rectocele and postpartum

[question13]

I am 7 weeks postpartum with mild bulging that seems to get worse in the afternoon and evenings after I've chased my 3 year old and infant all day.  It didn't present itself at my six week checkup but I brought pictures- my doctor said it looked like a rectocele.
1.  Is it safe to do high impact aerobic exercise such as step, kickboxing and/or weight lifting class.  I just turned 32 this week and am ready to hit the gym again.  
2. My gyn said that breastfeeding may makes the wall/tissues weak- does that mean it could improve when I stop breastfeeding?  
3.  My gyn said to not have the surgery until I was done having children.  I am not ready to make that decision yet b/c it will probably be 1-2 years before we would even try for another child. Can you have the surgery more than once (i.e. if I want to have it now and again after having a 3rd baby)? I don't want to live like this for one to two years if we decide to have another child...

[Lennox Hoyte, M.D.]

Bulging of the front and back walls (aks cystocele/rectocele) of the vagina can happen after pregnancy and/or childbirth.  It is usually not a problem unless the bulge can be seen pushing past the labia during  straining or at rest. To test this, put a mirror on the floor, and squat over it and bear down. If the labia separate a little that is ok, but if they are pushed apart and a pinkish bulges pushes through, that is either your vaginal walls or your cervix.  If you have bulging well past the labia, then that is usually not a life and death matter. sometimes it gets better, sometimes it gets worse, but mostly it stays the same. Prolapse is fixable with pessaries, or with surgery. In young patients like yourself, it may be curable in the short term if you try a course of Kegels (don't forget to relax the pelvic floor after you do the squeeze part !). To answer your questions; yes, you can exercise all you want. Heavy lifting can worsen the prolapse, but you should not be changing your lifestyle because of this. Breastfeeding usually makes you not ovulate, and does lower your blood estrogen levels, which can result possibly in weaker vaginal tissues. This problem goes away when you start ovulating again, although I am not sure if this would make your prolapse get better. Before you go thinking about surgery, first consult a urogynecologist to see if you have significant prolapse, requiring surgery. If it is significant (i.e., prolapse well past the labia), you certainly can delay surgery as long as you need to in order to complete your childbearing; you could also opt for the pessary, which you can insert into the vagina only when you need relief from the prolapse symptoms. If you have significant prolapse, and you choose surgery, the best, most successful  surgery is usually the first surgery you have. Repeat surgical procedures are usually not as successful. A short term surgical solution may be a laparoscopis uterosacral uterine suspension, which can pull up on the uterus from inside the abdomen, and reattach it to the ligaments which held it up originally. This can sometimes help your symptoms, while preserving your uterus for future childbearing. I recommend that my patients deliver subsequent pregnancies by cesarean section after uterosacral suspension, in order to protect the repair.

Dr. Hoyte