CONSIDERING SYMPTOMS OF POP
POP symptoms can be a real drag.
In an informal survey we conducted of 241 women, 85.1% said it was the symptoms, not necessarily the physical presentation of their POP, that bothered them the most.
What do symptoms mean?
Sensation is more than a physical phenomenon. While we typically think of sensation as being purely related to what is occurring at the level of our tissues, we now understand, through the developments in neuroscience (largely studying pain), that the experience of sensation is the result of more than just what’s occurring directly in the specific region of our body we perceive to be affected.
Here’s a very basic analogy: symptoms act as a smoke detector alerting us to a potentially dangerous situation. But sometimes alarms go off when there is no fire present (maybe there's just a little smoke from cooking, or the batteries are low), or they may continue to beep after any hypothetical fire is extinguished.
Symptom severity might be more of a reflection of the sensitivity of our system versus the actual “threat” present. The experience of them is real, but the degree to which they represent what is occurring in the tissue is not always entirely accurate.
How do we make sense of this?
Good question! Let's continue.
What are the symptoms of POP?
We define POP symptoms as a sensation of heaviness, dragging, and pressure within the pelvic cavity. While symptoms beyond the sensation of a bulge in the vagina can coexist in a POP population, they are not specific to POP.
“Patients with symptoms other than the sensation or visualization of a bulge in the vagina need to be informed that their symptoms might not be a direct result of the POP.“
How correlated are POP symptoms to actual grade of descent, according to the research?
Symptoms of POP and the degree to which the vaginal wall has descended do not always correlate.
The consensus, according to research, tends to be that the only symptom consistently related to worsening anatomical POP is a reported sensation of vaginal bulging, which correlates with anatomical changes only when the leading edge of the vaginal wall descended to 0.5cm above the hymen (Grade 2 on the Baden-Walker scale or 0cm on POP-Q). However, some women with more advanced POP deny experiencing symptoms and some with more minor grades (1) will experience more significant symptom bother.
This study noted that when based on symptoms, POP prevalence was identified as 3-6% and, when based on observation, POP prevalence was roughly 50%.
While there does seem to be a relationship to symptoms and anatomical descent, particularly when the descent surpasses the hymen, symptoms are not entirely descriptive of the current degree of descent.
This is also demonstrated in the reporting of symptom improvement following pelvic floor muscle training but not as robust an improvement of the grade of POP. The POPPY trial evaluated the impact of individualized pelvic floor muscle strengthening on POP presentation and symptoms.
74% (vs 31% in the control) experienced a reduced frequency of symptoms and
67% (vs 42%) experienced reduced bother of symptoms.
19% of women in the intervention group had an improved stage versus 8% in the control group
Additionally, we can consider that some describe worsening or alleviation of symptoms throughout the day with no apparent shifts in pelvic floor support.
We ran an informal survey of 241 women diagnosed with pelvic organ prolapse on the topic of symptom severity and POP presentation.
25.7% identified a symptom profile that they did not feel was consistent with their degree of descent;
11.2% described a diagnosis of a more significant POP (grade 3 or 4) with few or no symptoms;
14.5% describe significant and sometimes debilitating symptoms with a grade 1 (mild) POP.
In the same survey, we asked about symptoms and POP presentation.
40.7% describe feeling that their symptoms had improved without a change in POP stage
Despite the informality of this survey, the responses of those polled are consistent with much of the formal research conducted: symptoms can, but do not always, correlate with a change in anatomy.
HOW DO WE MAKE SENSE OF THIS?
Good question!
There is currently not a succinct consensus as to why people might experience an increase in symptoms of heaviness or pressure. There are some hypotheses, however!
Some potential hypotheses for when pelvic floor symptoms do not correlate to anatomical stage changes:
Sensations in the pelvic floor (that one may interpret as being related to POP) may be the result of muscular fatigue
The exact mechanisms of muscle fatigue and associated sensations are not fully understood, but it is not illogical to suggest that one would be able to sense fatigue in the levator ani musculature (like they might in their biceps, for example) that would draw one’s focus.
When allowed time to rest, many acute pelvic floor symptoms resolve, perhaps related to the ability to recover prior to another bout of increased activity.
If the fatigue hypothesis is correct, then training beyond symptoms (assumed to be related to muscle fatigue/failure) may increase the risk of one increasing the demand on the passive support structures of the pelvic floor, potentially increasing the risk of advancing POP.
If the fatigue hypothesis is correct, training up to the point of sensing muscle fatigue/failure in the PFM might be an important component of increasing hypertrophy and strength.
How relevant training to muscle failure or close to muscle failure (submaximal efforts) is for eliciting hypertrophy or strength adaptations is debated in the literature, but the basic concept of adaptation suggests that structures must be stressed beyond their typical demands to provoke that need to adapt to a new stimulus.
If the fatigue hypothesis is correct, training towards symptoms of the pelvic floor (that may reflect PFM fatigue) may not be an indication that an exercise should be “off-limits”, but rather the rationale for consistent exposure in appropriate doses.
Symptoms of POP induced by exercise reflect the perception of an increase in tensile stress.
This hypothesis suggests that it is the awareness of increased mechanical tension being applied that contributes to symptoms related to the pelvic floor during exercise.
If this hypothesis is correct, symptoms during exercise may represent a condition where the fibers of the pelvic floor musculature are reaching their current capacity for load.
It is key to consider that this tensile stress is needed to elicit adaptations that result in increased tensile strength!
It is then relevant to work within a range that allows for adequate recovery to promote increases in function over time versus injury.
Symptoms are related to sensitization.
In this scenario, the perception of symptoms modifies the way that the nervous system functions, so that it becomes more sensitive, leading someone to experience increased symptoms with less provocation.
In this scenario, it might be the case that the person experiencing symptoms they attribute to POP is noticing sensations of routine pelvic floor function and movement that they are interpreting as being hazardous.
The degree of nociception received regarding pressure and movement affecting the pelvic floor might be the same for two individuals, but the one experiencing central sensitization may interpret that information very differently.
This seems particularly relevant in the context of what most have been told to look out for: “avoid increased pressure on the pelvic floor”, “make sure you engage your pelvic floor every time you pick up something”, etc.
Does this information promote hypervigilance in pelvic floor sensations?
How might that increased awareness influence the perception of sensations?
In this study, approximately 30% of the participants with POP were shown to have significant central sensitization
Symptoms that present regardless of the activity, or that are not modified with any intervention (change in strategy/position, rest, use of a pessary, etc.) might suggest an increased likelihood of sensitization.
Sensitization does not suggest that symptoms are “all in the head” or that they inherently have no basis in structural changes or movement. Instead, it is suggested that sensitization may make otherwise insignificant changes seem threatening.
Amplified symptoms might be more likely to present:
When threat is perceived.
Research looking at pelvic floor muscle activity in response to violent imagery found that there is a relationship between feelings of threat and involuntary pelvic floor muscle activity.Does this amplified activity also suggest increased symptoms could result?
When someone is paying specific attention to their pelvic floor, or exercise.
Many describe feeling fewer symptoms when distracted, for example.
When someone has a belief that the exercise is dangerous.
When someone has a belief that their body is not capable of completing the task.
When someone has experienced symptoms during the same, or a similar, activity before.
When someone is fed information on what could go wrong, what they don’t want to feel, etc.
e.g. “Make sure you don’t bear down on your pelvic floor”
e.g. “Make sure you don’t feel pressure on your pelvic floor”
In summary,
POP symptoms may not be related to absolute pelvic floor descent or relative changes during an activity.
Those with observed “mild” cases of POP may experience more significant symptoms (or greater symptom bother) than those with higher grades of POP. Additionally, those who experience greater degree of descent during activity may or may not experience more significant symptoms than those who experience lessened (or an absence of) descent.
POP symptoms may or may not communicate an actual threat to the support system of the pelvic floor.
It is possible that symptoms of POP are reflective of an actual threat to the support structures of the pelvic floor, but it is also possible for this not to be the case. Attempts at determining the actual risk present requires the evaluation of a variety of factors involving both the individual and the activity. Currently, there is no standardized method for assessing symptoms in relation to anatomical POP progression risk.
Now what?!
It can be both comforting and confusing to understand that POP symptoms may be more complex than initially considered. If you would like some support in processing this information and moving forward, consider signing up for one of our courses!