When we come into the world as newborn baby girls, our spine is completely straight. Our three pelvic organs and their channels: urethra-bladder, vagina-uterus, rectum-sigmoid colon, form long, straight lines through a funnel-shaped torso.
Only when we begin to stand, walk and run under the forces of gravity do pronounced arches appear in our lower back and bottoms of our feet. By early childhood, the lumbar curve is a fully developed, large-radius arc.
As the lumbar spine is pulled forward with every breath we take, so the pelvic organs are pulled down and forward against the lower abdominal wall. The pelvic outlet is at the back of the body and the pubic bones are positioned front to back underneath like straps of a saddle.
It is the muscular uterus, and the equally muscular and contractile “round ligaments” of the uterus, that work to keep the uterus pulled forward. Because the bladder is connected to the uterus at the level of the cervix, when the uterus pulls forward, it takes the bladder with it. It is important to understand that prolapsed organs have not fallen down, they have fallen back from the lower belly to the outlet at the back of the body. When the uterus is positioned fully forward, or anteverted, the vaginal walls are pulled up taut, providing support to the bladder and rectum.
It is important that every woman understand that the uterus is the hub of a pelvic ring, and connected 360º around the body. Natural dynamics of breathing under the forces gravity either pin the organs into position at the front of the body, or push them backward toward the pelvic outlet, depending upon body alignment, or posture.
The uterus not only helps to hold itself and surrounding organs in place, but it also holds the bony pelvis together from the inside. The pelvis is made up of three bones and six moveable joints. Although unstudied by gynecology or orthopedics, there is much anecdotal evidence that great musculoskeletal change occurs after hysterectomy, especially if the surgery was performed during the reproductive years. The pelvis widens and the rib cage settles very close to the hips. The lumbar curve flattens, while a hump develops at the base of the neck. By age 60, one-third of American women no longer have the “hub of the wheel” and these musculoskeletal changes are very easy to identify in our population.
With these changes comes significant back pain as the lower spine is no longer connected to the muscular, forward pulling uterus. Prolapsed bladder and rectum are inevitable, and the possibility exists for the small intestines to eviscerate through either a closed and everted vagina (vault prolapse), or a vagina that has re-opened at the top due to dehiscence of sutures.
The surgical response to post-hysterectomy cystocele and rectocele is “A&P” repair, with or without mesh. In traditional anterior and posterior repair, front and back vaginal walls are dissected at the midline, and a strip of vagina is removed with the goal of “narrowing” the vaginal opening. The conventional framework is that a narrow “hole” at the bottom of a soft-tissue “floor” is less likely to allow organs to fall through. In reality, the opening is at the back and the organs are positioned at the front of the body.
When the uterus is removed and the vaginal walls “narrowed”, the long, normally flattened vagina becomes like a shallow cave. No longer can it protect itself by flattening down against intraabdominal pressure. Sitting atop the cave are the entire intestines, soft tissue against soft tissue. Just standing and breathing creates a tremendous amount of intraabdominal pressure and it is those pressures that result in epidemic proportions of post-hysterectomy vaginal vault prolapse.
Since its formation in the early part of the 20th century, gynecology has envisioned the orientation and dynamics of the female pelvis incorrectly. In truth, we have a strong, bony pelvic floor that, along with the multi-layered abdominal wall, supports all our pelvic and abdominal organs. This concept is very important for the post-hysterectomy woman to understand. You may not have your uterus, but the top of your back vaginal wall is still connected to your intestines through fascial layers. You can use the weight of your intestines to pull your vaginal walls forward enough so they can flatten against intraabdominal pressure. In this position, they are protected from the pelvic outlet, which is at the back of the body. This is a head-to-toe posture that pulls the abdominal wall up, never in.
Post-hysterectomy women need to understand the true dynamics of pelvic organ support as much as wombed women. The key is whether enough vaginal length has been left to flatten against internal pressures. All vaginal surgery for prolapse further ruins the dynamics of pelvic organ support.
Support the natural shape of your pelvis, as well as the health of your hip joints, with external belts worn lower in front and higher in back. Understand that the lower spine has lost its major internal support structure and begin the Whole Woman postural work slowly and carefully.