Pelvic organ prolapse (POP) is a condition where the pelvic organs, such as the bladder, uterus, and bowel, drop down into the vagina due to weakened connective tissues in the pelvis. This can cause significant discomfort and disruption to a woman’s daily life. In this case study, we reflect on the journey of Marilyn, a 70-year-old active woman with a history of bronchiectasis, who suffered from POP.
Marilyn had been experiencing intermittent period-type pain for two years, suspecting something was happening to her uterus. However, no vaginal bulge was noted at the time. Marilyn’s general practitioner (GP) advised her to perform pelvic floor muscle training (PFMT), which she had been doing for 30 years due to her bronchiectasis diagnosis (chronic cough), as Pelvic Organ Prolapse (POP) was a risk factor for the condition. Unfortunately, her GP did not refer her to a pelvic health physiotherapist for further evaluation.
Marilyn continued to experience bothersome period-type pain, prompting her to seek medical advice from her regular GP. Blood tests and ultrasound scans showed no abnormalities, but Marilyn mentioned that the GP who did her PAP smear had previously diagnosed POP. Her regular GP then referred her to a gynaecologist for further evaluation.
The gynaecologist performed an examination, which revealed no significant concerns about the stage of Marilyn’s POP. However, no assessment was performed to check the quality of her pelvic floor muscle contraction or if the pelvic floor muscles were intact. Marilyn was then given two ring pessaries to trial, but both were pushed down, and felt uncomfortable after 24 hours. While Marilyn was able to pass stools successfully with the pessary in situ, the gynaecologist requested that she stop using it.
Marilyn persisted with her daily PFMT routine and was eventually referred to a urologist specializing in POP surgery after requesting a referral from her GP. The urologist diagnosed Marilyn with moderate POP but did not mention the stages of POP to her. The urologist then recommended that Marilyn be reviewed by a pelvic health physiotherapist specializing in teaching PFMT and return for a follow-up assessment in six months if she still experienced bothersome symptoms.
The referral to a pelvic health physiotherapist took two years from the initial diagnosis of POP. Upon examination by the pelvic health physiotherapist, Marilyn had moderate to strong pelvic floor muscle strength, however, Marilyn performed a significantly bearing down pattern at the end of her pelvic floor muscle contraction and increased intra-abdominal pressure (IAP) on her pelvic floor.
The treatment focused on restoring the correct action of Marilyn’s pelvic floor muscles without the bearing down component to enhance pelvic floor muscle strength. The clinical reasoning regards why the pessary was not successful, could have been due to Marilyn trying too hard and adding a significant bearing down pattern, pushing the pessaries downward, There may have also been issues with Marilyn practicing the incorrect motor control pattern of her pelvic floor muscles for 30 years, contributing to the development of POP bother.
The emotional response to Marilyn’s diagnosis of POP was significant. Marilyn felt acute disappointment in herself that she had allowed this to happen.
It’s important for healthcare professionals to recognize the emotional impact of POP on their patients. Marilyn’s disappointment in herself is not uncommon, and it’s essential for healthcare practitioners to provide emotional support and education about the condition. The biopsychosocial approach (client-centred focus) to therapy is extremely important.
In conclusion, Marilyn’s case highlights the importance of early diagnosis and referral to a pelvic health physiotherapist for POP management, once no other cause of symptoms has been identified. The delay in referral resulted in unnecessary discomfort and frustration for Marilyn. It’s crucial for healthcare providers to be aware of the symptoms of POP and provide education and appropriate referrals to pelvic health physiotherapists. Additionally, it’s important to recognize the emotional impact of POP and provide patients with emotional support. POP is a common condition affecting many women worldwide. Understanding its symptoms, causes, and management is crucial in addressing its impact on women’s lives. By providing education, referrals, and emotional support, healthcare providers can empower women to take control of their health and manage their symptoms effectively.
