Under the Hood

Episode 38: "Is Something Going to Fall Out?!" Understanding Pelvic Organ Prolapse

• Rebecca & Alex • Season 1 • Episode 38

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0:00 | 17:49

Just hearing the word "prolapse" is enough to make many people panic because it sounds like their organs are going to just fall out. Thankfully, that's not what's actually happening.

In this episode, pelvic floor physical therapist Dr. Alex DiGrado and couples & sex therapist Dr. Rebecca Howard Eudy discuss what pelvic organ prolapse is and isn't; the different types, stages, and treatment options for prolapse; and what it all means for your sex life.

Whether you're newly postpartum, noticed something concerning in the shower, or were recently diagnosed with prolapse with zero explanation, this conversation will give you honest answers and practical strategies so you can keep living the vibrant, active life you deserve.


What you'll learn:

  • The 3D "suspension system" holding all your pelvic organs in place (you definitely didn't get this information in health class).
  • Why prolapse affects athletes, people who've never been pregnant, and postpartum parents alike.
  • Non-surgical treatment options like compression wear and pessaries (including the type that looks like fuzzy car dice).
  • Realistic surgery success rates—and why surgery isn't always the first step.


Tune in if you've ever thought:

  • "Something feels like it's bulging or heavy down there—is that normal?"
  • "I felt okay after having my baby, so why did this come out of nowhere weeks later?"
  • "Is dealing with a rectocele as messy as it sounds?"
  • "I don't want surgery. Are there other options?"
  • "Will sex make things worse? Will my partner notice?"


Helpful resources:

Some links below are affiliate links, which means we may earn a small commission at no extra cost to you if you choose to purchase. We only recommend products we love and use ourselves.


Connect with us:

Dr. Rebecca Howard Eudy
Website: https://rebeccaeudy.com
Instagram: https://instagram.com/rebeccahowardeudy
Newsletter: https://substack.com/@parentsinlove 


Dr. Alexandra DiGrado
Website: https://bostonpelvicpt.com
Instagram: https://instagram.com/bostonpelvicpt
Newsletter: https://bostonpelvicpt.myflodesk.com/underthehood 


Under the Hood Podcast
Instagram: https://instagram.com/underthehooddocs
Website: https://underthehoodpod.com
YouTube: https://youtube.com/@UndertheHoodDocs


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SPEAKER_02

Welcome to Under the Hood. I'm Dr. Alex DeGrotto, your pelvic floor physical therapist. And I'm Dr. Rebecca Howard Uti, your sex and relationship therapist. Hi, Alex. Hi. It's so nice to be back with you. We've taken a little bit of a break for the summer, so it's been a while since we recorded. I love being here. Me too. So today we're gonna talk about prolapse. Yes. Which I sort of know what that is. It's like when something falls out, right? But not all the way out.

SPEAKER_00

It doesn't fall onto the floor.

SPEAKER_02

Okay, that would be bad. Yeah, sometimes ammo bug isn't actually gonna fall all the way out. I'm like, oh no, there's ligaments that are attached. So this is like uterine prolapse, is what I'm thinking of. Okay. Can happen can happen with the bladder and the rectum. And the rectum. Oh wow, okay. This does not sound like something we want.

SPEAKER_00

Yes, but it's really common. And I think it can be extremely scary when someone gets this diagnosis or thinks they might have it. So I'm gonna start with what is prolapse? What might your symptoms be? Amazing. And then we can go from there. So your organs are held up in your body by attachments that attach to your bones and your and your and your tissue. And those are ligaments and fascia that support you, your connective tissue. So your bladder, your uterus, and your colon are all supported in that way. Certain things can make that support system weaker, like pushing for a long time when you're having a baby, straining chronically on the toilet, somebody that has a chronic cough, somebody that throws up a lot, all of those really heavy repetitive activities that that kind of cause a lot of pressure and stress. Yeah. Okay. Yeah.

SPEAKER_02

That makes sense.

SPEAKER_00

And so in that case, there's different degrees of a drop. So essentially, your bladder, your uterus, or your colon can dip a little bit too low into your vaginal opening or rectally. So it can come out the rectum. It almost looks like a rose blooming out of the rectum. And sometimes it only happens while you're having a bowel movement. Sometimes it happens when you're lifting weights, you know, but it basically feels like something's coming out there as well. And so it's very scary sounding. People will say it feels like I have a tampon sticking out, even though I don't have a tampon in, or they might say, I just feel a lot of pressure and heaviness that gets worse as the day goes on. And usually, if they get into a gravity-minimized position, like a supported bridge or the lying down with their legs up the wall, after a few minutes, their symptoms can get better. Okay. So gravity can kind of help everything go back in where it belongs, and then they're relieved. A lot of times, the way that this comes about is, for example, someone's newly postpartum. In the beginning, there's a lot of swelling, right? And so the symptoms don't show up immediately. They're like, oh yeah, I'm in a pretty good shape. I'm gonna take the kids to the zoo, then I'm gonna walk around downtown, then I'm gonna go to Target. And then suddenly they're calling me in a panic because they're feeling all of this pressure and heaviness. And it's like as those weeks go by and the swelling comes down, the real sort of sagging for lack of a more pleasant term happens. And people panic.

SPEAKER_02

Yes.

SPEAKER_00

You know, understandably. And so the really important thing to know is that it's not gonna fall all the way onto the floor, you know? Right. And so it starts to get a little too low, and and you feel that sort of pressure and heaviness, and you can mitigate it. And there's lots of tools and strategies to do that. Okay. So yeah, so I just want to start by saying that because I have had people in tears, you know, just saying.

SPEAKER_02

I mean, this sounds like something that is very scary. It also sounds like something that if you have this, it it seems bad. Oh, yeah. Organs falling out. That's right. But it sounds as common as it is. The other thing I that's really interesting is that you're talking about younger folks, this happening to to folk, you know, after childbirth, or you know, for for younger folks. I I would have thought that this was something that might happen with age, with the lack of estrogen, yeah. Yeah, which is also a common time. Yeah. But it's as always when we talk about this, it this is not just one person problem. This can happen anytime during the lifetime. Correct.

SPEAKER_00

Yeah. And so what I will say is I do think that that we want to understand that when this is happening, you should seek treatment, certainly.

SPEAKER_03

Yeah.

SPEAKER_00

And sometimes what happens is people have never looked inside their, they've never spread their labia and taken a mirror and looked. And then postpartum is the first time they've done that, and it's terrifying.

SPEAKER_02

A terrifying.

SPEAKER_00

So then they actually have no idea what it looked like before.

SPEAKER_02

Right. They're like, this looks Yeah.

SPEAKER_00

But we have nulliparis people who've never had kids, who are athletes, who, you know, have this, people who are chronically constipated, whatever. So sometimes you've already had it a little bit. Yeah. You know, there could be it could be a stage one or a stage, and and and the pop cue, which is the official sort of assessment, it's pretty rigorous. Lots of people who are asymptomatic still have some degree of the anterior or posterior vaginal wall kind of dipping a little bit. Yeah, okay. And so I do feel that we can over-diagnose it.

SPEAKER_02

Right. Over-diagnosis it, it also sounds like it this is not, you definitely want medical treatment, but this is not, you're not bleeding out. No, your organ is not gonna fall on the floor. This is something that is treatable and people should not panic instead of it. Don't panic. Yeah, absolutely. All right, so they don't panic, they call you. Yeah. They come to you. That's right. I have heard of like, I mean, again, I don't really know what this is, but like mesh, is that a thing?

SPEAKER_00

Okay. So there's the different treatment options. One, which is the least invasive, is called a pessary. And it almost looks like a period ring, like a disc that you would put in. And so there's different kinds.

SPEAKER_01

Like a cup?

SPEAKER_00

Yeah. Yeah, okay. Except it doesn't have the cup part, it just has the ring part. And so one thing that we do at our clinic is we can fit people for a pessary, and it's it's surgical-grade silicone, and it's it you squish it. So you can kind of compress it, you slide it up in there, and it just sort of props everything up.

SPEAKER_02

So it's like a Nuva ring.

SPEAKER_00

Yeah. And you just put it in and take it out at night and put it back in the next day. And that is a really great strategy for people who do not want to have surgery or who are planning on having more kids and all that. And that is something that I think is really important for people to know that they don't have to immediately jump to surgery. And sometimes they'll even recommend a hysterectomy right off the bat when they haven't done pelvic floor physical therapy. Maybe they didn't fix the underlying reason why it happened in the first place, and they haven't offered a pessary. So we can jump right to the mesh, which is surgery.

SPEAKER_02

Yeah, of course. Or just take it out.

SPEAKER_00

Yeah. And so what I would say there is if we don't fix the mechanics for why it was going on, then they're gonna come after anyway with the same problem. Same issue, you know. Okay. And so, because the actual vaginal vault can then prolapse. You know, once they take the uterus, it's it that can still prolapse.

SPEAKER_02

So come on now. Yeah, okay.

SPEAKER_00

But you know, I'm always a proponent of rehab anyway.

SPEAKER_02

Sure. Even if you're gonna have surgery.

SPEAKER_00

Yeah.

SPEAKER_02

That we've talked about this a lot with prostate. Yes. If you remove something, you want to do some pre and post special.

SPEAKER_00

Yeah, you think about a knee replacement. They do prehab to get the quad muscle really strong so that the knee, you know, recovery goes well. Same, same idea here. Okay. So the passery is a very non-invasive, kind of easy intervention. If somebody has had a avulsion where the muscle or the ligament actually tears off the wall, there's a more intense passery that's a cube that actually suctions. So it looks like dice that you play with, you know? Yeah, yeah. Or the people hang in their little uh mirror in the car. Yeah, yeah, except it's not fuzzy, thankfully. And so it has these little suction on the cube and it has a little loop that you can kind of undo the suction and pull it out. And so you put that in and it props everything up and then suctions there. Interesting. Okay. And so that would be a more involved pessary, but it that's another option. And then we try and strengthen the pelvic floor muscles and get the breathing mechanics as healthy and positive as possible. And then we try and give tools in the toolbox to figure out how to mitigate the prolapse symptoms. So getting into that gravity-minimized position, you know, pacing yourself throughout the day. So doing, say, let's say the example I gave when somebody took their kids to the zoo and then did 10 other things. You know, if you know you're gonna be at the zoo, maybe you wear your pessary for the zoo and then you have some rest in between your next activities. And so we do that in pelvic floor physical therapy to help people who aren't looking to go straight into surgery. And then there's surgery. And so the surgical options are diverse as well. So sometimes they will use mesh and sometimes not. And basically what they'll do is they'll go in and tack up the organs. Okay, yeah. And they sort of adhere them with, you know, stitches to the to the walls that they belonged on in the first place. So the mesh kind of is the thing that holds. If they do the mesh that yes.

SPEAKER_02

Wasn't there like a loss of the bigger?

SPEAKER_00

Yes, yeah, there are there are. Okay. Many. Yes. And so sometimes what happens is the mesh will erode through the tissue and cause pain and problems, and then they have to go in and take it out, and it can be really complicated. And so for a rectocil, which is the name for when the back wall comes in to the vagina, that's the colon kind of pocketing. What we'll do is So it'll push in, it's not coming through. No, it's not coming through. That would be a fistula. Yeah. Okay. So it's just it pushes. Yeah. And so basically you have this little pocket. They call it a poop pocket. Yeah. And so people can either press on their pernium, don't say that. Or they'll press on the posterior wall of their vagina.

SPEAKER_01

Oh my gosh, this is where this is. So sorry, I know, I know, I know. I just popped out. Yes, it's well, because it's how people feel. It's the way that you called it the pocket.

SPEAKER_00

It was how people feel when they get it, too. They're like, this is disgusting. And but it's so common. And the problem is, is that when people aren't they they can't wrap their head around managing it, it makes it so much worse. Yes. So if you think about stool pocketing in the recto seal, that sitting there is a problem. Sure. So what we want to do is we want to either prop up the back wall of the vagina so it can get out, or prop up your perennium so it can get out. So you're never actually touching the poop. No. You know, you're just supporting the wall.

SPEAKER_02

I was responding to you. Yeah, totally a poop pocket. I mean, is there a more technical term?

SPEAKER_00

It's a recto seal.

SPEAKER_02

Recto seal. Okay. That's that gross.

SPEAKER_00

Patients don't come to me saying, No, I have a recto seal. They're like, it feels like my poop is pocketing. Yes. Which is exactly what's happening. Yeah. And so there's this product, there's a couple now, actually, which is incredible. There's this product called the Femis, which almost looks like a shoehorn. And for people who just really don't feel comfortable touching their own, you know, vulva and vagina. Yeah. They just put it in and it props the back wall up. And then everything can come out easily and it's fine.

SPEAKER_02

So this is just while they're having a bowl moment.

SPEAKER_00

Yeah. Okay. And so what I was going to say though.

SPEAKER_02

If you're having it, the the the I'm imagining the contortions that touch your prop up.

SPEAKER_00

Yeah. Yeah. And so there's actually multiple different tools that you can use now, which one it's like a little balloon that inflates that you hold it there, and then the other one literally looks like a shoehorn. So, and then sometimes I just have people have like a warm, wet washcloth that they push up on their pernium and empties. And then that helps. Because otherwise they leave the bathroom, they still feel like they haven't emptied. Maybe they get like stains on their underwear, like a little more will come out later. It's just so awful. And so it's like, okay, why don't we mitigate this while we're in the toilet, you know? And so what I was gonna say originally was the rectocil has a pretty high success rate for the surgery. It's like an 80% success rate.

SPEAKER_03

Oh yeah. Okay.

SPEAKER_00

Versus the ladder, which is called a cystical, that one is lower. It's I I will I should have looked this up before, but it's more like 50%. Okay. And the interesting thing though is that some of the prolapse comes back, but they don't, they're not as symptomatic because they have a little bit more support. Yeah. So they just don't feel quite as symptomatic. And so we used to think of this as a ship in the harbor and the pelvic floor was at the bottom, kind of holding it up, and then the ligaments, but now we think about it as a ball suspended in a room. And so the pelvic floor is part of that suspension, but the ligaments and the fascia are the other part of the suspension. I see. And we can't really change that.

SPEAKER_03

Yeah.

SPEAKER_00

You know, we can change the mechanics, we can change what if you're a chronic breath holder, or we can change if you're a chronic strainer, or we can change how you lift your kids and your stuff so that you're not giving that descending pressure quite as much. But we're not really going to change the fascia other than to give it a rest.

SPEAKER_02

Yes. So that's why being realistic about what you can do in a day helps. Helps.

SPEAKER_00

And getting into that gravity-minimized position, giving it a break, strengthening the support underneath.

SPEAKER_03

Yeah.

SPEAKER_00

But I think we we've sort of in the past have overstated the role of pelvic floor physical therapy when in reality there's some aspects of this that we can't mitigate. And so I will say that we do tend to have quite a bit of success because we also have the pessary.

SPEAKER_02

Right.

SPEAKER_00

You know, and so it's like we're actually giving physical support. And for people that don't want to go through the process of getting fitted for a pestery, there's the Euresta, there's the Impreza, there's the pelvic bra, the SRC Health has compression shorts. So there's internal and external support that just gives upward support. Yes. And so for people that are just like Alex, the pestry is just too medical.

SPEAKER_03

Yeah.

SPEAKER_00

Then you can get over-the-counter products. And that those are the ones I just mentioned to help give you support for this. Yeah, which are tremendous because then you know you're gonna go for a run. So you wear your SRC health shorts and you just get that extra support.

SPEAKER_02

Yeah. Yeah. And it's and I would imagine much more comfortable as well. Like the the heaviness, the pressure, these are not even if you're not worried about your organ falling out because they talk to you and you realize that this is something that's very common and not cause for panic, still doesn't sound comfortable.

SPEAKER_00

That's right. Absolutely. And I think we want to, this is our recurring theme on our podcast is the tools in the toolbox. So we're just trying to get as many tools in the toolbox as we can for folks. And those things that I mentioned are great tools. And the breathing mechanics and the pelvic floor strength and coordination and endurance and the energy conservation and pacing. And I think once we get all of those tools, people can live a very vibrant life with this. It's just kind of getting over the initial panic and having accurate information about it.

SPEAKER_02

Yeah. Yeah. Which I could imagine, since you are, you know, the are, you know, we talked about this a lot where the medical is so silent. So silent. So when people come to you, I can imagine that you are a very good partner in the process. Even if you're saying in the past we've overstated what PT can do, it sounds to me like you still are doing a ton.

SPEAKER_00

Definitely. We're I think we're we're a big member of the team. And we can help people go through the surgical options and figure out what's realistic in their life right now and and strategies to mitigate in the meantime, if they are ultimately. There's different stages of prolapse. So stage one and stage two, I think are fairly mild, and we I wouldn't really be having a surgical conversation. Then stage three and four, we do think about that, you know, because sometimes the organs can actually be outside of the labia or like I mentioned, coming out with the anus, and it's and then you have to really weigh the pros and cons there, you know, and say this tissue was never meant to be extruded extruding from the body. It can cause tissue breakdown and it just isn't healthy for that tissue. So then we look at either the the pessary, a more intense pessary, or a surgical option.

SPEAKER_02

Yeah. Okay, so tell me about sexual function.

SPEAKER_00

Yes, this is one of those things that people get really nervous about and they also feel like their partner is gonna notice it, and so there's some shame and some embarrassment around it. There's really no sex is not gonna make it worse. It's not gonna hurt it. Sometimes I will have people kind of digitally sort of push everything back where it belongs before intimacy so that it's not hurting initially. But using lubrication, having plenty of foreplay, maybe having sex in a position where you're not super upright. You know, you could be on your back, propped up a little bit to sort of keep things where they belong. But generally It sounds like two words once. Yeah, yeah, totally. But generally speaking, sex is super, super healthy because it's utilizing your pelvic floor muscles. Yeah. And those muscles are getting their exercise with that. And I think it's a great option. It's not something that we need to avoid just because there's a prolapse.

SPEAKER_02

Okay. But I imagine for folks hearing that is so important.

SPEAKER_00

Yeah, totally. Oh my gosh. Because they don't want to do anything that's gonna make it worse.

SPEAKER_02

And even just the reassurance that it's not gonna be a different experience for their partner and they're not gonna notice it's not that's right. Nothing's gross about it. It's not anything that they should avoid. And it's not anything they should avoid for health reasons.

SPEAKER_00

Yeah, totally. And I actually think it can be very healthy because it's a way to get those muscles working, get the blood flowing, and all that stuff is really good for the pelvic pelvic health. Yeah. Okay. Yeah. I know prolapse is a scary topic, but hopefully this is like the quick little tutorial to say you can manage it, don't panic. Yeah, you know, get some resources, but once you do, I think you you'll feel like you know how to manage it. Yeah. Yeah. Okay. Thanks, Alex. You're welcome. Thank you for listening to Under the Hood. If you liked this episode, please take a minute and leave us a review. And we'd love to hear from you. If you have any ideas for future episodes, please let us know.