Pelvic Organ Prolapse - Physiotherapy advice & help
- Deborah Thomas BPT MCSP MAPPI Chartered Physio
- Mar 25
- 8 min read
Updated: Apr 3
Having a pelvic organ prolapse may be really upsetting or scary : you may have been told by your healthcare provider during another exam, or you may have found a bulge while wiping or cleaning yourself, or maybe you’re experiencing symptoms that are affecting your ability to exercise, bladder control, bowel movements and intimacy.
In this blog I aim to highlight what a prolapse is, why does it happen and what options are available to you, and to empower you to know there is lots that can be done to help you feel better, exercise with confidence and lead a symptom free life.
Prolapse is not an inevitable outcome of being a woman, and rarely do women require surgery (operations) nowadays, so read on:
What is a 'prolapse':
The organs in a woman’s pelvis (uterus, vagina, bladder and rectum) are normally supported by system of:
Connective tissue, fascia & ligaments, and:
A group of muscles known as the 'pelvic floor muscles', and:
The vaginal wall
If these support structures are weakened, overstretched, the pelvic organs can bulge / protrude / prolapse from their normal position into, or out of, the vagina. When this happens it is known as ‘pelvic organ prolapse’.
A prolapse is not life threatening, but it can affect quality of life and cause discomfort and other symptoms.
A few key points to bear in mind
Pelvic organ prolapse is common, affecting 1 in 10 women over the age of 50 years.
Prolapse can affect women after Pregnancy & child-birth
Mild prolapse often causes no symptoms and treatment is not always necessary.
Prolapse can affect quality of life by causing discomfort and other symptoms I’ll discuss below in greater detail.
Treatment choices for prolapse may include physiotherapy, support pessaries, vaginal oestrogen or surgery.
Your choice of treatment will depend on how the prolapse affects your quality of life. Not everyone with prolapse needs surgery or any other form of treatment.
Treatment for prolapse aims to support the pelvic organs and helps to ease your symptoms. It does not always cure the problem completely and prolapse may return
Anxiety regarding intercourse , exercise do's & don'ts are common and I hope to address these below
Pelvic organ prolapse - Symptoms
Pelvic organ prolapse symptoms differ between individuals, and will depend on the type and degree of the prolapse. Sometimes pelvic organ prolapse has no symptoms and is found during an internal examination carried out for another reason.
Symptoms might include:
A feeling of heaviness around your lower tummy, pelvis and genitals (vagina or back passage), these may get worse as the day goes on
Back ache
A dragging sensation inside your vagina or perineum, this also may get worse as the day progresses
Feeling like there's something coming down into / or out of your vagina – it may feel like sitting on a small ball
Feeling or seeing a bulge or lump in /or coming out of your vagina
Discomfort or pain during sex, changes in sensation during sex
Problems passing urine – such as feeling like your bladder is not emptying fully, needing to go to the toilet more often ( urinary frequency) or more urgently (Urinary Urgency), or leaking a small amount of pee when you cough, sneeze or exercise (stress incontinence)
Problems passing stool - such as struggling to fully empty your bowels, pocketing of stool, or needing to use finger pressure to help bowel movement (this is called 'splinting')
Prolapse symptoms can be improved with lifestyle changes, avoiding constipation and corrective exercise and breathing techniques while lifting - all these are assessed, taught and form part of what we do in physiotherapy.
What are the different types of prolapse?
The different types of prolapse depend on which pelvic organ is bulging into the vagina. Often, women will experience more than one type of prolapse at the same time.
The prolapse can be of various degrees (grades or stages) depending on how far down the vagina, the prolapse is coming.
Symptoms and treatment of different types of prolapse may differ from person to person. The main reason for grading a prolapse is to help healthcare professionals, identify who may require surgery, and the level or grade of prolapse may not correlate with the severity of the symptoms a woman experience.
Anterior vaginal wall prolapse: (cystocele or cysto-urethrocele) when the bladder and/or urethra bulges into the front wall of the vagina
Posterior vaginal wall prolapse: (rectocele) when the rectum bulges into the back wall of the vagina .
If the small bowel bulges into the back wall of the vagina, this is called an Enterocele.
Uterine (womb) prolapse: when the uterus lowers down into the vagina.
Vault prolapse: when the top of the vagina (or vault) bulges down. This can happen if you have had a hysterectomy
Why does a prolapse happen? The risk factors for developing a prolapse:
Pelvic organ prolapse can happen when the support from the pelvic tissues isn’t effective. This can be due to the following:
Pregnancy and vaginal delivery- Pregnancy, and especially several pregnancies close together, add a load on the pelvic support tissues; Child birth, especially a vaginal delivery, can lead to a significant stretch of these tissues, and at times muscle injuries a 3rd or 4th degree tear (you can read more about these in my blog here)
Assisted vaginal delivery - especially a forceps delivery
Age – prolapse is more common as you get older, particularly after your menopause. The pelvic tissues require the hormone Oestrogen for their strength and elasticity, and so when women’s natural levels of oestrogen reduce through hormonal changes, this can be one mechanism why the support is not as effective.
Conditions that cause excessive pressure on the pelvic floor like obesity, chronic cough, chronic constipation, repeated , incorrect technique for heavy lifting and straining: These can, over time, be the main cause for over-load on the pelvic support system. We all need to lift in our day-to-day life, but how we lift can make a big difference to the pelvic tissues.
Family history & genetics - Hypermobility is a condition where the connective tissues can be ‘over-elastic’ and provide less support; Genetically, some people are more prone to be hypermobile, and may have an inherited risk for prolapse, while some diseases affect the tensile strength of connective tissue, e.g. Marfan syndrome and Ehlers-Danlos syndrome. This can’t be changed, but needs assessing and identifying as a factor to consider in treatment.
Abdominal or pelvic surgery - past surgery in the abdomen or pelvis can increase the risk of the pelvic tissues not managing to support the remaining organs so well
Scar tissue - scar tissue is the body’s natural ‘glue’, and tends to pull or draw tissues towards it. There is evidence to show, that in some cases, scarring in the perineum, maybe form an episiotomy or a repair of a tear, can be a reason why tissues appear to be drawn downwards, and can lead to symptoms of prolapse, when sometimes no prolapse is found on assessment.
Often it is a combination of some of these factors that result in you having a prolapse.
How is a prolapse diagnosed?
The diagnosis is based on history taking, symptoms and an internal examination. The examination may be in lying or standing, and may use fingers only or a speculum. The prolapse may be be staged from 1-4 depending on the degree of prolapse. This may be carried out by your GP, nurse, Gynaecologist or Pelvic Health Physiotherapist (women's health physio).
About intimate examinations: The nature of women’s health obstetric & gynaecology care means that intimate examinations are often necessary. I understand that for some people, such examinations can be very difficult. If you feel uncomfortable, anxious or distressed at any time before, during or after an examination, please let me know. You may find this information about how I work helpful: https://www.deborahthomasphysio.co.uk/faq
Treatment options / getting help:
If you do not have any symptoms, or the prolapse is mild and not bothering you, you may not need treatment, but making some lifestyle changes can help you prevent any worsening in the future and can still help.
The recommended treatment depends on the severity of your symptoms, their effect on your quality of life, hobbies, exercise and intimacy; The type and severity of the prolapse, and your overall health. It is always helpful to see a physiotherapist specialising in pelvic health and go over the basics, as even if the prolapse is severe, we can help significantly with the symptoms that bother you.
What are your treatment options?
Treatment options vary from ‘conservative’, meaning non-surgical, all the way to surgery;
All treatment for prolapse aims to:
Support the pelvic organs
Ease your symptoms
Prevent any worsening, reduce risks of further or future deterioration
Empower you to return to your activity goals and enjoy your hobbies and past-time.
Treatment does not always cure the problem completely and prolapse may return. Your options for treatment will depend on the type and degree of prolapse you have and your individual circumstances, such as age, general health, past surgeries, whether you are sexually active and whether you have completed your family.
Your options may include:
Do Nothing - Prolapse is not a life-threatening condition and many women will choose not to have any treatment if they have no symptoms or discomfort.
Conservative Management:
Physiotherapy ( Women’s health physiotherapy, also termed pelvic health physiotherapy) ; Support Pessaries; Vaginal Oestrogen
Surgery
Physiotherapy for pelvic organ prolapse:
Physiotherapy may be the only treatment approach you use, or it may be used prior to surgery - ‘Prehab’ , or post operatively, as 'rehab' to make sure you are doing everything you can, and correctly, to have the best outcomes of your surgery.
Within physiotherapy, a wholistic, in-depth screening & assessment will inform the treatment, which may include:
Education regarding pelvic anatomy, function & health; Myth busting and evidence based information & advice.
Identifying your risk factors and how to improve them or reduce their effect
Improving diet, nutrition and hydration to reduce constipation & straining;
Tuition of breathing techniques to reduce straining and aid bowel movements; I have prepared a video to help you learn & practice the ‘Belly Big / Belly Hard’ technique, Here: https://youtu.be/QjcVnKA51sM
Learn correct lifting techniques - you may find reading my blog about ‘The Knack’ helpful - HERE
A musculoskeletal and pelvic health assessment of all the structures, joints, muscles & tissues involved in controlling the loads in the pelvis.
A Tailored exercise programme to reduce the prolapse, as well as strengthen any muscle groups which were found to be weak;
Practicing correct breathing while exercising to manage pressures down onto the pelvic organs.
Pelvic floor exercises can include training for strength, as well as letting go or ‘down-training’. It’s really valuable to use guidance from this app - The Squeezy app and even more important to come and check if you are doing these correctly.
Manual therapy to address any tightness / overactivity in soft tissues & muscles.
Scar tissue manual therapy and / or acupuncture if this is found to be a contributing factor
Pessary support - Some physiotherapy clinics provide a bespoke pessary fitting service
A return to activity & sports plan & programme
Communication with other healthcare providers such as GP, Gynaecologist, Urologist as required.
Surgery (operation)
If non-surgical options have not worked or the prolapse is more severe, surgery may be an option.
There are a few different surgical options for pelvic organ prolapse. Surgery is performed by gynaecologists.
They include:
surgical repair
hysterectomy
closing the vagina
Your gynaecologist will discuss the benefits and risks of each different option, and you'll decide together which is best for you.
It is important to appreciate, that if you are going to have surgery, a ‘prehab’ programme with a pelvic health physiotherapist will reduce post-surgical risks and improve the success of the surgery.
There are several useful guides that you can read to help you decide, together with your healthcare provider, which type of treatment or surgery would be right for you:
I also recommend these resources and further information:
The pelvic, obstetric & gynaecology Physiotherapy (POGP) : HERE
The Women’s Health Concern fact sheet: HERE
The POP-SS symptoms questionnaire can be accessed through: HERE
IUGA information leaflet and images about pelvic organ prolapse: HERE
An IUGA podcast discussing pessaries vs surgery for pelvic organ prolapse: HERE
An IUGA podcast about physiotherapy and post operative rehabilitation HERE
I hope I have given you a starting point and understanding about prolapse.
If you wish to come and see me, and start you rehab journey, you may book you appointment online via this link: https://clientportal.uk.zandahealth.com/clientportal/deborahthomasphysiotherapy
