#PTonICE Daily Show – Monday, December 11th, 2023 – Talking prolapse with your patients

In today’s episode of the PT on ICE Daily Show, #ICEPelvic faculty member Rachel Moore discusses how to better educate patients on prolapse, including a three-step framework focusing on education, risk factors, healing timelines, and empowerment.

Take a listen to learn how to better serve this population of patients & athletes.

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Good morning, PT on ICE Daily Show. My name is Dr. Rachel Moore. It is Monday morning, which means it is pelvic day on our podcast here. So, we are going to dive in today. Our topic is using words that heal to talk to our patients about prolapse. So we want to make sure that when we are talking about our patients that have prolapse or maybe have been given this diagnosis of prolapse, that we’re using words that are going to empower them. So we’re going to dive into that today. Before we do that, a couple of housekeeping things, just letting you guys know the courses that we have coming up within our pelvic division. So we are done for December, nothing left in 2023, but we are kicking off 2024 strong. We’ve got two courses on our live docket in January. So we’ve got one January 13th and 14th in North Carolina. We’ve got one January 27th and 28th in Hendersonville, Tennessee. And then February 3rd in Bellingham, Washington. So we’ve got three chances within the first like month-ish of 2024 to catch us on the road. um on the those live courses that’s where you’ll be taking your certification test if you’re interested in having that pelvic certification which includes taking all three we now have three of our pelvic courses our next online level one cohort starts january 9th and the sign up for our level two is now officially open so if you want to hop into that cohort it starts april 30th and that will be the first cohort of our level two so Really excited to kick that off and just kind of get that rolling.

So without further ado, let’s dive into our topic of the day. We talk a lot about ICE or talk a lot at ICE about using words that heal, not harm. We preach it a lot and sometimes it can be really tough to figure out how to explain like difficult diagnoses. Especially things that are maybe controversial when it comes to the postpartum space and we’re gonna see that with things like diastasis or prolapse and a lot of times our patients are coming in and maybe they’ve been given this diagnosis by another provider and it’s not really explained very well and so they go down this scary Google rabbit hole and they come in and with all of these preconceived notions um oftentimes mostly negative preconceived notions from all of this research that they’ve done and they feel like they’re empowering themselves with knowledge but in reality there’s a ton of negativity and fear-based messaging about these topics so today we’re going to talk about prolapse later on in a future episode we’re going to talk about diastasis and i really just wanted to talk about some actual quotes that i use with my patients or kind of an outline or a framework of how we can break these scary diagnoses down, especially if you’re newer to the pelvic population, you haven’t had a lot of reps practicing talking about this, so that we can make sure that all of our patients are leaving their sessions feeling very empowered and excited to be working with you.

So the first step of our three-step framework is going to be educate. I can’t tell you how many times I have people come into the office and they’re sitting there and they’re squeezing their legs together because they are so terrified that if they aren’t constantly contracting their pelvic floor and squeezing their legs together that their bladder is going to fall out of their vagina because they’ve been told that they have a bladder prolapse. with no other explanation this happens so often people will go to a provider the provider maybe will be doing a well women’s exam or a check for whatever reason postpartum follow-up whatever and they tell them you have a bladder prolapse or you have a rectal prolapse and then that’s it and they don’t really tell them anything else and maybe they don’t even really prescribe them physical therapy and they just wander into your clinic um on their own but there’s not a lot of follow-up in most cases. So the very first thing that I’m doing when I’m sitting down with patients is breaking down. Okay, you were told you have a prolapse. Did anybody explain to you what that is? And usually that’s followed with no, I went on Google and I saw a bunch of scary things. I’m like, okay, great. Like we’re going to undo all of that. And even sometimes if they were explained, it maybe was using a very medicalized definition that can be, again, terrifying if you don’t really know what’s going on. So I’ll bust out a whiteboard and I will draw out the pelvic organ. So if you’re watching on Instagram or YouTube, you can kind of see with my hands, but if you’re not listening, just visualize. I’ll draw out, like, here’s our bladder, here’s our uterus, here’s our vaginal canal, and here’s our rectum. All of these organs sit within our pelvic bowl. When we have pelvic organ prolapse, essentially what that means is there is a descent of one of these organs or a drop down that pushes onto the walls of the vagina. at this point usually i’ll take a minute to explain to people that the vagina is not a hollow tube it does not look like this it actually looks more like sides of soft tissue coming together most people don’t realize that because every picture we’ve ever seen of a vagina in a textbook in anatomy books anything Looks like a hollow rigid tube. So a lot of times even letting them know like hey your vagina is not like this It’s like this you’ll see a light bulb moment where they’re like, oh Okay, so maybe that’s not a prolapse that I’m seeing maybe that’s actually just my vagina. So that alone can be really helpful We’ll talk about the fact that the vagina is not a hollow tube and that it is soft tissue and with that it is influenced by other things around it and so then we’ll kind of break down here’s your bladder maybe you have a descent of your pelvic organs and we see this kind of drop down if vaginal canal is here and our bladder is dropping down slightly and pushing onto that vaginal wall what we may see is a slight drop down of that vaginal wall oftentimes we’re doing this test on our backs Oftentimes gravity is pulling everything down a little bit more and so when we take this person who’s upright like this and put her on her back, our bladder drops down and we can kind of see and maybe feel that drop down sensation. When we layer in gravity with standing, we’re upright, we drop down, we can sometimes feel that heaviness sensation from the vaginal wall not necessarily supporting that drop down quite as well. It is really important to highlight and differentiate an organ falling physically out of the vagina which can happen if we have a uterine prolapse where the uterus is dropping down into the vaginal canal versus an anterior wall or a bladder or a posterior wall or rectal prolapse where it is not the physical organ dropping down, it is just the wall of the vaginal canal dropping inwards. That education is huge. You will see people have this like weight lifted off of their shoulders knowing that their organs are not actually falling out of their bodies. Education is important.

Talking about risk factors is also incredibly important. Letting them know what the top risk factors are. Genetics and connective tissue immobility, BMI, chronic constipation, which comes along with that straining, that consistent straining mechanism where we’re bearing down repeatedly over time, pregnancy or parity, and vaginal delivery. A lot of those aren’t things we can necessarily control for, but what’s important to let them know is that exercise is not one of those factors. We want to make sure that our patients know that they didn’t cause their prolapse by doing too much too early, especially if they’re in the postpartum space or if they have this like shame associated with, I have a prolapse and I did it to myself. That’s not the case. More often than not, if a prolapse or a pelvic organ position change is going to happen, it’s going to happen in a vaginal delivery after a pregnancy. And it’s not necessarily something that they’re causing by doing activities later on. Letting them know that they didn’t cause this thing to happen, again, can be huge for somebody’s mental state. If they’re feeling like, oh, I did too much and I caused this, that can kind of cause this negative spiral of fear for movement in the future.

Finally, we want to talk about, on the education standpoint, timelines. It doesn’t make sense to have somebody at six weeks postpartum come in and say, yep, you got a grade three prolapse. Your bladder is dropped down and your anterior wall is coming out of your vagina. We expect there to be changes. we expect that after a vaginal delivery, those tissues aren’t just going to pop back and get to their original position or even a new baseline for a longer timeline. So talking about the fact that early postpartum is not the time to be diagnosed, quote unquote, with a prolapse or to even really be concerned about where things are. Instead, we want to talk about ways to talk to them about um body mechanics and um their strategies for bracing we want to talk about bowel health and making sure that they’re not continuously straining and bearing down and let them know that when we layer these two things in And then we allow time as a factor. Where they’re at at six weeks postpartum is going to look different than where they’re at at six months postpartum, even if that was the only things that they did. So education is huge. Educate them about what prolapse even is, educate them about what the risk factors are, and more importantly, are not, and talk to them about the timelines for healing. The next step in our little three-piece framework is going to be normalize. there is so much conversation happening in the pelvic floor PT world that a prolapse or a like a grade one prolapse which is just a slight descent of pelvic organs might be normal in the postpartum population. Just like we don’t expect our breast tissue to look exactly the same after breastfeeding, we can’t expect our pelvic organs to be in the exact same position after they’ve undergone nine to 10 months of low load, long duration stretch that creep has set into those tissues. And then we also potentially layer in a vaginal delivery. A grade one might not be a big deal at all. That might just be a typical postpartum change. On top of that a grade two might even be somewhat of a normal finding I have not yet seen a grade zero quote-unquote after a vaginal delivery I think it’s a unicorn that actually doesn’t really exist and we’ve had a lot of conversation about this within our pelvic crew of has anybody ever seen that The consensus so far is no. And so if you guys have, drop it in the comments. I’m curious. But we want to talk about normalizing this change. We expect physical changes in our body after pregnancy. We expect physical changes in our body after vaginal delivery. It’s OK to look like you’ve had a baby. It’s OK for your body to show those signs. this can be a big thing for people to wrap their heads around because there’s a lot of talk within our culture about bouncing back to what your body was before and Switching up that conversation to we’re not worried about what it was before We’re getting to a new baseline and that might show changes that have happened and that’s okay Normalizing the fact that our bodies are going to change during pregnancy after a delivery is important The other part that we want to normalize is that in the early postpartum timeline, those muscles are recovering, especially following a vaginal delivery where they’ve had a stretch injury, they’ve been stretched out, elongated, they’re returning back to their resting state. We expect those muscles to have a lower threshold for activity than they did before. as pts this makes sense as patients it not it doesn’t necessarily um come to the forefront of the mind so reminding them these are muscles think about any other muscle in your body maybe you’ve pulled a hamstring maybe you’ve pulled your quad maybe you’ve overstretched your shoulder those few days maybe weeks afterwards it took less activity for you to feel something in that area in this case specifically what I’m really kind of preaching to people is that if you get up and you’re feeling good one day and you go for a walk with your kiddo around the block and that’s the farthest you’ve walked and then later in the day you start feeling some heaviness you didn’t cause a prolapse likely those muscles are just tired. They worked harder than they have all this timeline leading up to this. And so they’re fatigued. And just like every other muscle that fatigues when it fatigues, it doesn’t work quite as well. And so we feel that heaviness sensation. normalizing that heaviness sensation. I love to do this when people are pregnant, set that expectation. Hey, look, as you start moving more, you might notice that you feel a little bit of heaviness. It’s not a big deal. That’s kind of our buoy lets us know where we’re at. You’re not causing any damage. It’s going to be okay. That heaviness will resolve and over time you’re going to build up your capacity where that heaviness sensation comes on later and later and later normalizing what a prolapse is, normalizing what the grades are, normalizing the changes of our body that happened during pregnancy and postpartum and normalizing recovery of those muscles and potentially having an onset of symptoms.

Finally, we want to empower our patients. This is where our bread and butter lies. This is what we are here for. We are all about empowering women in this pelvic space. we have evidence that we can reverse a prolapse up to one grade. So that means if somebody comes into the grade two, then potentially we can get them to a grade one. Realistically though, at the end of the day, I don’t even really care about that. What I’m really harping on more, really focusing on more with my patients is that We know that the degree of prolapse or the descent of those pelvic organs and how much they are descended has no correlation with your symptoms. You can have a grade three and be highly sensitized and feel everything. You can have a grade three and have no idea that you even have a change on the flip side. You can have a grade one and feel like things are falling out. so talking about the ways that we can directly impact that by calming down the system giving them tools like laying on their back with their feet elevated adding in some bridges to get some muscle activation kind of taking the pressure off of the pelvic floor so that they can decrease that symptom of heaviness discussing things like bowel health, like we chatted about earlier, avoiding straining, using a squatty potty, making sure that they’re drinking enough so that they’re not falling into this chronic constipation camp, and then talking about body mechanics. That’s one of the biggest things that we really want to focus on. We have to know what they’re doing when they brace. We have to know what they’re doing when they bear down. We have to know what they’re doing when they do a pelvic floor contraction. we need to collect that data. We need to calibrate to make sure that they’re not dropping down with their pelvic floor and increasing that heaviness sensation with their daily tasks. That is a huge piece of the puzzle. So our three-step framework, when we’re talking about somebody coming into the clinic day one terrified that they have a prolapse. The first thing we’re going to do is educate them. We’re going to talk to them about what a prolapse is. We’re going to talk to them about the risk factors and what potentially caused it and what definitely did not cause it. And we’re going to talk to them about timelines. We’re going to normalize. We want to make sure that they leave feeling like their body, their vagina, their pelvic floor are normal. And even if you have somebody come in with a grade four, We’re still normalizing. We’re still talking about all of the ways that we can help. We can work on prehab. We can take those same tools and improve things so that going into a potential surgery, they have better outcomes. And anything less than a grade four, you better believe I’m normalizing. You might have a change in your pelvic organ position, but you know what? That’s totally normal after having had a baby and a vaginal delivery. The third step is we’re going to empower. We’re going to make sure that our patients feel confident in movement, feel confident in that bracing strategy, feel confident in what they’re doing in their daily lives so that we can build a stronger and more resilient human being who can tolerate more things before symptoms come on. I hope you guys enjoyed this. I hope it helped clear some things up, especially if you’re newer in the pelvic space and you really understand what prolapse is, but you’re just not quite sure how to talk to patients about it. It can be intimidating, but I trust that you guys have got this. If you’re not confident in treating heaviness and pelvic organ descent, um, and that sensation of heaviness hop into our live course, we spend a ton of time going over bracing. We talk a lot about what prolapse is, We have a whole matrix and kind of framework about treatment approaches for each of these little camps, whether they have symptoms objectively or subjectively and what the combinations are. I hope you guys have a great Monday. Get out there and crush it. Thanks.

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