Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 52  |  Issue : 2  |  Page : 96-102

Case study: Reversal of pelvic floor prolapse symptoms with Ashtanga Yoga of Mysore


1 E-RYT AUM Yoga Sadhana Program Director, San Antonio, Texas, USA
2 Women's Health Clinic, BAMC, San Antonio, Texas, USA
3 Department of Psychiatry and Behavioral Sciences, University of Oklahoma College of Medicine, Oklahoma City, OK, USA

Date of Submission03-Sep-2020
Date of Acceptance31-Oct-2020
Date of Web Publication23-Dec-2020

Correspondence Address:
Hetal Nayak
5 Kelian Ct. San Antonio
USA
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DOI: 10.4103/ym.ym_19_20

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  Abstract 


The incidence of pelvic organ prolapse is 18%–56% 3–6 months postpartum in women of childbearing age. In spite of this common condition being more than just a nuisance, it also leads to hysterectomy in 20% of women, and other surgical interventions may be preventable with a course of pelvic floor physical therapy and elaborate training in yogic techniques, to improve the tone and strength of the pelvic floor muscles, after allowing time for tissue healing postpartum. This article outlines the details of such training, with the underlying scientific principles and physiological underpinnings. The article also describes these techniques in detail for novices, emphasizing the importance of experienced yogic therapists and physical therapists working closely with patients, physicians, and obstetrician-gynecologist specialists. The article illustrates the positive outcome of such techniques in a case study presented in detail. The article goes a little beyond its scope to elaborate the Ashtanga Yoga of Mysore to place the techniques in a holistic context to emphasize their integration in medical, gynecological, and physical therapy treatment modalities. Surgery needs to be the last resort for this reversible condition.

Keywords: Ashtanga Yoga of Mysore, pelvic organ prolapse, yoga for women with pelvic organ prolapse, yogic techniques for reversal of pelvic organ prolapse


How to cite this article:
Nayak H, Mehta S, Vinekar S. Case study: Reversal of pelvic floor prolapse symptoms with Ashtanga Yoga of Mysore. Yoga Mimamsa 2020;52:96-102

How to cite this URL:
Nayak H, Mehta S, Vinekar S. Case study: Reversal of pelvic floor prolapse symptoms with Ashtanga Yoga of Mysore. Yoga Mimamsa [serial online] 2020 [cited 2021 Jun 20];52:96-102. Available from: https://www.ym-kdham.in/text.asp?2020/52/2/96/304616




  Introduction Top


POP is the descent of female pelvic organs into the vagina (Bradley, 2018). It occurs when pelvic floor muscles, fascia, and supporting ligaments weaken or tear. The types of POP include cystocele/urethrocele (bladder or anterior vaginal wall prolapse), rectocele (rectum or posterior vaginal wall prolapse), uterine prolapse, vaginal vault prolapse, and enterocele (small-intestine prolapse).

Ashtanga Yoga of Mysore is a very traditional form of Asana practice wherein the order of the yoga postures remains fixed. It was devised by yoga guru Krishnamacharya and his student Pattabhi Jois. It utilizes a three-fold approach to yoga asana called Tristan . This case study describes how our patient with the consistent practice of ashtanga yoga of Mysore for 10 years was able to reverse the symptoms of POP.

Objectives

  1. Increase the awareness of nonsurgical treatment options for pelvic organ prolapse (POP)
  2. Bring awareness of the holistic approach and benefits of Ashtanga Yoga as an alternative or adjunctive treatment of integrated medicine for POP
  3. Highlight the method of Ashtanga Yoga of Mysore in reversing POP using anecdotal data from this case study
  4. Inspire further research on the topic.


POP is the descent of female pelvic organs into the vagina (Bradley, 2018). It occurs when pelvic floor muscles, fascia, and supporting ligaments weaken or tear. The types of POP include cystocele/urethrocele (bladder or anterior vaginal wall prolapse), rectocele (rectum or posterior vaginal wall prolapse), uterine prolapse, vaginal vault prolapse, and enterocele (small-intestine prolapse). The etiology of POP is varied. Pregnancy and childbirth are the common causes of POP in women. Vaginal delivery, a large baby, forceps- or vacuum-assisted birth, prolonged or very quick second stage of labor, and having multiple deliveries increase the risk of prolapse (Pelvic Organ Prolapse, n.d.). Lacerations, stretching of tissues, and tearing of the perineum can also affect pelvic floor integrity and damage nerves. Aging and the onset of menopause can cause POP, as the decline in estrogen levels can weaken the pelvic floor. Certain health conditions such as chronic cough, chronic straining due to constipation, obesity, and connective tissue disorders (genetic or acquired systemic disease) are also linked to POP. General lifestyle choices can also place a patient at greater risk of developing POP. Repetitive heavy lifting, poor posture, poor diet, smoking, and core muscle weaknesses are among the risk factors. A history of previous gynecological surgeries is not uncommon in the cases of POP.

Symptomatically, patients may notice a bulge or a feeling that something is falling out through their vagina. Pelvic or vaginal heaviness, pain or an inability to wear a tampon, and painful coitus can also be reported. Patients may also have vaginal dryness or irritation, bleeding, discharge, and infection. Urinary symptoms, such as the feeling of incomplete emptying of the bladder and urinary incontinence, especially postvoiding dribble, are also common. Patients may also experience lower back pain that increases in severity as the day progresses.

POP is a common problem many women face. Three to six months postpartum, the occurrence of POP is reported between 18% and 56% (Bø, Hilde, Stær-Jensen, Siafarikas, Tennfjord, & Engh, 2015). According to the American Urogynecology Society (AUGS), one in three women who have multiple vaginal deliveries have prolapse. Though in milder cases patients may not experience symptoms, more severe cases become symptomatic with noticed protrusion and the need for manual pushing of prolapsed organs upward and deeper. There are several theories as to why so many new moms experience POP. An increasingly sedentary lifestyle, lack of awareness, high-impact activity during early postpartum, a poor diet, chronic constipation, and poor tissue tensile strength have been proposed as contributing factors.


  Ashtanga Yoga of Mysore: Tristhana Method Top


Ashtanga Yoga of Mysore is a very traditional form of Asana practice wherein the order of the yoga postures remains fixed. It was devised by yoga guru Krishnamacharya and his student Pattabhi Jois. It utilizes a three-fold approach to yoga asana called Tristhana. Tristhana consists of Ujjayi Pranayama (breathing technique), Bandhas (energy locks or seals), and Drishti (gazing point). Through this three-fold method, practitioners develop control of the senses and a deep body or somatic awareness of themselves and their inner sensations, as well as emotions and workings of the mind. By maintaining this discipline of daily practice of Tristhana for 6 days a week in addition to a devotional approach, Ashtanga Vinyasa Yoga practitioners develop steadiness of body and mind after years of dedicated practice (Croft, n.d.). More about this method is described in the Vinyasa section below. This article focuses, as relevant for our purpose, only on five of the eight aspects of yoga initially expounded upon by sage Patanjali (Vinekar, Vinekar, & Vinekar, 2008). Ashtanga simply means eight aspects.

The process of using these tools to deepen one's psychological and somatic (mind–body) experience is one of the main characteristics that separates Ashtanga Vinyasa Yoga from other forms of yoga. We will also discuss the biophysics and biomechanics of the techniques illustrated below.


  Ujjayi Pranayama Top


Prana means “energy or life force.” Pranayama is the method of gaining control over the subtle energies in the body by using breath. This particular pranayama involves partially closing off the glottis (the muscle at the back of the throat used for swallowing) as one inhales and exhales. To practice it, the practitioner tightens the throat in the same way as when one whispers, or in the same way one would steam up a mirror, and breath through the nose to make a whispering sound at the back of the throat. The sound should be similar to waves rolling over pebbles on a beach. The pelvic floor if positioned properly gets pulled upward almost like a piston of a syringe designed for injections. Such slow gradual upward pulling of the pelvic floor conditions the muscles of the pelvic floor initially and gradually builds muscle strength in the pelvic floor over time. The founder of this method says: Ashtanga practice is a breathing practice ... the rest is just bending.

One significant feature of Pranayamic breathing is the stress that is laid on the pelvic diaphragm (Kuvalayananda & Vinekar, 1963).

Bandhas

The word bandha means “lock” or “seal” and refers to the activation of certain isolated muscle groups that act to control the flow of life force energy (prana) around the body during practice. There are three main locks. When mastered, the bandhas have the effect of retaining the prana that is created in the practice and channeling it around the body to cleanse and energize the system in the yogic way of thinking. In our Western medical way of thinking, the Bandhas are special isometric exercises just like yoga asanas. They are used to increase the tone of the skeletal muscles not used in large muscle movements. Increasing the tone helps reconditioning the deconditioned muscles. Over time, the muscles regain their lost tone and strength. The three important ones are discussed below:

Uddiyana bandha (the belly lock)

This bandha is engaged when the lower anterior abdominal wall is tightly drawn toward the spine while retaining a soft upper abdomen (the area above the belly button). This action of lifting through the lower belly helps maintain a strong inner core and brings lightness and grace to the bandha. The diaphragm also is lifted and the chest expands as if one is taking a deep breath. The uddiyana bandha gets stronger with proper use of shoulder girdle in the practice of this bandha. Swami Kuvalayananda demonstrated in his laboratory convincingly that this bandha creates significant negative pressure in the abdomen. It can be easily understood how this “exercise” helps POP by pulling up the pelvic floor and also the prolapsed organs in addition to strengthening the pelvic floor muscles.

Mula bandha (the root lock)

This is located at the base of the spine and can best be understood by a firm lifting of the pelvic floor (at the perineum). To begin with, engaging this bandha feels like a clenching of the anus, but in time and with practice, this becomes a gentle lifting of the pelvic floor. An important cue for women is to draw the mouth of the cervix up and back toward the spine [Figure 1]. In addition to conditioning the pelvic floor muscles, this exercise conditions the anorectal and vaginal skeletal muscles, increasing the conscious control over them. Over time, with regular practice, these muscles regain their original strength in postpartum phase (Mula Bandha The Root Lock - For Women).
Figure 1: (Mula Bandha The Root Lock - For Women)

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Jalandhara bandha (the chin lock)

This is performed by extending the chin forward and drawing it back toward the throat where the clavicular bones meet the sternal notch [Figure 2]. This bandha is used only in some asanas. Adding this third bandha, to the other two above, is like pulling the piston of the syringe all the way up, thus creating maximum negative pressure in the cavities of the torso (Tres Bandhas, 2016).
Figure 2: (Tres Bandhas, 2016)

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Drishti

Every asana has a gazing point. There are nine Drishti or different gazing points. These create increased awareness in the practitioner which reflects in all the aspects of life. These also help with correct alignment in every asana. It helps to draw the senses inward. In the premier book “Yogic Therapy,” Dr. S. L. Vinekar has called the aim of Drishti, “cerebro-ocular” adjustment to maintain a focus of attention.

Vinyasa

The word Vinyasa refers to the practice of breath-synchronized breathing movements. Opening and expanding movements are made on inhalation, and contracting, folding movements, or changes of position are made on exhalation. The correct use of vinyasa will facilitate a deeper experience of each pose while at the same time also encourage a fuller and deeper breath and build one pointed focus of mind (ekagrata).

The result is that asanas become linked together on the flow of breath; the practice becomes effortless and graceful, like a rhythmical dance where the music is the whispering of the Ujjayi breath. Vitally, Vinyasa also creates heat within the body, increases blood circulation, and flushes toxins from the system through sweat. It also stimulates the vagus nerve and brings in parasympathetic predominance in the autonomic balance to bring about a relaxation response. The relaxation response is facilitated also by experiencing oceanic consciousness in Shavasana particularly but in all asanas (Ananta samapatti).

The Ashtanga Vinyasa Yoga series today consists of primary (first series), intermediate (second series), and four levels of advanced series, which are collectively referred to by the Sanskrit term sthira bhaga, or “divine stability.” Each series includes challenging and restorative poses performed in the same order each time, but each series of Vinyasa is increasingly more difficult than its predecessor. The goal of Vinyasa in these series is to strengthen the body and mind (What is Sixth Series of Ashtanga Yoga, n.d.). It certainly is akin to choreography in classic dance. Over time, the practitioner can smoothly transition from one pose to the other without missing the heartbeat, as if this choreography is set to a musical composition. Such effortlessness is called “Prayatna Shaithilya” by Patanjali. Breathing and slow motor movements are well coordinated while the asanas intermittently are retained in stable positions, enjoying the sensation produced by each asana (Sthira Sukha Asanam). B. K. Iyengar himself and his group of students demonstrate this in their artistic choreographed productionon the stage (Jogi, 2011).

Thus, Ashtanga Yoga is a holistic practice with a perfect mix of all aspects of asanas working with the deeper core muscles, bringing in a right balance of strength and flexibility [Figure 3]. The finishing sequence in each of the series focuses on Padmasana or the Lotus pose. This helps to keep the pelvis at the requisite angle easily and thus facilitate the formation of Mula – Bandha. The pelvic inclination has a great bearing on the tone of the pelvic floor (Kuvalayananda & Vinekar, 1963). It is a spiritual discipline with a commitment required to practice 6 days a week. Teachers teaching this method are long-term sincere practitioners of the method and are well trained for years if not decades before they start teaching. “Traditional Ashtanga Yoga is founded on the concept of Parampara, a term meaning direct, experiential knowledge passed in succession from teacher to student” (Parampara, 2013, para.1).
Figure 3: (Ashtanga Vinyasa Primary Series)

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For those who find it difficult to attain the Padmasana posture, we would recommend Sukhaasana.

It is important to keep the spine erect while performing all pranayama breathing exercises and during formal meditation. Though this article is focused on women's health, men too suffer from weakness of pelvic floor muscles, sometimes manifested by rectal prolapse. The same exercises recommended for women can be helpful for men too. Males and females trying to reverse POP or rectal prolapse need to avoid any and all yogic postures that would increase the intra-abdominal pressure.


  Increased Awareness with the Practice of Ashtanga Yoga: An Important Aspect of the Holistic Approach of Yoga Top


Awareness is internal and external. It is enhanced by achieving more and more neuronal connections that occur in the deeper part of the brain. It is a deep level of understanding not just of one's self but also of one's surroundings. It is a sense of togetherness with the many parts of the mind and incorporating the body to become “whole.” Awareness can only come about from an open-minded attitude and a positive state of mind. It goes to the core of one's self, a yearning to learn more about oneself and/or one's surroundings. Persons who develop this state of mind can feel every part of their body (nakha-shikhanta) from the tip of the nails to the vortex of the skull, and will remain in touch with their senses. They are proactive and will always reflect first and become aware of their inner state while initiating all of their conscious movements. They take time to evaluate the situation before responding. They are continually in a state of control. The words “swami” and “swamini” have their origin in this concept of being in control of oneself. Yoga develops awareness of what is taking place in the moment. It allows one to perceive thoughts as they emerge in early stages, before they have acquired any real emotional valence. Awareness is a powerful skill to learn, however it is only learned by taking the journey inward. It is something that one can't learn at a class in university, but it can be learned by the practice of yoga. Yoga is more than just exercise; it is a way for psychological growth and never-ending improvement that one can experience. The person will make right choices and will always strive to do what is right versus what is easy. In a study, researchers observed that those who did yoga had better body awareness (Daubenmier, 2005). They were also more responsive to their sensations compared to the groups of nonpractitioners of yoga.


  Case Report Top


This is a single-subject case report describing history, evaluation, examination, intervention, and outcome.

The patient is a 32-year-old female with complaints of POP shortly after her second vaginal delivery. The patient was diagnosed with POP during a postpartum examination.

Chief complaints: The patient experienced heaviness and discomfort in the vagina, pelvic pressure. It caused mood disturbance, irritation, anxiety, fear, and anger. It required the patient to manually push deeper the protruding organ. She had to restrict physical activities, such as running/jogging.

The patient's demographic details were as follows:

  1. Height: 62”
  2. Weight: 140 lb
  3. Body mass index: 25.6 kg/m2
  4. Profession: Bookkeeping, yoga teacher, community leader, and anesthesiologist
  5. Hobbies: Yoga practice, reading and studying philosophy, cooking, and serving the community
  6. Medical and surgical history: Left lower ulnar fracture/open reduction and internal fixation following skating injury, 2010, removal of hardware due to complication, and polycystic ovarian disease
  7. Normal thyroid-stimulating hormone and serum glucose level
  8. Medications: None
  9. Obstetrician-gynecologist history: G3 LC2, miscarriage in 2001, vaginal delivery × 2 – 2002 and 2005
  10. Labor complications: Prolonged second stage of labor during first delivery, episiotomy, and 2nd-degree perineal tear
  11. Largest infant: 7 lb. 12 oz
  12. Breastfeeding: First one for 10 weeks and second for 1 year
  13. Birth control method: Uterine implant since 2012.


Bladder concerns:

  • Urgency – present
  • Pain with urination – None
  • Urinary leakage – None
  • Feeling of incomplete emptying – Sometimes
  • Daily voids – Every few hours
  • One or two night – Voids.
  • Bowel concerns – Constipation – some; straining – sometimes
  • Fecal or flatulence incontinence – No
  • Hemorrhoids – Yes
  • Prolapse symptoms: Heaviness – yes; pressure – yes; pain – no; bulge – yes
  • Sexual history – No pain
  • Aggravating factors – Prolonged standing, heavy lifting, walking, constipation, carrying infant, bending, lack of sleep, coughing, and weight gain
  • Relieving factors – Rest, laying down (here the authors note the value of Sarvangasana and Shirsasana as first steps before venturing into the three bandhas that can follow after this asanas are maintained for a reasonable long time to allow gravity to act on the prolapsed organs to move them in the direction opposite of the prolapse). In fact, the chronic backaches, prolapse, and even hemorrhoids are maladies the humans have as if to pay the price for achieving the ability to maintain the erect posture through biological evolution!!
  • Progression of symptoms – Gets worse with activity
  • Special tests – Q-tip test, urodynamics, pelvic exam in April 2011 – postvoid residue – 600 cc, moderate urethra vesicle junction hypermobility, normal urethral resistance, levator ani tenderness, pelvic floor muscle strength on Power/Endurance/Repetitions/Fast scale 1/3/5/5.
  • Significant difficulty with isolation
  • Clitoral and anal wink present
  • Q tip resting +40°, with straining +70°
  • Prolapse – Urethrocele and cystocele to introitus, mild rectocele, and uterine prolapse
  • Treatment received – None after first childbirth. After the second childbirth, a laparoscopic vaginal hysterectomy and a pelvic floor reconstruction surgery was recommended by the first gynecologist. The patient sought a second opinion from an urogynecologist. The patient was recommended six sessions of biofeedback over 4 months and was taught Kegel exercises (pelvic floor exercises). The patient reported no significant change in symptoms. The patient's goal was to avoid surgery.


In 2008, the patient started a gentle practice of Iyengar Yoga. In 2010, she switched to Ashtanga Yoga of Mysore. The patient adjusted to this physically demanding intense form of yoga asanas and it helped to improve mood (Emma, 2020). In 2011, the patient tried several different pessaries – Gellhorn, inflatable, donut size 5 and 4. None of the pessaries stayed well in desired positions. Bulging from the prolapse remained the same until about 2014. The patient did consult a physical therapist in Houston who specializes in pelvic floor disorders. The patient was recommended to continue yoga and monitor symptoms. The patient was recommended to try vaginal weights for pelvic floor strengthening. She tried but found it cumbersome and discontinued. The patient continued daily practice of 90 min of Ashtanga Yoga. The patient made healthy choices in food, pranayama/breathing exercises, and good sleep hygiene. Yoga practice led to gradual changes in lifestyle. The patient lost 15–20 lbs over 3–4 years. The patient gradually started noticing improvements in bulging and in 2016, reported being symptom free even with an active lifestyle.

Currently, the patient performs 120 min of advanced yoga poses and pranayama for 15–20 min daily. She has been teaching yoga in the community for the past 10 years.


  Conclusion Top


The abdominal canister (syringe) is made up of the diaphragm at the top, the transverse abdominis at the front, the multifidus in the back, and the pelvic floor and deep hip rotators at the bottom. The POP takes place when excessive pressure inside the abdomen and pelvis, pushing against weak pelvic floor muscles, causes “herniation” of pelvic organs in the vagina. The causes of POP are multifactorial. The buildup of pressure and inability to contain the organs by the core muscles of the abdominal canister can be due to excessive straining, pushing, poor alignment, aging, or a combination of many factors. Kegel exercises only focus on strengthening the pelvic floor (Bø, Hilde, Stær-Jensen, Siafarikas, Tennfjord, & Engh, 2015). However, effective POP management requires addressing all components of the abdominal canister. The mechanisms of action of these therapeutic techniques discussed above are to be understood as mediated through creating negative pressure in the canister repeatedly and as continuously as possible, and strengthening pelvic floor muscles simultaneously.

The practice of Ashtanga Yoga encourages healthy lifestyle changes as well as better usage of the abdominal canister. It encourages proper activation of the respiratory diaphragms both thoracic and pelvic (Ujjayi breath), which helps with proper pelvic floor activation/synchronization. It helps to improve postpartum posture and restore proper alignment (Zoolideh, Ghaderi, & Salahzadeh, 2017). Mula bandha helps to activate all the three layers of pelvic floor muscles (Sweta, Godbole, Awasthi, & Pandey, 2018). Uddiyana bandha activates core muscles including the anterior lower abdominals. Yoga poses improve myofascial sling activation. This can also help prevent postpartum development of panniculus.

The patient in our case study also made many lifestyle changes that resulted in weight loss, decrease in constipation/straining during bowel movements, better stress management with Pranayama, and improved posture alignment. During follow-up visits, the patient's pelvic floor strength had objectively improved from 1/5 to 4/5. The patient reported no bulging symptoms and has been able to lead an active lifestyle.

According to the AUGS, the prevention and treatment of POP can be managed through lifestyle changes and nonsurgical and surgical methods. Nonsurgical treatments such as physical therapy, mechanical support through pessary, and estrogen use are often considered before moving on to surgical treatments such as repairs, reconstructions, and hysterectomy. About 20% of hysterectomies are prolapse related. The rate of recurrent prolapse surgery is 29%–30%, suggesting that certain prolapse surgeries predispose patients to prolapse in another compartment (Karram, 2013). The authors propose that yogic techniques outlined above need to be given an adequate trial under expert guidance of a knowledgeable yoga teacher or physical therapist prior to considering surgical approach (Huang, Jenny, Chesney, Schembri, & Subak, 2014).

Science seems to be groping about for some external help in the form of substitution therapies, tranquilizers, antibiotics, etc., but it is being appreciated more and more that the approach should also be from the other end, that is, the internal systems of human have to be trained to cope with the new situations and circumstances. In other words, human has to be trained to be able to cultivate his/her own powers of adaptation and adjustments (Kuvalayananda & Vinekar, 1963).

Yoga, it must be pointed out, lays great stress on this aspect. It does that through the following three internal steps:

  1. Cultivation of correct psychological attitudes
  2. Reconditioning of the neuromuscular and neuro-endocrine-immune systems, in fact, the whole body (and mind) to enable it to withstand greater stress and strain
  3. Laying emphasis on a health-giving diet, and encouraging the natural processes of elimination, wherever it is necessary, by resorting to special lavages and baths. These constitute the three general measures of yogic therapy.


Limitations

This case study is limited to observations recorded in one individual. Because of the benefits of Ashtanga Yoga experienced by one patient, further research would be beneficial in establishing a link between the practice of specific techniques of yoga and the control/reversal of pelvic floor issues. If ethically acceptable, randomized controlled clinical trials may be encouraged.

(This article is dedicated to the revered memory of Dr. [Mrs.] Krishnabai Sanjiv Vinekar [1915–2000], the pioneer yogic therapist for women. She was the Women's Health Medical Director at Kaivalyadhama Yogic Health Center in Mumbai from 1949 to 1966, and practiced yogic therapy for select patients and was a yoga teacher until she was 85 years old).

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.[18]



 
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Bradley, C. S. (2018). Progress toward understanding pelvic organ prolapse. American Journal of Obstetrics and Gynecology, 218 (3), 267-268. [doi:10.1016/j.ajog.2018.01.042].  Back to cited text no. 2
    
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Bø, K., Hilde, G., Stær-Jensen, J., Siafarikas, F., Tennfjord, M. K., & Engh, M. E. (2015). Postpartum pelvic floor muscle training and pelvic organ prolapse – A randomized trial of primiparous women. American Journal of Obstetrics and Gynecology, 212 (1), 38. [doi:10.1016/j.ajog.2014.06.049].  Back to cited text no. 3
    
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