor muscle before rehab, or how important it is. I did not know how it works and had no idea how the muscle supported my organs or kept them staying out of my vagina.”

Findlay was introduced to a pessary (a soft, removable device inserted, non-surgically, in the vagina to support the pelvic organs if they prolapse) 12 weeks after childbirth, while she was still coming to grips with being a new mum. “It was a horrific experience – I was so sore in all areas... I was trying to breastfeed, trying to deal with a newborn and had complications in all areas from the birth. I was fitted by a male gynaecologist with very little tact and only wore this (pessary) intermittently as it made me feel worse. It took so much of my mental capacity.”

A pessary can be used intermittently – when doing heavy lifting, for example, or for activities that may aggravate symptoms or need extra support. Or it can be retained in a woman’s body indefinitely – although it does need to be regularly checked.

For Findlay, it wasn’t the solution. “I stopped with the pessary. I went into depressive state for a few months – I stopped seeing physio and wanted to pretend it wasn’t happening to me.”

To Findlay, these feelings were an extension of an already avoidant attitude towards the whole area of pregnancy and childbirth. “Growing up, we talk about it from a place of fear – the fear of falling pregnant, of childbirth. We can do a better job around this - the culture of conversation around birth needs to change. It is portrayed as terrifying, legs up in stirrups and in pain. This is not the reality for all – women have been giving birth for centuries – yet there is so much fear around birth and body bits.”

Rebecca Mooney, a pelvic health physiotherapist based in Pukekohe agrees. “There is a stigma around symptoms of pelvic health issues and it is taboo to talk about – we need to change this culture.”

She says if women knew the facts, they wouldn’t feel so isolated and embarrassed by their experiences. “One in every three women have some form of pelvic floor dysfunction,” says Mooney. They are not alone – we need to let them know this.

Davidson believes thinking around pelvic health needs to change, the way it has with other widespread health issues. “We view pelvic health the same way we viewed the topic of weight 20 years ago, and mental health 10 years ago – backward. We need to quickly change the way we think about pelvic health and talk about it.”

Symptoms of a prolapse can vary depending on the severity, anything from incontinence (both bladder and rectal) to a dragging or feeling of heaviness in the pelvic area. These, and of course pain during intimate relations with a partner, are signals from our bodies that something is not quite right.

For Hannah Findlay, it was when her baby was about four weeks old that she started feeling a heaviness in her pelvic area. “You are in a post birth haze – you are a little like, oh my God I have a baby. You are bleeding, you are healing, and then you have a physio give you a pamphlet!” The symptoms she was experiencing scared her. “I was panicked, this horrible dragging feeling.”

Mooney notes that prolapse occurs to varying degrees of severity. It’s not, as it’s often thought to be, a black and white issue. “Fifty percent of women have experienced a degree of prolapse – some won’t know this, but prolapses can be mild,” she says.

Melissa Davidson agrees. “When you look at the statistics, over 50 percent of women will experience some degree of prolapse, over a third will leak, and this number increases when they hit peri-menopause and menopause, regardless of whether they have had children or not.”

The most common solution – or prevention method – offered to women wanting to strengthen their pelvic floor is Kegels. These are daily exercises, often sold as something you do to improve your sex life, and they involve repetitious contractions of the pelvic floor (the type of movement we naturally do when we start or stop peeing).

Practising Kegels after childbirth could go some way to avoiding POP, but it’s not always the answer.

Sometimes the problem with pelvic floor is due to something known as high tone, which means a very tight pelvic floor. Mooney says, there are many reasons for very tight pelvic floor muscles, whether it is previous trauma or endometritis. And simply doing your Kegels, which further strengthens those muscles, isn’t the solution here.

“A tight pelvic floor is not the goal with this muscle. Pelvic floor should be strong – as well as flexible and mobile,” she says.

As we’ve said, leaking, or urinary incontinence is common among women (and happens to a quarter of men too actually, but that’s another column). But there’s a difference between common and “normal”.

And leaking is not normal pelvic health even though it’s treated as something that is just expected to happen with age. “Any sign of incontinence is not normal, yes it is common, but it is not normal,” says Mooney. “Leaking when you cough is not normal. Leaking when you sneeze is not normal. Leaking when you lift is not normal.”

The good news, says Davidson, is that women looking to address incontinence have an 80 percent success rate when working with a pelvic health physiotherapist, simply by doing exercises and learning methods of control.

She says that while a prolapse can’t be returned to the way it was before structurally, much can be done via a pelvic health physiotherapist to alleviate symptoms. The main approaches are exercises, the use of pessary, or in some cases, surgery.

In October of 2022, legislative changes meant ACC and publicly funded treatment was accessible to all those who experience birth-related injuries. This was a huge step forward in our healthcare system. However, all the experts spoken to agree more could be done in terms of registering patient damage, with a more unified approach to records.

In the public system, referrals to a pelvic health physiotherapist are made after significant prolapses and tears during childbirth. However minor damage is often not picked up and, if left, can deteriorate with changing hormones and age.

Mooney says, “At least 80 percent of women have had some form injury sustained during childbirth.”

On Mooney’s wishlist for post-natal care would be a compulsory pelvic WOF. “A post natal WOF - typically done six weeks post partum - is growing in popularity - but not standard. It can help identify any sign of prolapse even if mild, and any injury to the pelvic floor.”

Davidson agrees “We are now in the process of working with ACC to implement guidelines to be used in clinics. We need a consistent system to be able to record damage, no matter how minor. We cannot assume the mum is always doing okay – vaginal births do not mean you will have problems, and a Caesarian birth does not mean you will not.”

Her wish list takes pelvic health one step further, to a preventative, screening tool for all.

“Pelvic health specialists look at the bladder, bowel, vagina, pelvic floor muscle, lifestyle, prolapse, tears, all of it in a very holistic way. We are all over the country, and even online, but can only treat what and who we see. A brochure doesn’t work. Prevention and care goes a long way to help everyone.”

Hannah Findlay is back to living a full, functioning life. “I haven't and won't ever ‘fully recover’, she says. “But I have returned to almost everything I love to do, bar long distance running.” The turning point was nine months after her baby’s birth. “I began seeing a new physio who was great,” she says. “I began a rehab course for my prolapse and went back to the gym for some exercise... It was hard to prioritise myself initially."

Findlay believes that her history of being fit made the prolapse more difficult, initially. “As an active person it was quite shocking.” But by the same token, her love of movement showed her a way out. “It was easier to move into the physical training side of it – that was positive. I had guidelines and a way to move forward.”

Findlay’s openness is refreshing. The more we can do to get people talking honestly about pelvic organ health, the better our care and culture will be in the future. So start the conversation, and share your embarrassing experiences far and wide - you might be surprised by how many of your audience have been through the exact same thing.

Go to pelvichealthdirectory to find a pelvic health therapist in your region.