What is a 'relaxed vaginal outlet'?

Recently a 32-year-old mother asked me this question after her obstetrician mentioned the term during her six weeks post baby visit. I explained that damage to the perineal musculature from childbirth (or surgery) is a common cause of the relaxed vaginal outlet (not all women have symptoms). When the tissues between the rectum, vagina and perineal body (area between the vagina and anus) are weakened, this causes a relaxed vaginal outlet, which is usually associated with a rectocoele (posterior vaginal wall prolapse). Normally the rectovaginal fascia, which is attached to the levator ani muscles, prevents the rectum from prolapsing into the vagina.

The levator ani muscles support the pelvic organs and when the pelvic floor is intact the organs rest on the levator muscles, significantly reducing tension on the supporting ligaments and fascia.  The pelvic floor muscles and pelvic ligaments work together to support pelvic floor structures. If the levators are damaged during childbirth (related to use of instruments, episiotomy, back-lying or early forced pushing), the muscles fail to effectively lift and hold to support the organs. Extra loading is then placed on the ligaments (when lifting or exercising) leading to possible pelvic organ prolapse.

After childbirth or pelvic surgery a women’s health physiotherapist will evaluate the structural integrity of the perineal body, assess for pelvic organ prolapse, treat pain, specific muscle weakness or tendon damage and provide an individual program to restore pelvic floor function. This program may involve treatment of any muscle/tendon damage, pain relief, life style advice, postural correction, and guidelines for safe return to exercise, pelvic friendly exercises and specific pelvic floor muscle strength exercises.