Reader’s question about having a hard time pooping after childbirth
QUESTION:
I gave birth 6 weeks ago without any major complications. For a while now I’ve had trouble with my bowel movements. Everyone talks about anal incontinence but I‘m facing the opposite issue. I have a hard time getting the poop to come out. I also find it difficult to discern when it’s time to “go”. I’m so very scared that something in my pelvic floor is broken and that they didn’t tell me about it at the labor ward. What should I do?”
Reader’s question
ANSWER:
HI! AND CONGRATULATIONS ON YOUR NEW BABY!
There are several reasons why one can have difficulty pooping after giving birth. It takes up to a year for the muscles in the pelvic floor to recover fully. Your body has just about finished the “acute” phase of healing. I read somewhere that 20% of all women have constipation postpartum, but also that 20% of the population of the world suffer from constipation in general.
WHAT MIGHT HAVE HAPPENED?
During the birth all tissues in the pelvic floor are distended and stretched to about 300% of their regular length, including the vaginal walls and pelvic floor muscles. Some also experience reduced sensation or other symptoms in their genital area caused by nerve damage due to the nerves having been stretched or compressed during the birth. Nerves heal slowly, about one millimeter per day, which is why it may take a long time before the sensation in your pelvic floor area is back to normal.
WHAT CAUSES DIFFICULTY TO POOP?
Injury to the pelvic floor muscles can cause urinary or fecal incontinence, but some injuries can also make it harder to pass stool. If you have difficulty pooping, a bulging posterior vaginal wall may be the reason. Having a hypertonic pelvic floor is another possible reason. Vaginal childbirth is in itself a great trauma to the pelvic floor and it can be enough to hamper the muscles ability to relax, causing hypertonicity and thereby difficulty to pass stool.
HOW DO YOU KNOW WHAT THE CAUSE IS?
My answer to this question is: Your issues might be caused by having sustained muscle injury or a bulging vaginal wall from childbirth, but your issues might also just be part of the typical pelvic floor recovery process postpartum. You won’t actually know which until several weeks or months have passed. Have a look at the posts listed at the end of this post for more info.
HERE ARE SOME KEY POINTS AS TO WHY THIS ISSUE CAN ARISE:
You had a baby. The muscles and nerves of your pelvic floor have been stretched, pulled and compressed. You have swelling and bruising. Your tissues are slowly recovering, but the body memory of the pain is still fresh.
Just having had a baby you might be moving less than usual. Less movement means slower passage of food through your digestive system. You might also be forgetting to drink and eat enough. If you are breastfeeding, some of the fluid you drink will be used to make milk for your baby. This means less fluid will be available in your digestive system for keeping your stools soft. Maybe your mealtimes are no longer regular, or you might be eating different foods than you are used to.
All of the above makes you a little constipated. Coupled with the body memory of pushing while giving birth, along with worrying that pooping might hurt, makes pooping an all around unpleasant idea. This makes your pelvic floor tense and unable to relax, hampering bowel movements further, making you even more constipated.
All in all, it is very easy to end up in a downward spiral and end up having difficulty pooping.
SOME SIMPLE ADVICE WHICH YOU PROBABLY ALREADY KNOW:
– Eat at regular meal times
– Eat foods rich in fibre
– Drink extra fluids, especially if you are breastfeeding
– Move as much as your body allows you to. Moving less than usual will make your intestines work slower, increasing the risk of constipation.
– Listen to your body and the signals it is giving you. Go poop immediately when your body tells you it is time to go. If you don’t go at the first signal, the feces will remain in your bowels. The longer the feces stay in your intestines, the more fluid is absorbed by the intestines from the feces, making the poop dryer and harder. The next time you get the signal to go, the poop will be more difficult to pass.
SOME SIMPLE ADVICE YOU MIGHT NOT HAVE COME ACROSS:
Use a foot stool while on the toilet. Sitting in a position where your knees are higher than your hips will help your pelvic floor relax and open up. You will notice the difference!
Apply counter pressure on your perineum. Your perineum is the area of skin between your vaginal opening and your anus. Pressing on your perineum with clean fingers or some toilet paper can make pooping easier.
HOW TO POOP WITH A TENSE OR HYPERTONIC PELVIC FLOOR:
It might be enough to just shift your focus away from pooping. Distract yourself while on the toilet, maybe by reading something?
If this is not enough, do the following:
Sit on the toilet. Prop your feet up on a foot stool.
Place your hands on your belly
Tighten your abdominal muscles as if bracing for a punch
Relax and let your belly expand fully into your hands
Repeat the tightening and relaxation 10 times
Finish by relaxing fully for 10 seconds while also trying to relax your pelvic floor.
If you feel the urge to poop, push gently while exhaling.
If not, repeat the procedure of tightening and relaxing another 10 times.
This website is mainly in swedish. If you want to read more about pelvic floor issues and pelvic organ prolapse, you can use Google translate to read the swedish posts.
On your computer, go to Google Translate.
In the text box, enter a URL.
To choose the language you want to translate to, at the top right, click the Down arrow .
On the right, click the URL that appears. The URL will open a new tab and the website will be translated.
“I have a rectocele which mostly makes it difficult for me to empty my bowels. It sometimes also bothers me while standing or walking and it makes me apprehensive about working out. What should I do? Can I work out with a prolapse?”
Reader’s question
Rectocele is the term for when the rectum bulges toward the back vaginal wall due to a weakening of the structures in the wall between the rectum and the vagina. I have written more on rectoceles here (Swedish post).
Symptoms of a rectocele may involve feeling a heaviness in the vagina or having difficulty emptying your bowels completely. Defecation can be uncomfortable or even painful. In this post I will offer advice on what to keep in mind regarding physical exercise when having a rectocele.
CAUSES
A rectocele can be caused by giving birth vaginally, especially if the birth was very quick or if the baby was big. There are however also those who develop a rectocele without having ever given birth. Age, menopause and a decrease in estrogen levels can also make tissues less elastic and thereby increase the risk of developing a prolapse. Chronic constipation, chronic cough and being overweight are also factors which increase the risk.
TREATMENT
When diagnosed with a prolapse, most receive advice to start doing pelvic floor exercises (“kegels”). This advice is based on the fact that a strong pelvic floor has the potential to better support and lift the pelvic organ that is bulging down. Pelvic floor exercises have been shown to reduce symptoms of prolapse, but cannot “fix” or “heal” a prolapse. During the months following a birth a prolapse can “heal” on its and doing pelvic floor exercises can help speed up that recovery. It is also important to try to keep your stool soft and avoid straining while sitting on the toilet. Straining to poop or pee puts a lot of pressure and a high load on your tissues in and around your pelvic floor.
If you have a rectocele you should avoid long periods of constipation and long periods of coughing. If you smoke, quitting may be important in order to avoid having recurrent coughs. If you are overweight, weight loss may decrease your current symptoms and will reduce the risk of your prolapse worsening over time since excess weight means an excess strain on your pelvic floor.
If the advice above proves insufficient, there are surgical treatment options which aim to reinforce the tissues which separate the vagina and rectum.
WHAT EXERCISES SHOULD I DO?
Pelvic floor exercises (also known as “pelvic floor contractions” and “kegels”) aim to improve the strength in your pelvic floor muscles, so as to provide better support to your vagina and rectum. This is why pelvic floor exercises are recommended. Physical exercise which targets the rest of your body is also beneficial, see links below.
IN WHAT WAY WILL PELVIC FLOOR EXERCISES HELP ME?
When you do pelvic floor exercises your pelvic floor muscles will grow stronger and thicker and will be able to better support your pelvic and abdominal organs. When properly executed they may result in a reduction of symptoms and better control of your bladder and bowels. Those with milder symptoms might expect better results from pelvic floor exercises alone than those with severe symptoms. Still, even in the case of a rectocele in need of surgical treatment, having a strong pelvic floor will improve chances of recovering well after surgery.
Consequently it is wise to do pelvic floor exercises prior to surgery. However, prolapse is sometimes the result of damage to the pelvic floor muscles sustained during childbirth. In this case, doing your pelvic floor exercises won’t be enough to strengthen your muscles, since they can’t function properly. When some muscles of the pelvic floor aren’t intact and can’t contract properly, doing pelvic floor muscles may even give rise to muscular imbalances as the muscles which are still intact might become overworked and hypertonic. This can cause pain and is counterproductive. If you are uncertain as to whether you might have such muscular imbalances you ought to see a pelvic floor physiotherapist who can give you individually based advice regarding pelvic floor training.
CAN I MAKE MY PROLAPSE GO AWAY BY DOING ANY KIND OF EXERCISE?
Unfortunately, neither working out nor doing pelvic floor exercises will make the vaginal walls or surrounding fascia or ligaments stronger or firmer. Physical exercise which is properly executed, dosed and modified may however contribute to a reduction or complete withdrawal of symptoms.
HOW TO DO PELVIC FLOOR CONTRACTIONS (“KEGELS”)
First, try to contract your anus as if you were holding a fart. Second, contract you pelvic floor muscles as if holding wee. Third and last, try to lift the entire pelvic floor up and inward. Hold. Then let go, relax and rest a little before starting over.
Initially it may feel like nothing whatsoever happens when you try to contract your pelvic floor. Don’t give up, keep at it. After one to two weeks of regular training (or regular attempts) the connection and communication between your muscles and your brain should have developed enough for you to now be able to feel your muscles contract when you tell them to do so.
HOW MUCH AND HOW OFTEN SHOULD I EXERCISE MY PELVIC FLOOR?
Recommendations vary. Thirty pelvic floor contractions three times a day (e.g. once in the morning, once at noon and once in the afternoon) seems to be the most common general advice. You can alter the execution of the contractions. Quick contractions, long contractions, or contracting with maximal force.
You need to train daily for three months before you can evaluate whether your pelvic floor has become stronger or if you notice an improvement in symptoms.
WHAT IF I DO THEM WRONG?
A common mistake is to push out rather than to lift up. Another is to hold your breath while contracting your pelvic floor muscles. Try to breathe normally! Many also tend to contract their glutes and thighs in the attempt to contract their pelvic floor muscles. Relax your butt and thighs! You can read more about common mistakes here. (Swedish post)
WHAT ABOUT WORKING OUT AND OTHER PHYSICAL ACTIVITIES?
The general advice is that adults should at least do 150 minutes of moderate intensity physical activity a week. This is equivalent to 30 minutes brisk walking at least five days a week. If 30 minutes is too long, you can do it in three bouts of 10 minutes, or two bouts of 15 minutes. It is the total time spent on physical activity that counts. Shock absorbing footwear and walking on flat terrain may help.
Most tolerate vigorous intensity activity well, as long as it isn’t too much of a high-impact exercise. The more high-impact, the higher the demand on your pelvic floor. Using an exercise bike or a crosstrainer may help reaching vigorous activity while not demanding maximum effort from your pelvic floor. Other examples of suitable exercises are swimming, aqua jogging and water aerobics. Preferably, dance and group workout classes should not involve jumping.
Experiencing heaviness or discomfort or pain can be a warning signal indicating that the current exercise level is too challenging for your pelvic floor. If you experience any such symptoms after a workout, try reducing the time spent exercising on that level or check your form. Read more about having symptoms during or after physical activity here: Do workouts always have to be asymptomatic? (Swedish post)
PROLAPSE AND WORKING OUT
If you have a prolapse you should avoid workouts which increase your symptoms over time. Prolapse symptoms tend to decrease during the first year postpartum. Physiotherapists usually refer to two principles when it comes to modifying workouts if our client is experiencing symptoms from their pelvic floor. These principles are “Tension to task” and “Spread the load”. Basically this means having a pelvic floor strong enough for the activity in question and to not contract your core muscles more than absolutely necessary. You should only recruit your core muscles just enough to be able to execute the exercise.
HERE ARE SOME MORE POSTS ON PELVIC FLOOR SAFE EXERCISE
This website is mainly in swedish. If you want to read more about pelvic floor issues and pelvic organ prolapse, you can use Google translate to read the swedish posts.
On your computer, go to Google Translate.
In the text box, enter a URL.
To choose the language you want to translate to, at the top right, click the Down arrow .
On the right, click the URL that appears. The URL will open a new tab and the website will be translated.
The pelvic floor is a group of muscles. Like all other muscles in the body, the muscles of the pelvic floor can become tense and sore. The easiest way of explaining what a hypertonic pelvic floor is, is to compare your pelvic floor muscles to the muscles in your shoulders. When you’ve been cold, stressed or have worked hard the muscles in your shoulders can feel so tense it’s impossible to relax them and lower your shoulders. In the same way your pelvic floor muscles can become tense and give rise to pain and other issues.
THE PELVIC FLOOR; A HAMMOCK
The pelvic floor muscles attach to the inside of the pelvis, similar to the suspension of a hammock. This ‘muscle hammock’ lifts and supports the bladder, uterus or prostate and rectum. When these muscles function optimally they will contract together to make sure we don’t pee or poop when we don’t want to, and will relax well when we do. The pelvic floor muscles are also important for sexual function in both men and women.
When these muscles become hypertonic they can cause pain or a frequent urge to urinate or difficulty voiding your bladder or emptying your bowel. There are also individuals who for different reasons have a combination of both weak and hypertonic pelvic floor muscles. In such a case it is important to first reduce the muscular hypertonicity before working on strengthening the muscles.
SYMPTOMS OF A HYPERTONIC THE PELVIC FLOOR:
Frequent urges to pee
Difficulty starting the flow of urine when peeing or difficulty voiding your bladder completely
Pain while voiding your bladder
Difficulty emptying your bowels
Pain in your genital area or pelvis which cannot be explained by other causes
Pain during or after intercourse or orgasm
HOW DO I KNOW IF I HAVE A HYPERTENSIVE PELVIC FLOOR?
To really know you will need someone to examine your pelvic floor muscles, such as a gynecologist or pelvic floor physiotherapist. The examination is done by palpating your pelvic floor muscles vaginally while you contract and relax your pelvic floor, and to see if pain can be triggered by pressing on any of the muscles. External palpation is not enough to make a complete assessment.
IS THERE SOMETHING I CAN DO TO REDUCE MY SYMPTOMS?
The most important things to reduce your symptoms can be done on your own!
Start by giving yourself enough time to pee and poop. Be mindful about relaxing and letting your muscles go rather than straining.
Get going on self-care tips on how to reduce constipation
Do relaxation and breathing exercises regularly at home
Stop doing pelvic floor exercises (‘kegels’) until someone has assessed your pelvic floor muscles and says you can start again.
RELAXATION EXERCISES FOR THE PELVIC FLOOR
Lie down and belly breathe, at least 10 deep breaths
Apply a heating pad or hot water bottle on your genital area (on top of your panties) för 20-30 minutes before starting on the exercises which you feel are most difficult
Imagine your pelvic floor is a hammock which has the ability to close around your anus, urethra and vaginal opening. Imagine gently lowering your pelvic floor and opening these three passageways. This exercise is the opposite of a pelvic floor contraction (“kegel”). Try to combine this exercise with belly breathing.
If the advice above is not enough you probably need to see a physiotherapist or other health care professional who offers hands on treatment for pelvic floor issues. Common treatments are manual therapy and stretching exercises in order to reduce hypertonicity and optimize your ability to control the muscles and their tension.
TIPS/SELF PROMOTION
The online class ‘Become free from pain and hypertonicity’ is a 6 month program created for those with pain and pelvic floor issues. As of yet, the program is only available in Swedish. Read more about it here: Online classes
TRANSLATE WEBSITES WITH GOOGLE TRANSLATE:
This website is mainly in swedish. If you want to read more about pelvic floor issues and pelvic organ prolapse, you can use Google translate to read the swedish posts.
On your computer, go to Google Translate.
In the text box, enter a URL.
To choose the language you want to translate to, at the top right, click the Down arrow .
On the right, click the URL that appears. The URL will open a new tab and the website will be translated.
Firstly, both the vagina and vulva undergo several changes during pregnancy. The labia may swell due to increased blood flow as well as due to the weight and downward pressure of the growing belly. In some people, this can cause vulvar varicocities.
During a vaginal birth the cervix, birth canal and vulva opens in order for the baby to pass through it. During the baby’s descent, all surrounding tissues are stretched. The pelvic floor muscles are stretched 250-360 percent. Immediately after birth the labias will be distended and the pelvic floor and vaginal walls will be like an unstable hammock.
THE PELVIC FLOOR
This post offers information on the type of birth related injury called perineal tears, which are graded from first-degree tears to fourth-degree tears. These tears are located between the vaginal opening and the anus, and involve the muscles which make up the superficial muscle layer of the pelvic floor.
An illustration of the pelvic floor anatomy. The deeper muscle layer is depicted to the left, the superficial muscles to the right.
FIRST-DEGREE TEARS
Most who have a vaginal birth will sustain some degree of perineal tearing, also known as perineal laceration. In most cases, a tear will need to be sutured in order to heal well. First-degree tears are small and only involve laceration of the skin and/or mucosa. These tears do not involve any muscle tissue and may not need sutures. The vaginal opening is distended and everything feels a bit wobbly or shaky, but the muscles are intact. Given time, the body will heal and recover. Anatomically however, some things will remain permanently altered following a vaginal birth. The supporting structures in the vaginal walls will need at least 6 months to recover and the pelvic floor, though intact, will need about 12 months.
SECOND-DEGREE TEARS
Second-degree tears involve the perineum, the area between the vaginal opening and anus. These tears involve the perineal muscles, as well as skin and vaginal mucosal. These tears always need suturing in order to heal properly. If injured pelvic floor musles are left unsutured, they will not recover fully and the support of the pelvic floor will be weakened. Restoring the anatomy while suturing is sometimes difficult which is why the vaginal opening can become longer or wider than prebirth. This may result in the perineum becoming shorter in women who have given birth vaginally. If the perineum is too short, this is an indication of the pelvic floor muscles not having been sutured well enough. You can read more on this topic here (Swedish post).
THIRD- AND FOURTH-DEGREE TEARS – ANAL SPHINCTER TEARS
The anus is encircled by two sphincter muscles, the internal anal sphincter and the external anal sphincter. These muscles control the opening and closing of the anus. A tear involving one or both of these sphincters is also known as an obstetric anal sphincter injury (OASI).
A third-degree tear involves injury to all of the perineal muscles as well as the external and/or internal anal sphincter. If the anal sphincter tear is not sutured properly, this will result in fecal incontinence (also known as anal incontinence) which is the inability to stop your bowels from emptying at an inconvenient time. It can be very hard to differentiate between a second-degree tear and a third-degree tear. In order to do so, the midwife or doctor needs to examine the tear by so-called bidigital palpation.
Bidigital palpation means palpating with one finger in the rectum and one finger in the vagina at the same time, in order to be able to determine how much muscle mass is intact between the two fingers. If the muscle mass is thin this may indicate an anal sphincter injury, in which case the tear should be sutured by a doctor in an operating theatre.
A fourth-degree tear involves the rectal mucosa as well as the external and internal anal sphincter. This means that before the tear is sutured, there’s nothing separating the rectum from the vagina. In such a case the rectal wall and both sphincters need to be sutured, as well as all the rectovaginal fascia, vaginal wall and perineal muscles. (This is the type of injury I got when our first child was born.)
AFTER THE BIRTH
The recovery process starts immediately following the birth. If you were sutured, the healing starts as soon as the final stitch is in place. The appearance of the vulva and vagina may be somewhat altered permanently. The end result of the recovery process depends on several factors, such as the size of the baby, how the birth went and in what way the tearing was sutured. Genetics also play a part in how the healing process goes and in how much scar tissue will be left once the tear has healed.
Whether or not you will experience a persistent change of function in your pelvic floor depends largely on how well your tear was sutured. As with all muscle injury, the end result is also affected by how well the injured muscle is rehabilitated, which in the case of pelvic floor muscle injury is made up largely by pelvic floor exercise.
This post was first published in 2015 as a part of a four part series. You can read the other parts here: (Swedish posts)
This website is mainly in swedish. If you want to read more about pelvic floor issues and pelvic organ prolapse, you can use Google translate to read the swedish posts.
On your computer, go to Google Translate.
In the text box, enter a URL.
To choose the language you want to translate to, at the top right, click the Down arrow .
On the right, click the URL that appears. The URL will open a new tab and the website will be translated.
Pelvic organ prolapse is a term used for when the bladder, uterus or rectum has shifted to a lower anatomical position. These three organs are usually kept in place by supporting and suspending structures such as connective tissues and ligaments, as well as by the pelvic floor muscles which support the pelvic organs from below. If these tissues become damaged, overdistended or weak they may no longer be able to keep the pelvic organs in their original anatomic position. The bladder, uterus (cervix) or rectum may then start to push down into the vagina and toward the vaginal opening.
DIFFERENT TYPES OF PELVIC ORGAN PROLAPSE
CYSTOCELE
If it’s the front vaginal wall which is pushing into the vagina or down toward the vaginal opening, it may be due to the bladder having shifted from its original place. A prolapse of the bladder is called a cystocele. A cystocele may cause symptoms, such as pressure or heaviness in your pelvis or vagina, especially after having been on your feet for a while. You may leak urine or feel that you’re not voiding your bladder completely when peeing. A cystocele increases the risk of frequent urinary tract infections. A cystocele can also be asymptomatic, meaning you have no symptoms. Visibly, a bulge shaped like an egg may protrude from the vaginal opening, especially while bearing down, and may be felt while standing.
Prolapsed uterus
Uterine prolapse typically causes a feeling of something protruding out of the vaginal opening. The sensation of heaviness or protrusion is often exacerbated by standing and walking. Physical activity such as heavy lifting often causes a worsening of symptoms, at least temporarily. Uterine prolapse can cause difficulty voiding as well as difficulty passing stool.
RECTOCELE
If it’s the back vaginal wall which is pushing into the vagina or down toward the vaginal opening, it may be due to a rectocele. A rectocele is when the rectum pushes onto the back vaginal wall so that the vaginal wall falls into the vagina. This is caused by lack of support from the connective tissues and muscles which are located in the space between the posterior vaginal wall and rectum. A rectocele may cause symptoms such as a feeling of something protruding, difficulty passing stool and the need to press i.e. with your thumb or fingers on your perineum or back vaginal wall in order to have a bowel movement. Bowel movement may be incomplete and stool may be trapped in the rectocele. A slight rectocele may be asymptomatic.
HOW DO I KNOW IF I HAVE A PELVIC ORGAN PROLAPSE?
If you have read the text above, you may understand why it can be difficult to determine on your own what type of prolapse you may have, since the different types of prolapse often give rise to very similar symptoms. In conclusion, pelvic organ prolapse can cause any of the following:
A sensation of something filling the vagina or protruding out of it
Dragging and a feeling of fatigue it your pelvic floor
Sensation as if a tampon is stuck or falling out.
Being able to palpate or see something pushing down or out of the vagina
Difficulty voiding your bladder when peeing or frequent urination
Difficulty passing stool or emptying your bowel completely
Symptoms may worsen during the day and improve when you lie down. If your prolapse is protruding out of your vaginal opening this can also cause chafing.
HOW COMMON IS PROLAPSE?
This question is difficult to answer. It’s not always easy to diagnose a prolapse. Many have a so-called asymptomatic anatomical prolapse where there is a visible anatomical change but no symptoms whatsoever. An asymptomatic prolapse is not necessarily a sign of something bad or wrong, which is why a diagnosis is not always warranted. Others may have a symptomatic prolapse that is hardly visible. A symptomatic prolapse means having symptoms due to your prolapse. A small prolapse may not be diagnosed properly, even if it is highly symptomatic.
Internationally, one in five women undergo surgery due to prolapse. This may however be just the tip of the iceberg, since many don’t seek help for their symptoms.
WHAT CAUSES PROLAPSE?
Vaginal birth is the by far largest risk factor for developing pelvic organ prolapse. While descending down through the birth canal, the baby stretches the surrounding connective tissues and muscles. Due to this stretching, the tissues often sustain some degree of damage.
Other things which put frequent or long term pressure on the pelvic floor may also contribute to the development of prolapse, such as chronic cough and chronic constipation. Age, overweight and heavy daily lifting i.e. due to a physically demanding vocation may also be contributing risk factors.
Genetics and heredity play a large role regarding the risk of developing pelvic organ prolapse.
HOW IS PROLAPSE TREATED?
Treatment of prolapse is based on what, if any, symptoms you have.
Pelvic floor exercises and lifestyle changes may be enough to cause a reduction or complete removal of symptoms, especially if your prolapse is of a smaller grade. Lifestyle changes may include avoiding constipation, adjusting your way of exercising as well as losing weight if needed. Some may benefit greatly from using a supporting device such as a pessary.
Pelvic organ prolapse may need surgical treatment. The specific type of surgery and method used is determined by what type of prolapse you have and what symptoms your prolapse is causing you.
I THINK I HAVE A PROLAPSE BUT MY GYNECOLOGIST SAYS IT LOOKS NORMAL!
Lower grades of prolapse can be hard to diagnose, especially if you are not told to bear down during the examination. This is due to the fact that the prolapsed tissues slide back into the vagina when you are lying down. It is also important to know that just as some may not have any symptoms despite their prolapse being clearly visible, others have a lot of symptoms despite their prolapse being very small.
I’M GOING TO VISIT MY GYNECOLOGIST, WHAT SHOULD I ASK ABOUT?
What questions should I ask?
1
What is causing my issues? Can you please show me and explain which anatomic structures are involved?
2
What do you consider to be a suitable first-choice treatment for my issues?
3
How long will it take before I can assess the result of the treatment?
4
What other options of treatment are there? Is there a risk I may need surgery?
5
Do I need a referral to another healthcare provider or specialist to receive further examinations, treatment or in order to have all my questions properly answered?
6
Who will provide follow ups for my issues? Who do I contact if I have further questions?
7
Where do I turn to receive psychotherapy if needed?
8
Is there anything I need to know prior to a subsequent pregnancy?
HOW DO I KNOW IF I HAVE A PROLAPSE?
If you have a symptomatic prolapse you will notice something doesn’t feel right. In such a case, you should visit a gynecologist for an examination.
An asymptomatic prolapse is not a cause for concern.
Translate websites with google translate:
This website is mainly in swedish. If you want to read more about pelvic floor issues and pelvic organ prolapse, you can use Google translate to read the swedish posts.
On your computer, go to Google Translate.
In the text box, enter a URL.
To choose the language you want to translate to, at the top right, click the Down arrow .
On the right, click the URL that appears. The URL will open a new tab and the website will be translated.
”What is the difference between a bulging, lax vaginal wall and a prolapse? At my postpartum check-up, my healthcare provider told me I have a bulging vaginal wall, and when I’ve researched my symptoms it makes me think I might have got a cystocele, front wall prolapse. What is the difference between bulging, lax vaginal walls and prolapse, really?”
Reader’s question
OKAY, IT’S LIKE THIS:
Bulging vaginal walls and prolapse are really the same thing. It’s the same anatomical structures that have been displaced and both conditions can cause the same symptoms. The definition of av prolapse is pretty much ‘a lowering of one or more of the vaginal walls and/or cervix’. There are different stages of prolapse, and a small prolapse and a bulging vaginal wall is basically the same thing.
The thing is that a prolapse is considered a chronic condition where supporting structures such as the pelvic floor muscles and connective tissues have gradually become less firm whereby the tissues and pelvic organs are being pulled down by gravity. This is generally not the case in someone who recently gave birth.
A RECOVERY PROCESS
I read somewhere that 70% of all who have given vaginal birth have bulging vaginal walls/some stage of prolapse. However, this condition differs greatly from the diagnosis of prolapse referring to a chronic condition, even if the symptoms are the same. In someone who has recently given birth the body will go through a spontaneous recovery. What looks like a prolapse a month postpartum won’t necessarily look or feel the same 12 months postpartum. The process and level of recovery will of course differ between individuals and there are women who will have remaining symptoms, but it’s impossible to know how much recovery can be expected based on what it looks or feels like shortly after birth. Some have a substantial bulge or bulges due to lax vaginal walls following birth but have no issues at all a short while later.
We can however be sure that vaginal birth is the greatest risk factor for developing prolapse later in life, typically after menopause. It’s possible that prolapse-like symptoms experienced postpartum may predispose you to developing prolapse later on.
THIS IS HOW I USUALLY EXPLAIN IT:
This is a vagina seen from the side (the clitoris is to the left and the anus is to the right):
││
(Now imagine that the vagina is the space between the bars and that the bars are the vaginal walls.)
This is what the vagina looks like during vaginal birth, as it is stretched A LOT by a descending baby:
(<-B A B Y->)
(Imagine the vaginal walls being pushed to the sides by the baby as it descends)
Due to this, the vaginal walls become significantly stretched and will look something like this immediately after birth:
S S
(Imagine something loose and mushy which bulges in a variety of directions)
And then the body starts to recover, whereby the vaginal walls looks something like this:
) (
(Imagine the walls are somewhat distended and that gravity pulls them down making them bulge toward each other in the vagina)
That is, when the walls are more lax, gravity will more easily cause them to bulge.
And in time, it might look something like this:
││
(Fully recovered vaginal walls, yay!)
Or it might looks like this:
│(
(A bulging back vaginal wall. When enough time has passed and no more spontaneous recovery can be expected, a remaining posterior vaginal bulge may be diagnosed as a rectocele. If symptomatic it can be treated surgically)
Or like this:
)│
(A bulging front vaginal wall, which may later be diagnosed as a cystocele. This too can be treated surgically if it causes symptoms)
TREATMENT
Just because a vaginal bulge doesn’t disappear completely on its own but is instead in time diagnosed as a prolapse, surgery isn’t necessarily the next step in treatment. Sometimes, it may be better to choose not to have surgery. If you plan on having a subsequent pregnancy and birth within not too long, it may be better to wait and see if and in that case what type of surgery might be suitable for you. Sometimes age needs to be taken into consideration when deciding whether to have surgery or not. Some surgeries might not last for years and years, and re-operation can only be done so many times, so delaying surgery for as long as possible might be a good idea for some.
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Sometimes, a supporting device such as a pessary can be an effective treatment to reduce a bulge and any associated symptoms. I’ve written more about pessaries here. (Swedish post.)
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PELVIC FLOOR EXERCISES
If your pelvic floor muscles are weak and an examination shows they may respond well to strengthening exercises – that is, the examination shows that your muscles are intact and haven’t sustained persistent damage from childbirth – you might become asymptomatic from ‘only’ doing pelvic floor exercises. Not because the exercises in themselves will ‘heal’ the prolapse or remove the bulge, but because strong pelvic floor muscles will offer better support to your pelvic floor organs. This will help lift your bulge further away from your vaginal opening, resulting in a decrease in symptoms.
THE DIFFERENCE BETWEEN A BULGING VAGINAL WALL AND A PROLAPSE
A bulging vaginal wall is actually a small prolapse. However, the two conditions are separated by one big difference; the chance of spontaneous recovery. A bulging wall may well be able to disappear by spontaneous recovery and perhaps a little bit of pelvic floor exercise, whereas a prolapse is considered a more chronic condition which may require surgical treatment if it causes debilitating symptoms.
“I’ve given birth to three children in four years. My youngest is now three years old and I’ve recently noticed some issues. I have difficulty pooping, sometimes the rectum sort of pushes on the back vaginal wall and makes it cave into the vagina. Is this something that can be fixed by medical care?“
Reader’s question
When the rectum bulges into the vagina it’s due to that the wall between vagina and rectum has been weakened or overdistended. This causes faeces to become trapped in a pocket of sorts and you may have difficulty emptying your bowels completely. In medical terms, this kind of vagina bulge is called a rectocele.
Many find that supporting your back vaginal wall or perineum (the area of skin between your vaginal opening and anus) helps with passing stool. Supporting your vaginal wall in this way is called splinting.
The largest risk factor for developing a rectocele is having had a vaginal birth. Constipation, heredity, ageing and a physically demanding vocation are other risk factors which may contribute to developing a rectocele.
SEEKING MEDICAL CARE CAN HELP
Choice of treatment is based on type and severity of your symptoms, how large the bulge is and whether or not you wish to give birth vaginally again. If you haven’t tried any kind of treatment, pelvic floor exercises and bowel retraining may be a good first-line treatment. Pelvic floor exercises can never ‘heal’ a vaginal bulge or prolapse, but a strong pelvic floor can decrease symptoms. Good bowel habits and having stools that are soft and easy to pass can also help reduce symptoms. Keeping your faeces between a 3 and 4 on the Bristol Stool Chart tends to help with being able to poop without having too much trouble. If you suffer from constipation, a visit to your GP is a good place to start. A gynecologist typically can also help with counselling and an assessment. A physiotherapist can offer advice on exercise as well as ergonomics to facilitate bowel movements.
HAVE A LOOK AT SOME OF MY OTHER POSTS ON THE SAME SUBJECT
Below are some tips and advice on how to optimize recovery and healing!
JESSICA’S STORY
Jessica gave birth eight months ago. The birth was long and the pushing stage was hard, but eventually the birth ended quite well and Jessica only needed a few stitches. The first few days Jessica had a hard time walking and she felt rather sore and swollen. It hurt to sit and to stand or walk more than just a little bit. Gradually, the discomfort improved but didn’t go away completely. At her postnatal visit, Jessica was told that her vaginal walls bulge a bit and that her kegels are quite weak.
WEEKS LATER
Weeks later, Jessica was still bothered by a heaviness and an aching feeling of fatigue, especially after having been on her feet for a long time or having walked far. Sometimes Jessica had a feeling of something bulging in her vaginal opening. After a while, Jessica booked a visit at a gynecologist clinic. The gynecologist assured Jessica that what she felt was ‘normal’ and to be expected and told Jessica to go home and practice her kegels, and return if her issues still remained a year postpartum.
When checking with a mirror, Jessica saw a small pink bubble protrude from her vaginal opening. It was only visible when she was standing, while lying down the bubble disappeared. Jessica felt super frustrated that something obviously had changed with her body, but that no one seemed to take her concerns or symptoms seriously. She feared everything would come falling out of her. All in all, Jessica felt her identity, sexuality and self confidence suffered from the physical change.
Nykläckt
WHAT HAD HAPPENED TO JESSICA?
It’s not uncommon to have lax and bulging vaginal walls following a vaginal birth. The vaginal walls are stretched to such a degree by the baby’s descent through the birth canal, that they become distended and weakened for some time. This distension allows for the pelvic organs which rest upon the pelvic floor to sag somewhat. Furthermore, the hormones which prepare the body for birth also have a loosening effect on the vaginal walls as well as the tissues surrounding the vagina. This, too, can contribute to laxity postpartum.
WHAT SYMPTOMS CAN BE EXPECTED FROM HAVING BULGING VAGINAL WALLS?
Bulging vaginal walls can cause a great many, some or no symptoms at all. If there are symptoms, these often include a feeling of heaviness or having a bulge in or above your vaginal opening, having an ache in your pelvis or low back, difficulty inserting a tampon or emptying your bowels completely. Symptoms typically worsen during the day.
HOW SHOULD JESSICA GO ABOUT CARING FOR HER VAGINAL BULGE?
As always, I believe birth related injury to the pelvic floor and vagina should be treated in the same approach used to treat athletic injuries (that is, injuries sustained to muscles or connective tissues following a highly demanding physical feat).
Here’s guidance on what you can do to reduce your symptoms. (This links to a Swedish post. You can use the Google translate tool to translate the content of the post.)
Taking care to not overexert your already weakened supporting tissues may help with recovery. If Jessica needs to lift and carry her child a lot during a specific day, she might benefit from avoiding doing the grocery shopping, carry heavy grocery bags and doing the laundry that same day. Similarly, she should perhaps refrain from both going on a long walk pushing the pram which aggravates her symptoms during the day, as well as be up on her feet cooking later that evening.
AVOID CONSTIPATION
Avoiding constipation and emptying your bowels in a gentle way is an important part of caring for your pelvic floor postpartum.
Jessica would do well following the advice given in this post (Swedish post). When Jessica starts working out she should choose a type of exercise which isn’t too demanding of her pelvic floor (Swedish post). That said, she may not need to mind her pelvic floor while working out forever
It’s important to know that healthcare providers such as physiotherapists, gynecologists and midwives see bulging and lax vaginal walls in women who have recently given birth on a daily basis. Most women’s’ symptoms disappear during the first year postpartum. Just as the skin on your once pregnant belly will become more firm again, so too will your vaginal walls gradually recover. For those with remaining symptoms there’s help readily available, i.e. by wearing a supportive device or by having surgery.
HOW DID JESSICA DO, IN THE END?
Jessica is an imaginary patient of mine, a woman whom I typically meet a week or so after she’s had her postnatal check-up. I’ve comforted her as she cried during her visit with me, and I’ve assessed the strength of her pelvic floor contraction (‘kegel’). I’ve nagged her about pelvic floor exercises and we’ve tested different workout exercises in the gym. A year after her first vaginal birth she’s doing okay. She still has some symptoms during ovulation and menstruation, but her pelvic floor contractions are stronger and she dares to do almost everything she wishes to in the gym. She has sex without any issues and is considering trying for another baby. She’s mindful about avoiding constipation and uses a squatty potty to put her feet on when she’s having a poop.
HOW DO I CARE FOR MY BULGING VAGINAL WALLS FOLLOWING BIRTH?
Bulging vaginal walls postpartum often heal on their own. Even if symptoms may be both frightening and debilitating initially, they usually gradually improve with time. For those few who have remaining issues there’s help offered by healthcare providers. Unfortunately, I’ve met a great many patients who feel they have had to fight to receive such help. My advice to these individuals is this; be a demanding patient. Don’t settle with less than a good examination and a plan devised to find a solution for you and your symptoms.
QUESTIONS, THOUGHTS, OWN EXPERIENCES?
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