Madeleine Hamilton had read all the birth and parenting books she was supposed to.
“I was focused on breastfeeding, how I would cope if my birth plans didn’t go to plan, how I would recover psychologically … those kind of things,” she said.
What she had not been warned about, like so many women, was the long-lasting damage her pregnancy and birth could do to her pelvic floor muscles.
“I was a little bit familiar with urine leakage and things like that … but prolapse was very far back in my mind as the worst-case scenario.”
Six weeks after the birth of her third child, Madeleine became one of the millions of Australian women who experience some level of pelvic organ prolapse.
“I was trying to enjoy the luxury of an unpressured bowel movement while my baby and toddler were asleep … and lo and behold, part of my insides appeared on the outside,” she said.
What surprised Madeleine most was the reaction of the women around her.
“They’d say, ‘Oh yeah, I had one too’ or ‘I’ve had troubles with incontinence’ and all kinds of things, and I never had any idea,” she said.
“I think we really owe it to women who are considering having children to tell them that these things can happen, but that there are preventative measures and things you can do after birth to help.”
Half of women with children have symptoms of prolapse
In Australia, it is estimated at least half of women who have had more than one child have some degree of pelvic organ prolapse.
Prolapse is when the muscles and ligaments that support a woman’s pelvic organs (known as the pelvic floor) weaken, causing those organs — the bladder, bowel and uterus — to stretch and drop down into the vagina or against the wall of the vagina.
The most common symptom of prolapse is bowel and bladder incontinence, the latter of which affects more than a third of Australian women.
Symptoms also include uncomfortable feelings of fullness or swelling in the vagina, and for some women, sex may become painful.
While pregnancy and vaginal birth are the primary causes of prolapse, heavy lifting, chronic constipation, obesity, and ageing can also weaken the pelvic floor.
Contrary to popular belief, giving birth by caesarean section does not prevent pelvic floor problems either. Hormonal changes and the extra weight and pressure of a baby during pregnancy can also overstretch the pelvic floor muscles.
Prolapse symptoms may occur during pregnancy or following childbirth, but they are most common after menopause, when women’s oestrogen levels — which help to keep the pelvic floor muscles well-toned — start to decline.
Strengthening the pelvic floor
Without intervention, pelvic floor problems usually become worse over time.
While individual treatment will vary depending on the severity of the prolapse, there are a number of ways women can strengthen their pelvic floor muscles and improve their symptoms.
According to Women’s Health Queensland: “Simple measures such as losing weight (if overweight), avoiding lifting heavy objects (including children) and treating conditions like chronic coughing and constipation may alleviate some symptoms”.
Then there are pelvic floor exercises (sometimes known as Kegels), which are designed to strengthen pelvic floor muscles, reduce symptoms, and prevent disorder.
These exercises, which can be performed sitting down, standing up, or lying down, involve actively tightening and lifting the pelvic floor muscles at different intervals.
Over time, strengthening these muscles with regular exercise can help women to better control their bladder and bowel motions, and help reduce or stop leakage, said urogynecologist Jenny King.
“There’s good evidence that if you start pelvic floor muscle training during pregnancy and maintain it afterwards, you definitely reduce the number of problems,” said Dr King, head of the Department of Urogynaecology at Westmead Hospital in Sydney.
While such exercises are crucial to the recovery of muscle function and bladder control (especially after birth), Sydney-based physiotherapist Angela James said all women — pregnant, post-birth or otherwise — should exercise these muscles regularly as a way to prevent pelvic floor weakness.
“I’d love women to know the importance of these muscles, and to know exactly what they need to do to keep this area in good health for the long term.”
She added because many women had difficulty locating the right muscles and practicing the correct technique, it may be helpful to develop an exercise program with a pelvic floor physiotherapist.
More intensive treatment options
While most women will benefit from pelvic floor exercises and physiotherapy, others will require more intensive treatment, especially if they have symptoms of moderate to severe prolapse.
Dr King said the use of a pessary — a plastic or rubber device inserted into the vagina to support the uterus — can in many cases be an effective non-surgical option.
“Some women need to wear a pessary consistently because they have pelvic organ prolapse … but some only wear it while they are loading their bodies during activities like skipping, running or boot-camp,” she said.
In more severe cases, where prolapse is significantly impacting a woman’s quality of life, surgery may be required to repair and reconstruct the pelvic support structures.
There are a number of different surgical procedures available which can involve the use of supporting mesh, tissue graft or tape to support the bladder and urethra in place.
Vaginal mesh implants, however, were banned in Australia in January after they left hundreds of women with chronic, debilitating pain and recurring infections.
According to the Continence Foundation, even after surgery to mend prolapse, one in three women will prolapse again.
‘Don’t be ashamed or embarrassed’
Madeleine, now several years on from her prolapse, has been able to manage her pelvic floor disorder with the help of ongoing physiotherapy and postnatal care.
“I have felt so demoralised and despairing at times, but there are treatments which improve things … and certainly make life a bit easier to manage,” she said.
She said she wished women, as well as midwives and obstetricians, spoke more openly about the risks of pelvic floor problems, including how to mitigate those risks during pregnancy, birth, and during the postnatal period.
“There is so much focus on getting your post baby body back in shape … but the focus should definitely be on making your insides fit.”
Dr King said she was “still disheartened” by the number of women who were too embarrassed to talk about their symptoms or seek help.
“We can’t magically fix everyone, but [we] can make a difference … and hugely impact on their quality of life,” she said.
Madeleine added that although the word prolapse implied the body had “lapsed” or “made a mistake”, women experiencing pelvic floor problems “haven’t done anything wrong”.
“I say to women: don’t be ashamed or embarrassed about it … but do get support to get yourself better, because it is out there.”
If you’re experiencing symptoms of prolapse, you can phone the National Continence Helpline on 1800 33 00 66 to speak with a continence nurse advisor.