Understanding Prolapse: Real Questions, Real Answers with Jeanice Mitchell

This week's podcast is about prolapse—what it is, how it affects daily life, and what you can do about it. A few weeks ago, I joined Janice Mitchell from MyPFM and had the chance to answer some incredible questions from her coaching group. The conversation was honest, insightful, and filled with the kinds of questions I hear every day in my practice.
We talked about whether prolapse can improve after childbirth, how to manage symptoms without surgery, and what to know if you're considering one. I also shared tips on pessary use and how to find a skilled urogynecologist and even addressed one of the most personal topics: sex and prolapse.
If prolapse has left you feeling unsure or overlooked, this episode is for you. These are the questions real women ask and the answers they deserve. Listen and learn.
 

https://thewomensbladderdoctor.com/

Timeline:

00:30 Introduction to Prolapse Discussion 

01:02 Understanding Rectocele and Postpartum Recovery 

02:39 Non-Surgical Options for Prolapse Management 

03:46 Physical Therapy Techniques for Prolapse 

05:26 Innovative Tools and Devices for Prolapse 

07:06 Prolapse Surgery: Expectations and Outcomes 

08:04 The Mesh Controversy in Prolapse Surgery 

10:17 Pessaries: Types and Usage 

12:48 Choosing the Right Urogynecologist 

14:34 Final Thoughts and Q&A

Transcript

 Hi there. My podcast this week is going to focus on prolapse. A few weeks ago, I spent some time with Janice Mitchell from my PFM, and I answered some questions from her coaching group. There was a really great discussion that came from this and I thought you would benefit from it too. So today I'm going to include the questions that I got about prolapse, listen and learn.

Let's jump into prolapse. Okay. Are you ready? Favorite. Okay. So can erectus seal, which is, you know, weakening of that back vaginal wall, for anyone watching that may be wondering about what Erectus seal is, can it be improved at seven months postpartum? You know, when I was in medical school somebody said to me that all answers should start with, it depends.

Um, and I think it depends. So, and what I think it depends on is what your delivery was like. So if you're someone who has had a traumatic delivery, meaning that it was an operative delivery, you know, you deliver it with forceps or with a vacuum, you have a really big baby, you had a big tear into the sphincter, or you know, all the way into the rectum.

And also sometimes older moms too. All of that means that the recovery time is just gonna take longer, right? So at at seven months, your body could still be recovering, your muscles could still be waking up, you could still be regaining function. So in those patients, there still could be some improvements, you know?

And then I think there are some functional things like. How constipated you are. Are you still breastfeeding? All of those things can play into it too. For most people. I think if you have a rectocele at at seven months, it's probably going to stay there, right? That's a defect in your connective tissue.

Over time, it may not bother you as much, so for some people to get better, but for a lot of people it's just related to the delivery and some damage. Let's jump into one of the options because there are multiple options other than surgery because I think a lot of people think, oh, I have this. That means I'm gonna have surgery.

I have to have surgery. You mean with a rectus so, or with prolapse in general? Both. Okay. I mean, I think the thing with prolapse is you never have to have surgery. I mean, you can almost always live with it. With a rectocele, if you can change the fiber in your diet, change your stool consistency and it, it doesn't really bother you 'cause you're pooping without any problems, then I mean, you can totally live with that and that's absolutely fine.

The only people that I think really have to have prolapse fixed are people who have a prolapse that impacts their ability to empty their bladder. So every now and then I'll see someone who really can't empty very well and then they're getting recurrent UTIs. It could put your kidneys at some risk, but, but that is very extreme, right?

That's probably one to 2% of people. That's not most people. So yeah, you never have to have surgery, you know, in physical therapy. So for people with erectus seal, we teach a lot of. Hands on things to help with pooping. So we do abdominal massage where we're helping to stimulate, and then also like using a finger or a thumb on the outside of the perineum or inside the vagina and kind of pressing up and back.

And then sometimes even digitally stimulating the rectum via that posterior vaginal wall. Have you had any? And so that kind of helps to empty the poop pocket, helps reduce the strain and so forth. Have you had or seen any luck with that? I don't wanna call it luck, but any positive outcomes with people doing that with the anterior wall?

So using a finger or using a tool to help push up that anterior wall so that it's emptying better? Yeah, I mean, you can absolutely do that. You can. You can push it back up to empty. A lot of times women will kind of rock forward because when you rock forward, it kind of tucks up that bladder prolapse a little bit.

The thing that I will tell you is that even though that works, it's hard to do gracefully. So, I mean, you can do it if you need to. If you're having a really hard time emptying your bladder. Yes, absolutely do that. But then frequently what people say is, oh, you know, I peed all over my hand and, and so it's great if it helps you in that one incidence, but I think that's, it's a hard thing for people to do over and over again is a hard thing.

Yeah, it's a hard thing. I don't know if you've seen this tool. I was at, the American Physical Therapy Association has a annual conference and so 16 to 18,000 people every year. And so last year in the exhibit hall I came across a vendor and I wish I didn't, I don't have the name, I think it's re ve. And so basically it's a tool that has a handle and you insert it vaginally and it has this little pump and so you pump it up.

That's a way to either help support that back wall or that front wall without getting your hand messy. You know, it still requires some manipulation, but I thought it was a cool option to have. Yeah, no, I, I haven't seen that. I'll find the link and I'll send it to you and I'll post it in the comments here.

Yeah, I mean, it sounds kind of like the inflatable, right, which is that pessary that you blew up and can push everything back up. I've seen the one that's like a shoehorn, right, that you can use to push everything back up. It, I mean, it's interesting the tools that, that people come up with. And then I think that, you know, the next conversation and, and you know this 'cause you have all these conversations too, but you know, the next thing people will say is, oh, that works when I'm at home in my bathroom.

But you know, when I'm out and about this is, this is not an easy thing for me to do. Right. Do I wanna carry this in my bag and Right. Do I wanna bring a bag, gonna clean it And Yes. All the things. All the things. All, all those. Okay. Let's see. So would you say that most people that have prolapsed surgery are pleased with how it turns out turns?

I think that's a little bit of an art, right? So I don't think prolapse surgeries are perfect. I think that I am, I'm a big believer in under-promising and over-delivering, and so I think that's what makes people pleased. So if you go into surgery and you're told everything will be perfect and nothing's ever gonna come back and everything, you know, will just be a hundred percent, you will be disappointed.

Without doubt, I mean, something will happen and you'll be a little bit disappointed. And so I, I think it's really setting the expectations. What do you think is gonna be fixed? You know, what can we fix? What can't we fix? I think all of those conversations are really important. I kind of sidestepped your answer, didn't I?

I didn't say yes or no. That's good. That's fair. That's fair. Can you talk about the mesh controversy? So we've heard terrible things about mesh, but there's still mesh being used in some surgeries. What's good mesh and bad mesh and so forth. Yeah. So there were some bad meshes on the market, and those meshes have been off the market for a very long time.

So initially, I mean, what we figured out is that the weave, because meshes kind of look like lace, so those holes in the lace, they have to be pretty big. At the beginning they were small, and what that meant was bacteria could get into the mash, but your own white cells that fight infection couldn't. And that was not a good thing.

So, I mean, you have to have a, a big weave mesh and all the meshes that are on the market are, are kind of this, this large weave mesh now. But then the other thing is that there's good and bad ways to place mesh. And when mesh goes through muscle, it can create some irritation and some pain. And so you, you wanna understand where that mesh goes and kind of how it is attached.

So there were a whole bunch of surgeries kind of in the early two thousands where meshes were put in for prolapse, and the meshes were put in through a vaginal incision and to get the meshes to stay. They were kind of hooked to muscle or hooked through muscle, and those surgeries had a very high complication rate, and a lot of that was because they were designed to be very easy to put in, but nobody really thought about taking them out.

They, they pulled on the muscles, they created some pain. Those surgeries are, are kind of long off the market. The surgeries that we do now, you know, in the United States, we think so sling surgeries to stop leaking. We consider mesh slings to be the gold standard. That's true in the United States. It's not true in Britain or Australia.

They actually don't let physicians place them because they worry about the mesh so much. Then if we do meshes for sacral colpopexy and we're placing the mesh through the abdominal through an abdominal incision, those surgeries have a lower complication rate than if you place the mesh vaginally. Do you use cube PSEs?

First off, do you, are you somebody that regularly fits pries or do you have another provider that you send to for that? So we do it in my office. Sometimes I will do it, sometimes one of the nurse practitioners in my office will do it. You know, every now and then I'll see someone and you know, they come in and they say, I have a prolapse.

I'm here for a pessary. I say, oh, okay. Well, let's fit you. And so if I'm doing it all on one appointment, I do it. If they have to come back for whatever reason, then you know, one of my nurse practitioners will do it. So yes, I think everybody should be offered a pessary. Some people love pessaries, some people hate pessaries.

I don't think everybody has to try a pessary, but I think everybody should be offered a pessary. Most of the time the pessaries that we start with are rings or ring with support. And the reason the ring is the one that we start with is because it's the easiest to put in and take out, right? You fold it in half, it looks like a taco, it fits in the vagina, it opens up.

Those work really well after that. The next one we usually try is agel horn, and the gel horn kind of looks like a a mushroom, and it's a little bit harder to get in and out. There are bigger pessaries. If, if those pessaries don't work, then there are a whole group of pessaries that I call space occupying pessaries like a donut.

And a donut looks like a donut and they're hard to get in and out because they don't really collapse. Or a cube a a cube does a great job of holding up the prolapse. You have to be pretty nimble to get it in and out yourself. A cube will also form a suction on each one of the sides, and so it can irritate the tissue.

You don't wanna leave it in too long because of that other pessaries you could leave in overnight for. So for some patients, I think a cube is great. I've never had anyone use a cube for a long period of time. Like keeping it in for time or over a long duration, like over a long duration. Like people get kind of irritated with it.

But I've definitely had some patients who were fairly newly postpartum, right? So had pretty young babies and were still healing in that healing process. Who benefited from a bigger pessary like that until their anatomy kind of shifted back? Great. Okay. If you were going to look for a urogynecologist for to do prolapse surgery on you, this is my last question 'cause we're winding down here.

What are some things that you would ask or want to know about that person? Yeah. You know, this is such an interesting question 'cause it's really hard to evaluate physicians right there. There isn't criteria. There isn't a list. And you know, it would be nice if it was easier. You know what I tend to do if I need a surgeon, I tend to ask the nurses in the operating room who they would pick.

So if you have a friend who's a nurse in the operating room, you should definitely do that. I think the thing that you want. I would ask. So you want someone who's high volume. There've been a lot of studies that have shown that people that do the same surgeries over and over again get better at them.

Right. And that makes sense. So you want someone who's high volume, if you're seeing someone who says, oh, I do that surgery once, once a month. That's, you know, not reasonable. You want someone that you trust, that you feel like is a good match for you. If you don't feel like you have a good relationship, then I would not have surgery with that person.

And I think the other thing that I would ask is, you know, if you have a complication, once you're at home, what happens? You kind of wanna understand that process and how that office works. 'cause you wanna make sure that you could easily contact your surgeon or your surgeon's people. Ask your questions if you're not feeling well, assess you if you're having a problem.

I mean, that part is really important. Very, very helpful. Okay. Anything you'd like to share before we close out for today? There was one question. Can you have sex with the pessary in place? And the answer to that is, yes, sure, if that works for you, if that works for everybody involved. So I used to tell everybody, no, you can't have sex with a pessary in place.

And then I had a couple patients who came in and said, but I did. I said, oh, okay. Great. Right and mean if that works for you, it's absolutely fine. You're not doing any damage to anything. Okay, great. Okay. Those are my wording words. Thank you. So I love it. It's liberating, you know, uh, it depends. And if it feels good to you, great.

You and your partner, yeah, just try it, right? And if it works for everybody, that's fine. All right. Again, so many great questions. If you have a question that you'd like me to answer, please send it to Sarah at the women's bladder doctor.com. That link will be in the show notes and remember, if you have a question, someone else does too.