When Prolapse Isn’t Actually Prolapse
I want to talk with you about prolapse today, and I want to ask a question that has changed my own pelvic health practice with clients:
How do we really know when prolapse is actually prolapse?
Because here’s what I keep seeing.
Client after client walks into my office and says, “I’ve been told I have prolapse.” Sometimes that came from a midwife or an OB. Sometimes it came from another pelvic health therapist. And by the end of our session together, I get to look at them and say, “You don’t have prolapse.”
That moment never gets old. And it’s why I want to share this education on assessing for prolapse with you.
Start with this question first
Let’s begin with symptoms, because symptoms are where our clients start.
When someone tells me it feels like a tampon is falling out, I agree – that is typically prolapse. That one I trust.
But vaginal heaviness? Perineal heaviness? For years I heard that and immediately thought, okay, we’re dealing with prolapse here.
My clients have taught me differently.
So here is the question I want every single one of us asking:
Does the heaviness get worse at the end of the day?
If it truly is prolapse, that heaviness worsens as the day goes on. Gravity, load, fatigue – it builds. That’s a real indicator.
But if your client says, “No, not really, it’s pretty constant from the time I get up until I go to bed” – now I’m thinking about something entirely different.
I’m thinking about an open birthing pattern in the pelvis. The ischial bones splayed apart. The sacrum stuck in flexion. The pelvic floor muscles sitting on stretch in a pelvis that isn’t as stable as it needs to be, so those muscles crank up their tension trying to create stability for her. (Learn more about working with the pelvic patterns in Treating the Postpartum Pelvis).
That constant heaviness isn’t descent. It’s tension doing a job it was never meant to do.
And when you address the pelvic outlet – bring the ischial bones back together, get the sacrum out of flexion – those muscles can finally relax and release. The heaviness goes away instantaneously. Gone.
Please file that question away and pull it out every time you hear “I have vaginal heaviness.”
What internal work can reveal
Now let’s talk about what happens internally, because this is where I’ve been genuinely blown away.
I can think of at least five cases in the last four months alone where clients have come in already having been told they have prolapse. My approach is always the same order:
- Address the bones externally first
- Move into the intravaginal protocol I use and teach (check out the Holistic Treatment of the Postpartum Body course for more info if you’re interested)
- Get the bladder back into midline.
- Work with the cervix, which is so critical.
- Tonify the uterine ligaments, the uterosacral ligaments, and the cardinal ligaments (see note below).
- Bring my client up to standing and assess.
NOTE: the cardinal ligaments deserve a moment. We call them the transverse cardinal ligaments, but they don’t insert into the vaginal walls laterally the way that name suggests. They insert superiorly, running only about 18 degrees from midline. They are very much a vertical cervical support. Understanding that changed how I think about supporting the uterus, and I believe we can tonify them after birth. The sooner we can get to a mom postpartum, the better off she’s going to be.
Once the internal work is done and the pelvic floor muscles are functioning in a much stronger way, which is usually what happens after the intravaginal protocol, I bring my client up to standing and assess. And there’s no prolapse.
Sometimes I wish I did an internal standing assessment right at the start so I could see the before and after. But honestly, I don’t like that approach to the body. It doesn’t feel as respectful to me. Especially with a first-time client. I want her body to get used to my touch. I want to address the bones and build that relationship first. That’s my approach, and I’m not willing to trade it for one more data point.
So, instead, toward the end of the session, I do the assessment. I have her blow up the balloon. I have her bear down and cough. We lift, we do all the things. And if I am not feeling any movement in the tissue…
That’s when I get to tell her: you do not have prolapse.
I let her know we were able to get the system working more effectively, more efficiently, and to get the structures to back into better alignment and function.
Because sometimes what looks like prolapse is really a rearranging – the shift that happens as a baby comes through vaginally. And we can help reorganize those structures and tissues back to where they belong so things function better and there’s real support in there again.
And then there are true defects
I want to be clear: true defects exist.
A defect is a prolapse. An avulsion is real.
And when I find one, I am a big fan of getting a pessary in there as soon as possible to support those tissues so they have a chance to heal in a shortened position.
Think about it the way we’d think about any other tissue. If we tore an Achilles tendon, we wouldn’t keep walking on it. We’d put it in a boot. We’d unweight it. So if there’s a defect or an avulsion, why wouldn’t we unweight those tissues as soon as we can – often with a cube pessary – to take the tension off those structures?
Because here’s the thing: we can’t not use our pelvic floor muscles. Those tissues are being strained constantly. Can a pessary offer them a chance to heal that they simply don’t get otherwise?
I hope so. And I hope we get more research to see if that is the case. Right now there are a couple of papers Taryn Hallam has shared in her research review on prolapse that do support early pessary use and tissue healing. I’d love to see that body of evidence grow, because I think it points somewhere important – maybe toward the idea that we don’t have to have prolapse forever.
Don’t say prolapse until you’ve checked in standing
If you take one clinical practice point from this article, let it be this one:
Do not tell a client she has a prolapse unless you have assessed her in standing.
Standing is the gold standard for prolapse care in my opinion. I’ve been fooled too many times – not tricked exactly, but I simply didn’t assess in standing. In supine, everything felt great. Tissues up and in, functioning well. Then she stood up and boom, it was right there at the opening.
Not all prolapses show up in supine.
I’m also not a big fan of relying on bearing down alone. It can be helpful when a client does it well, but over the years I’ve found that most clients don’t. That’s why I always use a balloon. When she’s blowing up a balloon, she’s not thinking about her pelvic floor at all, and I get an honest read on what’s happening with pressurization in that pelvic space. A brand-new balloon that’s never been inflated takes real force to get going, which makes it even more revealing.
It’s a beautiful teaching tool, too. Have her blow it up without thinking about anything. Then have her really engage her core and pelvic floor and do it again. She’ll say, “Oh, that was easier.” That’s learning she can feel.
The invitation
So much of pelvic health is taught as though it’s only about the muscles. If you’ve done your beginning trainings, that may be all you were given. I want more for you than that.
Learn to assess the bladder. Learn to work with the cervix, the uterus, and the uterine ligaments. Learn the bones. That whole picture is what makes lasting change possible, and it’s what I’ve built my courses to include – the bones, the uterine ligaments, and the intravaginal protocol that gets those muscles working better.
And when a client comes in saying another provider told her she has prolapse, I invite you to investigate. Do your assessments. Really look. You may find that she doesn’t.
About the Author
Lynn Schulte is a Pelvic Health Therapist and the founder of the Institute for Birth Healing, a pelvic health continuing education organization that specializes in prenatal and postpartum care. For more information, go to https://instituteforbirthhealing.com