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Pelvic Organ Prolapse – A Hidden Epidemic

The six-week-old baby nestled peacefully in his mother’s arms was like a dream come true. His birth had gone almost according to plan and everyone who came to visit noticed how closely he resembled his handsome father. Only those who knew Emily well could sense something amiss in this joyful scene, but when asked she would smile anxiously and insist everything was fine.

In truth this new mother was struggling with a condition she had never heard of and had no idea was even possible. Extreme perineal heaviness accompanied by an alarming bulge at the entrance to her vagina had sent her terrified to her gynecologist a couple of weeks earlier. Diagnosed with pelvic organ prolapse, where the bladder, uterus and/or rectum fall into the vaginal space, Emily was told to not lift anything heavier than five pounds and referred to physical therapy for pelvic floor exercise. She was also advised that her condition would only worsen and that when she had completed her family she would require reconstructive pelvic surgery.

For over a century the most silent epidemic in history has resulted in radical and experimental surgeries performed on hundreds of millions of women around the world. Today by age 65 half of all women in the United States no longer have their uterus, 25% of these operations performed for symptoms of prolapse. Hysterectomy leads to vast and permanent skeletal and biochemical changes, often resulting in bowel and bladder dysfunction, chronic pain, and sexual disability. Uterine suspensions and operations that narrow the vagina in an effort to correct prolapse are also associated with high failure rates and poor outcomes.

The human body is greatly protected against prolapse and for the first time in history the true story of female pelvic anatomy is told in the book Saving the Whole Woman – Natural Alternatives to Surgery for Pelvic Organ Prolapse and Urinary Incontinence, Second Ed. www.savingthewholewoman.com. Medical science has only recently begun to correct a 500-year misrepresentation of the position of the human pelvis in the standing body. In reality the pelvis is not a “bowl” with a “floor” but rather a vertical structure with a muscular wall behind it (Figure 1). Our true pelvic floor consists of wide, flat pubic bones that come together like straps of a saddle underneath us (Figure 2).

This concept has huge implications for women because it means our pelvic organs are not held up by a floor, but rather forward away from a vertical pelvic outlet. The way we keep them forward is not through Kegel exercises but by maintaining the natural shape of our spine, from which the pelvic organs are suspended. The pregnant body is a revealing example of how the pelvic organs are actually located over their true floor, the pubic bones (Figure 3). In the non-pregnant state, the bladder, uterus and sigmoid colon remain positioned directly behind the lower abdominal wall where they are pinned into position by the forces of intra-abdominal pressure(Figure 4). Natural breathing, coupled with a relaxed lower belly, creates and maintains pelvic organ support.

During the last weeks of pregnancy the fetal head drops into the birth canal, a process often referred to as “lightening.” In order to accomplish this the spine must assume a position of lesser pelvic stability. Breathing becomes easier but women also become less steady on their feet. During the birth process the spine must once again reconfigure so the baby can pass under the mother’s tailbone to be born. Birth positions that allow full movement of the spine, such as hands and knees or half-squat, open the pelvic outlet completely and help prevent abnormal stretching of the vaginal walls.

Rarely does a woman stand up after giving birth to discover prolapse. Rather, symptoms usually arise in the early weeks postpartum. This can be explained by the fact that most modern women do not engage in postures that return the pelvis, and therefore the pelvic organs, to natural positions of stability. Rather, they spend long hours in bed or upholstered furniture cuddling their newborn. Anatomically, the slouched, C-shaped spine destabilizes pelvic organs so they become subject to moving back from the lower abdominal wall and toward the pelvic outlet.

Several weeks of quality rest is highly desirable for postpartum mothers. However, to help prevent prolapse rest should be alternated with seated and standing postures that sustain the natural shape of the spine and consequently the pelvic organ support system. Additional lifestyle practices, such as discontinuing all straining against the toilet seat, are encouraged to prevent or stabilize prolapse.

Emily may never be completely free of vaginal bulges due to the resistance of pelvic connective tissue to regaining its original shape. However, by recreating the natural contours of her spine Emily’s symptoms may greatly improve. Coming back to inherent female posture means returning to natural pelvic organ support, the most reasonable and successful strategy for prevention and treatment of pelvic organ prolapse.

{ 10 comments… add one }
  • granolamom March 15, 2010, 12:56 am

    lightbulb!
    Submitted by granolamom on May 21, 2008 – 7:40am.
    got it louise
    thanks for your patience, I can see what you mean now. don’t know why I had all that trouble.

  • louiseds March 15, 2010, 12:55 am

    trochanter troubles
    Submitted by louiseds on May 20, 2008 – 5:42am.
    Hi Gmom

    Try this. Take an imaginary 3D x-ray woman, and fire a laser up the axis of each trochanter and out the end of the ball joint. Where do you think the two lasers will meet? I reckon it will be somewhere near the centre of the front wall of the sacrum when she is in WW posture. Now get your imaginary 3D x-ray woman to start walking and watch where the little red dots move. I bet the two little red dots track a symmetrical pattern on the sacrum as she walks. The sacrum will also rotate in 3 dimensions at the same time. I think the little red dots will never move off that sacrum, or else she *may* fall over.

    The upward force from the left leg is directed onto the surface of the left acetabulum, where it splits and is directed from the acetabulum in two directions, up through the lefthand side of the pelvis and through the left SA joint to the sacrum, and downwards through the pubis symphysis to the righthand side of the pelvis and up past the right acetabulum and via the right SA joint to the sacrum. When the right foot hits the ground the opposite happens.

    With either leg the circular pelvic bones act like a circular spring to distribute the forces from each step in both directions, and in basically one plane, to the sacrum. I know it is not that simple, cos of all the little anticipatory and compensatory actions that you described, but I think that is the principle. Isn’t the body awesome?

    Cheers

    Louise

  • Christine March 15, 2010, 12:55 am

    stability within movement
    Submitted by Christine on May 19, 2008 – 9:57pm.
    Oh Louise…I saw your original post about pelvic movement weeks ago – but so much has happened since that I didn’t think of it again until now with gmom’s response. I really don’t have much to add to all your insightful meanderings and think the best way (for us laywomen) to try to understand the body at its deepest level is to consult a good book on sacred geometry. There you will find Louise’s icosahedrons and also mathematical representations of the center of gravity of ALL animals – the sacrum.

    In the book I describe how energy moves from the ground up through the pelvis, which I think answers your (central?) question. S.A. Gracovetsky’s theory of human gait could keep you highly entertained for hours and is probably closest to ultimate reality on the subject. According to him, at heel strike a compressive pulse of energy travels up the leg, across the SIJ, and into the first intervertebral joint of the spine. I suppose this would be L5-S1. The intervertebral joint must bend laterally and fully rotate axially (in a plane around the spine) to advance the acetabulum into the direction of locomotion. Then, as the spine begins to unwind, the pulse is able to reach the next intervertebral joint.

    “Like a child on a swing reversing its motion just before receiving a push, the unwinding spinal motion is accelerated by the kick of energy it receives from the compressive pulse.”

    He does say gait is absolutely dependent upon the “massive ligamentous structure” across the SIJ and “high axial torque” created by the strongly curved human lumbar spine.
    Too bad (and beyond embarrassing) is the fact that these noble scientists are STILL using a Vesalius model.

    I think the body is ingeniously “hinged” at many points – sacrum, hips, shoulders – with suspension as the primary source of stability. Stability within movement.

    What I believe is key for women is that we regularly get into positions that hinge our CORE into its most forward-leaning posture. This can be accomplished by taking a wide stance with externally rotated hips and deeply bent knees. The upper torso remains fully upright while the lower belly is almost horizontal underneath you. THIS is what was required if we were to maintain our essential mammalian inheritance while at the same time becoming bipedal. From my perspective, the only way we could’ve arrived here is through dance.

    Cheers,

    Christine

  • granolamom March 15, 2010, 12:55 am

    ya lost me again : )
    Submitted by granolamom on May 19, 2008 – 6:02pm.
    was with you through the ‘sacrum, center of the hub’. makes sense, I think.

    don’t know why I’m having a hard time visualizing forces from greater troch. to sacrum. I see the axis, and iirc, those are the origin/insertion points for some muscle or other (glut medius? maybe? I should look it up when I have a chance, lol, as if I have more than 20 sec to myself these days)

    ah, dd needs her bedtime story

    will continue to think about this

  • louiseds March 15, 2010, 12:54 am

    hmmm..thinking…
    Submitted by louiseds on May 16, 2008 – 1:07am.
    Yay Gmom, you understand more mechanics than I do.

    Try this. The difference between the force dissipation in the toes, foot and knee, and the hip/pelivs/sacrum/spine part is that when the forces from impact hit the heel it is a case of “the foot bone’s connected to the shin bone, the shin bone’s connected to the thigh bone, the thigh bone’s connected to the …” acetabulum, in one direction, where the forces after that have to split into forces that go through the pelvis towards the pubis and forces that go towards the sacrum.

    The forces that go towards the pubis from both legs must be resolved in the pelvis somehow, somewhere, and are from there transmitted to the sacrum from each side, where they are in turn combined to go up the spine (to be resolved further in the upper body in the ways you describe).

    In the pelvic area there is splitting and combination of forces happening, not just direct transmission upwards (damped by muscles, cartilage etc.).

    The geometric centre probably is somewhere in all the soft tissue. I am not really certain what I am talking about (really??), but I think there is a point, or it might be a line on the sacrum, or even the whole mass of the sacrum, that stays still during standing/walking motion while the rest of the body rotates around it in space. In my mind I can see that resolution point on the sacrum as a tiny marble rolling around in a shallow, moving bowl, which is the sacrum.

    If you look at a video on Shambo’s website, http://www.yoga.com.au , the little video that is behind the thumbprint of the guy with shaved head (Shambo in fact) in the white shirt sitting behind a desk in a classroom, he talks about the pelvis as the hinge for the whole body, which is a similar analogy. (That sentence was too long, sorry.) He goes on about some other interesting stuff too about the pelvis too, as the centre of tension.

    If any of these upward forces through the pelvis is resolved at a point outside the sacrum, I think the person would fall over. That’s why I think the sacrum is the most important bit, the hub of the wheel, through which all upward forces of impact with the ground are transmitted.

    You still with me?

    BTW, I still think the bit about the alignment of the trochanters is true, but I think that 3D movement capture software would be the only way to illustrate it. I am currently working on a cunning plan to investigate it.

    Cheers

    Louise

  • granolamom March 15, 2010, 12:54 am

    hmm..thinking…
    Submitted by granolamom on May 15, 2008 – 8:05pm.
    not sure louise

    I agree that the sacrum is probably the center, or as close to center as bone can be. real center probably being inside (uterus maybe??). my sacrum, even the center of it, moves plenty when I walk. not as much as the outer parts of the pelvis, but that’s because its smaller and more central.

    not sure I follow you on the axis from greater trochanter to sacrum thing. forces generated from ambulation are absorbed at many places, starting with the small joints of the foot. also, the forces are anticipated and thus absorbed partially by anticipatory muscle contractions as well as anticipatory postural adjustments higher up (head, shoulders, upper back). the entire body responds to each step as a spring, if you want to think of it that way, with the forces dissipating somewhat at each coil (ankle, knee, hip, each vertebral joint,etc). the coolest thing (I think) is to watch footage of a running cheetah. its entire spine moves like a slinky. ours is similar but bipedal so different. maybe I’m rambling now.
    10 pm, time for bed.

    sweet dreams all!

  • louiseds March 15, 2010, 12:54 am

    firgure eights
    Submitted by louiseds on May 2, 2008 – 1:17am.
    Hi Gmom

    I am so glad you answered my post. I am sorry I lost you. I know I did not use all the correct terms (slap on the wrist!) for what I was trying to describe. It would have made it much easier for you to work out whether my thoughts are total BS or not if I was talking anatomical language proper(ly). It all popped into my head pretty thick and fast yesterday. I hope I am not wasting everybody’s time on this. I am not certain that I have it exactly right. As you know, I do not have an anatomy background (just a body that I am learning about!).

    I know what you mean by the figure of 8. I have felt it myself. I have a strong feeling that there is a point on the sacrum (or maybe two zones, one on each
    side of the sacrum) where the lines extended from the axis of the greater trochanters of the femurs inwards, hit bone and the forces generated on the body are dissipated through the body via this point. I think this angle between the femur and the greater trochanter is a critical angle designed to dissipate the forces of impact with the ground via the pelvis to the sacrum.

    I suspect that the site /zone on the sacrum is a kind of focus for the forces through both legs, so the movements of both legs kind of cancel each other out, with one half of the sacrum in nutation and the other in counternutation. It is precisely the nutation and counternutation that shifts the faces of the sacrum to collect these forces, just like a moving satellite dish. I also suspect that, when walking, the sacrum *is* the centre of all movement, about which the rest of the body rotates, the top half balancing the bottom half and the left balancing the right. I think this is why the sacrum is such a solid, plate-like thing. It “is” the hub of the body, and probably the centre of gravity. IMO the centre of the sacrum hardly moves at all. It is like a satellite dish that sits in one place and collects signals and sends them elsewhere.

    Men’s bodies? Who knows?

    I will leave it at that. Tell me if this bit makes any sense to you as a person who has training in all this stuff.

    I also suspect that movement capture technology could be used to prove (or disprove) all this stuff, and to prove that the ‘good’ posture that we were all taught as we grew up, and is the stuff of all those skeleton diagrams and models, is wrong, because it doesn’t actually dissipate forces the way it is supposed to do.

    It was that Tim Burton videoclip of The Killers’ song, Bones, that set me off on this movement capture technology journey, and spawned all these thoughts. Humankind never had movement capture technology when all those original anatomical diagrams were done, and if they had MCT in the 19th century they never would have got it wrong in the first place.

    BTW, please tell me if I am totally off the planet with this theory.

    Cheers

    Louise

  • granolamom March 15, 2010, 12:53 am

    uh, you lost me, louise
    Submitted by granolamom on May 1, 2008 – 9:52pm.
    your post sounds fascinating, but I think I’m still suffering from Mommy-brainfog, so most of it is going right over my head.
    but I will just comment on the gait bit, the pelvic movements during gait isn’t so linear (nutation/counternutation) but more like figure-8’s. there’s alot of rotation going on.
    could be that’s what you said and I totally missed it, if so, I apologize for being so dense.

  • louiseds March 15, 2010, 12:52 am

    New understanding of your model
    Submitted by louiseds on April 30, 2008 – 10:07pm.
    Hi Christine

    It’s good to see you re-expressing this model again. Every time I read a different version I understand another aspect of it.

    This time I understand the bit about the straps of a saddle, that I couldn’t quite get before. You are talking about the girth !! It does indeed look like a girth, but I don’t think it works like a girth, because a girth is always in slight tension against the forces in a horse’s body that press outwards against it, and prevent the saddle slipping to one side or the other.I have been trying to visualise another example, but am having difficulty.

    When I look at your two diagrams in figure 1 I see two different sets of forces at play.

    TOP DIAGRAM (pelvis as a bowl). The pelvis exerts downward force at the acetabulum on the head of the femur at the hip joint. This joint is in compression. It is a pity there is not also a side view to illustrate that the joint must also have a force of rotation trying to tip the pelvis backwards further, because of the weight of the upper body pushing down the sacrum. It is creating a dogleg (because the spine and legs are not in the same vertical plane), which finds it very difficult to transmit downward forces without counternutating the pelvis.
    At two other major joints, the two sacro-iliac joints, the spine and its extension (the sacrum) is exerting a downward shearing force on the ilia, like butt welds, causing tension in the ligaments holding that joint together that is trying to shear the joints apart. In addition the upper part of this joint would be in compression and the lower part in tension all the time, trying to keep it stable. No wonder we experience lower back and hip pain without a large wide lumbar curve! The pubic symphysis where the two halves of the pelvis meet at the front would be in compression at the bottom and incredible tension at the top because the downward weight of the upper body would be trying to twist the front half of the pelvis relative to the back half. No wonder my back pain has resolved at last, as my pelvis has found a new stability with WW posture. I keep thinking of that impossible picture by Vesalius of the man with the bowl-shaped pelvis leaning up against the classically styled pedestal. He must indeed have been in so much pain, as all his pelvic joints were unstable. It would not be possible to stand without external support your pelvis was in this orientation, as you have pointed out before.

    BOTTOM DIAGRAM (Pelvis as a vertical wheel)
    The sacro-iliac joints push together with the weight of the upper body pressing down, wedging the sacrum down into the pelvis, twisting slightly with alternate nutation and counternutation as we walk. The femoral heads push in a straight line upwards and inwards towards the sacrum, the direction of these forces being readjusted back to the sacrum by the nutation and counternutation of the pelvis as we walk! The pubic symphysis just holds the two halves of the pelvis in contact with each other and responds to the alternate nutation and counternutation as we walk. One of its roles is to flex with the sacro-iliac joints as gravity pushes down and attempts to deform the circle. there must be a little spring in this circular shaped pelvic girdle of ours! I am in awe of this design which resolves *all* the forces acting on all parts of the pelvic framework towards the centre, like a well-constructed dry stone wall which utilises gravity to hold it together, for centuries! No wonder it is taking engineers so long to reproduce a proper human gait in robots. They are using the wrong orthopaedic model! I think the hub of the structural wheel might be the sacrum, not the uterus, as both genders have a sacrum. The ligments and fascia holding the uterus in place are sides of triangles in a multiple triangle, multiple tetrahedral, 3 dimensional pelvis where there are multiple structural elements, some major, some minor. This is a truly awesome structure.

    MAYBE WW SHOULD BE LOOKING AT ROBOTICS TO VALIDATE THE WW MODEL, BECAUSE THEY ARE LEARNING ANEW, WITH ENGINEERING MINDS THAT ARE NOT CLOUDED BY SEVERAL CENTURIES OF THE EXISTING FALSE MEDICAL MODEL. (Sorry, I was shouting. I couldn’t help it. I am excited by this!) I think what they will ultimately do is to reproduce the human musculo-skeletal form all over again. What a surprise that would be! Or not a surprise, perhaps? I wonder what the man who makes tensegrity structural models of the human body would think about this, Steven Levin? Remember him? See http://www.biotensegrity.com/index.php?option=com_content&task=view&id=14&Itemid=29

    What do you think?

    Louise

  • alemama March 15, 2010, 12:52 am

    not enough time to be thorough
    Submitted by alemama on April 30, 2008 – 8:07pm.
    I can agree with the statements above EXCEPT that I think maternal injury/obstetric damage can cause POP. I firmly believe this. I never stood with my tailbone tucked under-I never had the upper body posture exactly like WW posture but for the most part my natural posture before finding WW was pretty close-
    but I ripped three times in three years and deeply. I have come to believe that I can not expect to rip like that and not have any lasting consequences.

    Also it is a belief of mine that I developed the beginnings of my prolapse during pregnancy. My births were mostly gentle and I had a pretty short pushing phase for the first birth and almost no pushing for the second 2 births.

    I guess I just don’t like the implication that if I had just *stood* differently I wouldn’t be in this predicament.

    SO maybe just qualify it by saying IF there was no obstetric damage………then returning to WW posture will help prevent POP.

    Sorry to sound so critical. I am not really. Just rushing to get to bed- but didn’t want to miss commenting on this.

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