The short answer is yes! Absolutely! Pelvic Health physical therapy should be your first stop if you have a grade 1, 2 or 3 prolapse-- in other words, if your organ is not completely falling out of your body-- you should do physical therapy. A 2010 randomized controlled trial of women with grades I, II and II prolapse concluded "Pelvic floor muscle training is without adverse effects and can be used as treatment for prolapse” (Brækken). But, physical therapy is way more than just “kegels” or pelvic floor muscle training…
So, let’s dive into some details!
What is prolapse?
Pelvic organ prolapse (POP) occurs when the female organs drop down below their normal anatomic position. (Saunders) The name is based on what organ is “falling”: bladder prolapse (cystocele), urethral prolapse (urethrocele), rectal prolapse (rectocele), small intestine prolapse (enterocele). Prolapse of the uterus and/or vagina may also occur. Symptoms can be:
Pelvic heaviness
Vaginal bulging
Incomplete bowel or bladder emptying
Urinary or fecal incontinence
Needing to splint (push up on) the area between the vagina and anus OR inside the vaginal wall to have a bowel movement
Sexual discomfort
Some women also report the sensation of having a “golf ball” in their vagina or rectum. While this might seem like a prolapse symptom, it is often irritation of the pudendal nerve. Because of this common mistake, seeing a physical therapist specializing in pelvic health is very important.
About ½ of women lose support (or have some degree of pelvic organ prolapse) after childbirth (Saunders, Bo), though not all have symptoms. Prolapse can be very scary for patients! At RVA Holistic PT, we are always talking about “control the controllables!” However, some risk factors for prolapse are out of your hands.
Risk factors for prolapse include:
Older age
Menopause
Vaginal childbirth(s)
Neurologic issues
connective tissue abnormalities
Joint hypermobility syndromes (like Ehler’s Danlos)
Family history (genetic component)
Frequent increases in intra-abdominal pressure (heavy lifting, chronic constipation, chronic cough)
Increased BMI
Smoking (Saunders)
While there are risk factors that are out of control (such as a family history), there are others that you can influence (weight, smoking, constipation). So, let's control the controllables...
Prevention: Honestly, most women are unconcerned with prolapse until they have prolapse, but prevention is always the best cure! Tips to prevent a prolapse are…
Keep your bowels moving! Straining, pushing and sitting on the toilet for prolonged periods of time (over years or decades) puts a lot of strain on the ligaments and fascia that hold the organs up. Use a squatty potty and eat a diet rich in fruits and vegetables.
Maintain an optimal weight (I know, I know, this is hard!).
In pregnancy: the pelvic floor stretches 3-5 times it’s length during delivery, so prepare your pelvic floor muscles and bones for birth with appropriate strengthening and stretching exercises (click to learn more in another blog post). While there is no evidence that perineal massage helps prevent perineal tearing, it is useful to teach you to relax into an intense sensation.
In the postpartum period, you are at a higher risk of prolapse due to decreased estrogen levels and the laxity of pelvic floor muscles, ligaments and fascia that are recovering from birth. Know this! And this is why you should be careful to avoid lifting heavy objects (common advice is nothing heavier than your baby) for the first month after delivery.
In the menopausal years, you may want to take extra care of your pelvic floor. This is another time of life where there is a dip in estrogen, which can contribute to prolapse and prolapse symptoms.
Treatment options for prolapse:
Pelvic Floor Muscle Strengthening, aka “kegels”
A study by Braekken found improvement in stage I, II and III prolapse with the intervention of pelvic floor muscle exercise. The dosage this study used was 8-12 repetitions and 3 sets of close to maximal contraction. There are different “compartments” of the pelvic floor muscles. A loss of elasticity in the pubovisceral portions (front compartment) of the pelvic floor has been shown in prolapse (Saunders). In some patients, the "back compartment" gets extra tight in an effort to substitute for the "front compartment," which can make your symptoms worse. This is why prolapse is hard to “DIY” or even just take suggestions from your gynecologist or urogynecologist. An individualized assessment by a physical therapist in this subspecialty of pelvic health can help to make sure you are doing “kegels” correctly and find the right word cues to help you get a good lift and squeeze. We assess our patients for strength in the different “compartments” and find the right words to help YOU get the most
out of your pelvic floor muscle exercises.
The effectiveness of pelvic floor muscle training in women with prolapse has been demonstrated in several studies such as this (Saunders, Braeken) (yay!!), but there seems to be some women who respond really well to pelvic floor muscle strengthening and other women who do not. Wiegersma found younger age OR the presence of obstetric trauma (including high birth weight, episiotomy, perineal laceration during vaginal delivery, forceps delivery, or vacuum extraction) to predict “responding” to pelvic floor muscle training- aka- these folks tend to get better! (Wiegersma). Perhaps with obstetric trauma, the muscles and fascia do recover with training and time (another yay!). There is hope! I have seen (well, actually “felt”) a patient who had significant atrophy of her pelvic floor muscle and I thought it may be a tear, but after several weeks of pelvic floor muscle strengthening, her muscle hypertrophied! The body can compensate quite well, unless it is a full avulsion (Saunders), but that is another blog post! Head to the bottom of this blog post for a 6 minute video on pelvic floor (and hip) exercises for prolapse that follows the research (of course, every person is unique and PLEASE have an individualized assessment by a Pelvic Health Physical Therapist).
2. Rebalancing the pelvic floor muscles and tissues. New resaearch by Dr. Anna Crowley, PT suggests that tension in the pelvic floor can cause more prolapse symptoms. This approach is called the biotensegrity model. We assess each person and rebalance the pelvic floor through hands-on treatment, corrective exercises, visercal mobilization and low pressure fitness.
3. Squeeze before you sneeze (or cough)
If you have symptoms of prolapse with cough, sneezing or lifting, try the “knack”. Before lifting a heavier object or sneezing, “squeeze” your pelvic floor first. This is using your pelvic floor in action. See if it helps!
4. Alignment
Imagine your “core” is a balloon. The top of the balloon is the diaphragm (breathing muscles), the front of the balloon is the transverse abdominis (deepest abdominal muscle), the back of the balloon is the multifidus (the back muscle) and your pelvic floor muscles are the bottom of the balloon. If you have slumped posture, there is a lot of pressing on the top of the balloon. That pressure has to go somewhere… it goes to the body’s weakest link-- sometimes that is the pelvic floor. Having increased kyphosis (a fancy way of saying having forward shoulders, slouched around the bra line and/or stiff around the bra line) has been shown to increase prolapse symptoms. So, alignment matters!
Having good alignment is more than standing up straight. You need to be able to stand up straight. Which means you may need more mobility in order to do so. Below is a video on postural cues that help some of our patients with alignment. Many others need individualized guidance on mobility of their hips, chest, mid-back and shoulders in order to be able to stand up straight!
5. Hypopressives
Hypopressives or low pressure fitness is here at RVA Holistic PT --in-person and virtually! Hypopressives are a technique of training the core muscles popular in Europe. Hypopressives have been shown to strengthen the core muscles without kegels or sit ups. Sit ups increase intraabdominal pressure and are generally not recommended while your prolapse is symptomatic. Hypopressives are advantageous because they use a breath hold to create a LOW pressure environment which lifts the pelvic organs. and hypertrophies (get bigger, thicker muscles) pelvic floor muscles without doing kegels. Hypopressives have been shown to help prolapse symptoms and strengthen the transverse abdominus and pelvic floor. They are surprisingly difficult! Low pressure fitness (aka hypopressives) are very useful in those that kegels or pelvic floor muscle training has not worked effectively for, those with a dominant outer or upper abdominal wall and women with prolapse. Plus, they are fun!
6. Pessaries
Pessaries can be very useful for prolapse. Pessaries are devices that are inserted into the vagina to provide support to the vaginal walls. A vaginal tampon is the most simple version of this. The Poise Impressa is an over the counter device that is much like a tampon and can be used as a pessary. In a study by Glavind (1997), six women with SUI demonstrated total dryness when using a vaginal device during 30 minutes of aerobics (Bo). There are many different versions of pessaries and this is a great nonsurgical option to try. Some of our patients like using a pessary during higher impact activities such as jogging or when they have a planned event that they will be on their feet for a long period of time. Others use a pessary most or all of the time. (Others find that pelvic floor muscle training alone is quite effective and never even need to try a pessary).
7. Surgery
If you have tried high quality specialized physical therapy and pessaries without success, there are surgeries available to give your pelvic floor organs, muscles and fascia more support. Because prolapse reoccurs in about 58% of women post-surgery, we still recommend you see a pelvic floor PT prior to surgery. PT can assess what is happening in your abdominal canister leading to so much pressure going down your pelvic floor.
8. Diet & Lifestyle
Healthy eating is an essential part of health. Our pelvic organs are held up by fascia. Fascia encases and supports our pelvic organs; when you cut into a chicken breast-- the white encasing is fascia. When fascia is stiff, stuck and bound down, it creates a pulling. This pulling contributes to prolapse symptoms. Diet is essential for healthy fascia. Diets rich in amino acids, connective tissue like bone broth, foods that help collagen production (lots of zinc, vitamins and minerals) and gut healing foods help us absorb nutrients better.
With prolapse, it is ESSENTIAL to keep your bowels moving easily without having to bear down or push. Chronic constipation is a risk factor for prolapse and also is a known trigger for prolapse symptoms. Your bowels should move easily and without straining-- every day! Your stool should be like a soft banana. Putting your feet up on a stool or squatty potty and "going" like you are camping in the woods can help you evacuate better without having to push or strain.
If you are overweight, losing weight can also be helpful to decrease prolapse symptoms. I know this is easier said than done and sometimes prolapse prevents women from exercising (a downward spiral: can't exercise, can't lose weight). We are here to support you by helping you find exercise you can do without symptoms and support your weight loss goals.
Healing prolapse means building pelvic floor muscle and helping connective tissues heal. Animal studies of the vaginal wall suggest that oxidative stress (inflammation) increases prolapse. An anti-inflammatory diet may be helpful to decrease inflammation and provide the body the building blocks of strengthening and tissue health. That means you need a lot of nutrients - proteins, vitamins and minerals, essential fatty acids and water. “Eat the rainbow”, consume 8-11 vegetables/ fruits a day and lots of healthy fats like fish, nuts, oils and seeds. Adopt an “anti-inflammatory lifestyle”: moderate exercise, adequate sleep (7-9 hours/ night), stress management and avoiding or stopping smoking (Saunders).
Sleep: Did you know that a 2014 study found that women with pelvic organ prolapse symptoms had poorer quality of sleep? This study also proved that younger and peri-menopausal women were more likely to have poor sleep. In these groups pelvic floor symptoms were significantly worse for poor sleepers. What does this mean? Getting 8-9 hours of sleep is an anti-inflammatory and great for our overall physical and emotional well-being. Improving your sleep quality may improve your prolapse symptoms.
While prolapse can be really scary, there is a lot that physical therapy can do to help-- from pelvic floor muscle exercise and optimization, to alignment, to new techniques such as hypopressives and low pressure fitness, to helping you get your bowels moving and getting you back to exercising and doing the things you love. If you are in Virginia, we would love to see you at our Richmond, Virginia locations or virtually. We are one of the few places that do "all the things" for prolapse including hypopressive exercise. Give us a call today at 804-372-0291 or book online.
For those wanting an online course, we offer a postpartum core recovery course that is prolapse-friendly and a yoga/pilates-based exercise subscription that gets to the ROOT of prolapse issues in our Movement for {M}others Membership. Below is a 10-minute snippet of our 45-minute class.
Brækken, Ingeborg Hoff, Majida, Memona, Engh, Marie Ellström, & Bø, Kari. (2010). Can pelvic floor muscle training reverse pelvic organ prolapse and reduce prolapse symptoms? An assessor-blinded, randomized, controlled trial. American Journal of Obstetrics and Gynecology, 203(2), 170.e1-170.e7.
Bø, K., Freeman, Robert, author of introduction, etc, & Abrams, Paul, contributor. (2015). Evidence-based physical therapy for the pelvic floor : Bridging science and clinical practice (2nd ed.).
Crowle A, Harley C. Development of a biotensegrity focused therapy for the treatment of pelvic organ prolapse: A retrospective case series. J Bodyw Mov Ther. 2020 Jan;24(1):115-125. doi: 10.1016/j.jbmt.2019.10.008. Epub 2019 Oct 11. PMID: 31987530.
Saunders, K. (2017). Recent Advances in Understanding Pelvic-Floor Tissue of Women With and Without Pelvic Organ Prolapse: Considerations for Physical Therapists. Physical Therapy, 97(4), 455-463.
Wiegersma, Marian, Panman, Chantal M C R, Hesselink, Liesbeth C, Malmberg, Alec G A, Berger, Marjolein Y, Kollen, Boudewijn J, & Dekker, Janny H. (2019). Predictors of Success for Pelvic Floor Muscle Training in Pelvic Organ Prolapse. Physical Therapy, 99(1), 109-117.
Ghetti C, Lee M, Oliphant S, Okun M, Lowder JL. Sleep quality in women seeking care for pelvic organ prolapse. Maturitas. 2015;80(2):155-161. doi:10.1016/j.maturitas.2014.10.015