Dreams for a big family dashed?

[Mom2FourBlessings]

I am a 30 year old mother of four and self-diagnosed POP and diastasi recti after my first baby at 24. It was a natural and uncomplicated birth, as they have all been. I have never had long or very difficult labours, never laid on my back to birth, no significant tearing with the last three (ie. no stitches).  The first there was only a "skid mark" on the side wall which formed a keloid scar, possibly due to an allergy to the stitches used. I am petite and a healthy weight (and BMI), my biggest baby was only 8lbs, 5oz. It has become worse with each child, but symptoms are off and on. Definitely something I could "live with" most days. I do have horrible posture and definitely sit with my tailbone tucked and my lumbar spine flattened or even curved forward. It seems so hard to change habits!

After my first baby I had a lot of pain and pressure and noticed the bulge of the rectocele while using the washroom. Not one doctor ever suggested that I had prolapse, which I always believed was because the rectocele sunk backwards when lying down for exams. After about 6 months or so I would say I was without symptoms until I became pregnant again.

I began physio while pregnant with number two doing exercises and using a biofeedback probe about 8 weeks post-partum. I didn't notice any real change at the time and I was able to perform the exercises.  It was very difficult to arrange transportation and child-care during my appointments so I stopped going.  I definitely had uncomfortable days, but usually no pain.

After my third I was fitted for a pessary with an OBGYN but it was unbearably uncomfortable to wear (I think it was due to pushing on the rectum/rectocele).

After the birth of this child about 12 weeks ago I began to also have a rectal prolapse. And I thought pelvic organs bulging out made me feel "gross"! This concerns me far more than the rectocele, cystocele and who knows what else since I have not heard any of my doctors talk about non-surgical treatment options. Thankfully I do not experience incontinence of any kind. I do struggle with constipation and due to the rectocele and especially the rectal prolapse I am taking a lot of stool softeners to avoid straining. I have had pain/discomfort off and on as well as the fact that I am very "aware" of the bulges all the time.

I saw a urogynaecologist at a "conservative management" clinic at the end of last month at 2 months post-partum. She said the cystocele and rectocele are stage 2 and the anal sphincter (internal?) is loose. I was referred for pelvic floor physio and a pessary fitting in the same clinic. I am experiencing a lot of anxiety due to the issues with bowel movements.

My first physio appointment is in two weeks. My baby will be 3 months old. I hope that it helps, but I am beginning to think this is all too little too late. It is ridiculously difficult to get information on POP. Both my family doctor and a doctor I saw for hemmorhoids thought I "needed" surgery. I now live in a small town and that means visits to the physiotherapist or urogynaecologist are a1.5 trip each way and my husband needs to take the day off work.  I am opposed to surgery in general. I am nursing my newborn and would be devastated to stop, I usually nurse until they are at least 18 months old. I am not excited at the prospect of a pessary, but would take that over surgery if it helps.

My biggest fear other than needing surgery for the rectal prolapse is that I would like to have more children and I worry this isn't an option anymore. Has anyone managed POP non-surgically and gone on to have more children?

[kianaidan]

Hi, I.m a 29 yr old mum of 3 concerned regards rectal prolapse. I wondered if I cud pick ur brain about symptoms and ask how hr getting on now. Thanks in advance

[sherrieP]

You certainly want to find out what is causing the problems-it all could be related to the rectocele though. When we can't poop (remove the toxins from our bodies), it typically results in bloating, abdominal dystention as your dr mentioned. That continual pressure is also to some degree connected to the rectal prolapse, continual pressure plus the additional pushing pressure when you try to have a bowel movement.

I sure hope the treatment plan from PT helps somewhat. In the meantime, check out video links on youtube put out by Tasha Mulligan, Julie Wiebe, and Mary O'Dwyer, they are all great PTs and have wonderful pelvic floor youtubes out. Also that connect of mine in the UK is looking for a link for that device I mentioned.

[Mom2FourBlessings]

I am certainly not volunteering for anal sphincter surgery. I asked for the referral more because I want to ask questions about rectal prolapse (not rectocele), and figured he might have the most information on treatments available. I see a women's health PT on Monday to be assessed and start on a treatment plan.

I think I may have other colon/gastro issues now since I often feel now I don't know when to go, etc. I understand that the constipation and incomplete voiding can be due to the rectocele, but it seems like it might be something more. I often feel my entire bowel large and distended through my abdomen in the morning (my torso is very thin). The doctor I saw seems to think that I need to surgically correct the rectocele to solve my problems. But she doesn't deal with POP or rectal prolapses.

[sherrieP]

I'd be concerned about having surgery to rectal sphincter; I think the potential complications far outweigh the chance of benefit. Less invasive treatments should truly be your first plan, addressing nerve fire which feeds muscle contraction. Finding the right therapist is hugely significant, APTA Women's Health division is a good place to start. Any POP will be more pronouced when standing and will get worse as the day goes on if you are on your feet (and in your case picking up babies).

Biofeedback will not help with constipation though from a rectocele since stool is caught in the tissue bulge. So little helps with this symptom of rectocele.

Skip the gastro/colo/rectal surgeon, a urogyn is your best bet-can address both cysto & recto and much more experienced since this is their area of expertise.

Sher

[Mom2FourBlessings]

Not exactly sure what her specialty is. She is from the nearby city and comes to the rural hospital to do procedures every few weeks. I think they mostly do colonoscopies (sp?) but my doctor was trying to get me in somewhere faster because I was freaking out. Since she didn't see the rectal prolapse happen so she thought banding hemorrhoids might help. It didn't, and I would be shocked if I am wrong and it was just hemorrhoids pushing out. She  definitely didn't miss the rectocele, she said there's "nothing there" and "you need to get that fixed" and "bolster that up" referring to the thin posterior wall/rectocele.  She recommend metamucil as the only advice and said that while things may have changed since she was a resident the surgery to tighten a spincter is not good as it makes the muscle no longer able to contract/release. She referred me to colon/rectum specialist who does that type of surgery in the larger city nearby because I'd like to at least ask questions and know more about it. I was supporting the perineum and around the rectum and that's how I noticed the rectal prolapse my first BM 4  days after this baby (now 12 weeks old).

The rectocele is right at the opening (introitus), and the urogyn called it grade 2 the cystocele appears to now meet it in the middle when I stand. I always wonder if it's worse if I am standing though. I feel like it is larger and it takes up more of the vagina than it used to, but doesn't feel like it comes out further. The tissue is smooth and not ridged anymore. The urogyn didn't see the rectal prolapse either, but I think she may have only had me cough during the exam, and it doesn't happen every time. Grade 3 is when it drops outside right?

I heard recently about a study using biofeedback to retrain the sphincters as being helpful in constipation, and since I saw that devices like the Kegel8 seem to have anal attachments I was hoping that it might help?

It's interesting that the only doctors who said I "needed" surgery now were doctors who are not gynaecologists.  

[sherrieP]

In my opinion once you get to grade 3 there's not much you can do that will improve your scenario, you can utilize treatments to assist comfort level but will not likely get back to a grade 2. Have you tried bridging the labia when you have BM? The chronic constipation from rectocele is so difficult to treat unfortunately. There is a plastic device to insert into the vagina that is supposed to help with this but I can't remember the name of it, if you think you might be interested let me know and I'll see if I can find it. (You can shoot an email to me at ***@****, faster than loading the MedHelp site.)

What I meant on the FB page is that it should be assessed to see if there is good contraction or not-many women have nerve damage from childbirth that prevents good contraction. You can also try bridging close to the rectum to see if that helps contain the rectal bulge. Push up on surrounding tissue when you are bearing down, it will help contain the bulge.

Who banded the hemmi? Many drs miss rectocele.

Sher

[Mom2FourBlessings]

Hi Sherrie,

I shared so much because I really haven't told more than a few people, since I am embarrassed. And even telling doctors is difficult. I usually end up crying. It's so much easier to type.

"All women should consider treatments b/4 going to the surgical page if POP is caught early enough."

In your opinion, what is "early enough"? I am currently 2nd degree (at the introitus) of both cystocele and rectocele. Even though I think the rectocele has worsened, I always felt the rectocele at or slightly protruding - that's why I noticed it.  My biggest concern now is the effect this is having on BMs. I have needed to push on the rectocele periodically to start or finish bowel movements, but generally only if I am constipated.  I try to go first thing in the morning, and if I don't I start to panic, worrying about the rectal prolapse and being constipated, etc. and not wanting to leave the house until I can go. Even on 6 stool softener pills a day and eating prunes, etc. I am still afraid and sometimes still have harder stools. I am trying to drink more water but with a newborn and a 2, 4 and 6 year olds my brain is pretty scattered.

On the APOPS Facebook page, it was mentioned that the anal sphincter should be assessed during a pelvic floor exam and can be tightened if noticed soon enough - can you elaborate? During BMs I have what I am 99% sure is a rectal prolapse through the anus, sometimes even if I don't need to bear down. It does goes back, but is often uncomfortable to sit even then (maybe mucusa prolapsed?). Two doctors have been unable to see the prolapse during a digital exam, but I am scared to bear down so I believe that I simply did not push enough during the exam for it to occur.  I don't want it to occur! The urogynaecologist did say the (internal?) sphincter was loose, but only that they really only "fix" rectal prolapse with surgery if it's prolapsed a certain amount all the time. Surgery terrifies me. It seems to me I have heard much more promising things about helping bladder issues with PT, not so much about rectoceles. The Dr. who banded a hemorrhoid for me said there's "nothing there" referring to the posterior wall of the vagina.

[sherrieP]

Wonderful detail in your post, thank you for sharing so much. It is truly unfortunate that there are no programs in place to establish recognition of POP in women prior to pregnancy or at least after they become pregnant so they can jump on the preventative maintenance band-wagon.

All women should consider treatments b/4 going to the surgical page if POP is caught early enough. There are multiple layers of non-surgical treatments available, a PT is your first stop but it is important to make sure the PT is a pelvic floor specialist. Some of the treatment options you've already experimented with, pessary, biofeedback, electrical stimulus, myofascial release therapy, visceral manipulation, neural manipulation, multiple exercise programs. Problem is most women aren't aware POP exists until after the fact, most women aren't screened for it, often women get blown off when they complain about symptoms to their physicians, not education/recognition protocol in place. Working hard to change that.

There should be no problem with nursing your baby for 18 months, and you never need to have surgery-it will always be a choice. It is imperative however that you utilize some treatments to keep POP from progressing.  A pessary that is fitted properly can't be felt (like contacts in your eyes), 75% of women that are fitted have no problems. I'm hopeful this time the fitting will work-there are multiple kinds of pessaries and may sizes. If one works a different type should be tried. An exercise regimen is vital, it is important to have a daily maintenance program (difficult to pull of with a baby). You can try Kegel8, a e-stim at home device. Important to pay attention to how you pick up and carry your baby, contract your pelvic floor prior to lifting-when you lift heavy things the pelvic tissues are pushed downward. When you have a bm, "bridge" your labia (place your fingers in a V alongside the labia and "contain" the soft tissue from pushing down when you bare down for bm).

I'm going to send you a PM (private message) with some other info.
Sher