Pelvic Organ Prolapse Prevention and Management

This information is for educational purposes only and should not be taken as medical advice. If you have any concerns regarding pelvic organ prolapse, we advise that you see your healthcare provider, such as a pelvic health therapist, for a proper assessment and management plan specific to you. 

What is Pelvic Organ Prolapse?

Pelvic Organ Prolapse (POP) is a common pelvic health condition that affects approximately one third of postpartum women (1). Symptoms can start during pregnancy, but are more common after a vaginal birth and/or subsequent pregnancies (2,3). POP occurs when the position of a pelvic organ descends, resulting in bulging of the vaginal wall or rectum.

There are various types of POP, including:

• Urethrocele is when the urethra pushes into the vaginal wall 
• Cystocele is when the bladder pushes into the vaginal wall 
• Uterine prolapse is when the cervix/uterus descends into the vaginal canal 
• Rectocele is when the rectum pushes into the vaginal wall
• Rectal prolapse is when the rectum descends into/through the anus

(London Health Sciences Centre, 2023)

What does Pelvic Organ Prolapse feel and look like?

Signs and symptoms can vary, but POP is commonly described as: 

• Heaviness or pressure around the vagina or anus
• An observable bulge at the entrance of the vagina or anus
• The feeling that a tampon is stuck in the vaginal opening 

There are different grades (degrees) of POP, ranging from 1-4. Low grade prolapses do well with physiotherapy, whereas high grade prolapses may require surgery and/or internal support (pessaries). This article will focus on conservative care, and the key contributing factors to address prenatally, during childbirth, and postpartum. 

How do you treat and/or prevent Pelvic Organ Prolapse?

Treatment and prevention of POP comes down to 2 main strategies: 

1. Minimize pressure from above, and 
2. Optimize support from below.

Minimizing pressure from above:

During Pregnancy:

The changes to your body during pregnancy increase the amount of pressure from above (AKA “intra-abdominal pressure”), which can weaken the tissues that support your pelvic organs, and overwork (and weaken) your pelvic floor muscles from below.

Here are some tips you can try that will reduce pressure from above, to prevent and manage symptoms of POP:

1. Breathe.

As your pregnancy progresses, you might feel weaker and less mobile as your core muscles and tissues continue to stretch, to accommodate your growing baby. When performing heavier tasks and exercises, the strategy your body often takes naturally is to hold your breath and brace. This is not optimal, as breath-holding increases the pressure from above, putting excess strain on the tissues that support your pelvic organs.

Instead of holding your breath and bracing, try inhaling to prepare (expanding your rib cage and belly), then exhale while performing the heavier task, such as lifting a laundry basket or child. Make sure to breathe throughout when performing repetitive physical tasks as well, such as climbing stairs.  

2. Mobility.

Your rib cage and abdominal wall need to be flexible in order to expand and lengthen while breathing, or else an increase in pressure can be transferred down to your pelvic floor.

Consider mobility exercises such as spinal twisting and Yoga cat-cow, unless contraindicated for your body, to release tension in the tissues surrounding your rib cage. Be sure to breathe “into your rib cage and belly” when performing these exercises (versus your chest and shoulders). 

3. Toileting.

Another daily task where you might find yourself holding your breath is on the toilet. Constipation is common during pregnancy, but straining on the toilet (holding your breath and pushing hard) increases pressure from above, putting excess strain on the tissues that support your pelvic organs. There are many strategies to treat constipation that don’t involve straining. A few simple and common recommendations are as follows:

• Place a stool under your feet so that your knees are above your hips
• Focus on relaxing your body (and mind) with diaphragmatic breathing 
• Breathe in to relax your pelvic floor muscles before you push, and breathe out while you gently push, instead of holding your breath
• Consider increasing your fibre and/or water intake (speak to your healthcare provider for more guidance).

4. Exercise.

It is important to learn how to modify your exercise during pregnancy, as research shows that being active is an important part of a healthy pregnancy for most expecting parents. We highly recommend participating in evidence-based pregnancy workouts and consulting with a Pelvic Health Physiotherapist or qualified exercise professional for guidance.

To prevent and manage symptoms of POP, see Jenni’s tips below, under “How to Manage POP During Exercise”. 

During Childbirth:

In order to minimize pressure from above, and protect the structures that support our pelvic organs, we need to look at the evidence on the pushing stage of childbirth.

• Labour and Birth Positions. Upright positions that use gravity can help your baby descend, may shorten the pushing stage, and may require less effort to push, thus less intra-abdominal pressure overall. Examples include standing, kneeling, or all-fours. Lying on your back (e.g. lithotomy position) requires you to push against gravity and restricts your sacrum from moving freely. Ultimately, this may translate to more pressure required for pushing, leading to an excessive amount of pressure on your pelvic structures. 
• Pushing Method. When it comes time for the pushing stage of childbirth, birth providers may instruct you to hold your breath for 10 seconds and push as hard as you can (i.e. valsalva maneuver), which would assist your baby out faster (if needed). This approach increases intra-abdominal pressure significantly, and may be more likely to weaken the tissues that support your pelvic organs. Thus, in a non-emergent situation, breathing (exhaling) to push, with a relaxed jaw, can be an effective method to birth your baby, without excessive intra-abdominal pressure. 
  

The above birth practices are often seen in a midwifery model of care. For more information and the evidence on labour and birth positions, refer to Evidence Based Birth here.

*Refer to the disclaimer above. These birth practices may not be the best for you. Talk to your healthcare provider about your “birth preferences”. It is also important to educate yourself prior to the birth of your baby(ies), ask questions, and learn to advocate for yourself (with help from your birth partner). 

Postpartum:

Managing intra-abdominal pressure is especially important postpartum as your abdominal and pelvic floor tissues are recovering from pregnancy and childbirth. 

1. Breathe.

As with the prenatal tips above, be sure to breathe while performing heavier or repetitive daily tasks. Without proper breathing, these tasks can increase accumulated intra-abdominal pressure and aggravate symptoms of POP.

Inhale to prepare (expanding your rib cage and belly), then exhale while performing the heavier task, such as lifting your baby, car seat, or stroller. Make sure to breathe continuously when performing repetitive tasks as well, such as climbing stairs or walking with a stroller.  

2. Mobility.

Your rib cage and abdominal wall need to be flexible in order to expand and lengthen while breathing, or else an increase in pressure can be transferred down to your pelvic floor.

Consider mobility exercises such as spinal twisting and Yoga cat-cow, unless contraindicated for your body, to release tension in the tissues surrounding your rib cage. Be sure to breathe “into your rib cage and belly” when performing these exercises (versus your chest and shoulders). 

3. Cesarean Scar Tissue.

Tight abdominal scar tissue can also force the pressure downward to your pelvic floor. The first strategy we usually recommend early postpartum is to breathe into your incision (expanding your lower abdomen on inhalations) to gently mobilize the healing tissues and minimize stiffness. Once tissue has healed, massaging above/on/below the scar for a few minutes per day can help mobilize scar tissue and ultimately minimize the pressure from above. Please see your Pelvic Health Therapist to assess your scar and for guidance on massaging it. For further guidance on healing after cesarean delivery, check out of blog on C-Section recovery.

4. Toileting.

Similar to pregnancy, constipation can also be common postpartum. A few simple and common recommendations are as follows:

• Place a stool under your feet so that your knees are above your hips
• Focus on relaxing your body (and mind) with diaphragmatic breathing 
• Breathe in to relax your pelvic floor muscles before you push, and breathe out while you gently push, instead of holding your breath
• Consider increasing your fibre and/or water intake (speak to your healthcare provider for more guidance)

5. Exercise.

It is important to learn how to safely return to exercise postpartum. For example, you should always begin at a lower intensity and gradually progress according to your body and symptoms. We highly recommend participating in an evidence-based postpartum workout program and consulting with a Pelvic Health Physiotherapist or qualified exercise professional for guidance.

To prevent and manage symptoms of POP, see Jenni’s tips below, under “How to Manage POP During Exercise”. 

Onto the second strategy… 

Optimizing support from below:

The following are considerations to help you optimize support from below.

1) Pelvic Floor Muscles.

Your pelvic floor muscles have many functions, one being to support your pelvic organs (bladder, uterus, bowels) from below. Optimizing muscle function is not just about strengthening (“kegels”). You can have a very strong pelvic floor and still experience symptoms of POP. The resting tone, mobility, timing, and coordination of these muscles are all equally important. If the muscles are too tense (from overuse), they can be weak and unable to manage increased pressures from above. Learning how to relax (lengthen) your pelvic floor muscles is just as important as contracting them. It is especially important for toileting, intercourse, and childbirth! We strongly recommend seeing a Pelvic Health Physiotherapist to assess all aspects of your pelvic floor muscles, and to create a treatment plan specific to you. If you are currently pregnant, consider scheduling an assessment in your second trimester. 

2) Core Coordination.

Learning how to use your breath, abdominal and pelvic floor muscles in coordination is key to preventing and managing symptoms of POP, by both managing the intra-abdominal pressure properly and preventing the pelvic floor muscles from overworking (thus weakening). You should then apply this coordination to daily physical tasks and exercises. You can learn how to properly connect to and coordinate your breath, abdominal and pelvic floor muscles in this video here. A Pelvic Health Physiotherapist can help you ensure that you are performing this exercise correctly.

3) Protecting the Pelvic Floor in Childbirth.

The same birth practices that minimize the amount of pressure from above (upright birthing positions and breathing to push) are also protective of the pelvic floor (i.e. less perineal tearing). Upright positions also lower your risk of “needing” medical assistance, such as an operative vaginal delivery (forceps, episiotomy) which increases the severity of tearing and your risk for POP (3). When possible, breathing (exhaling) to push may allow for a slow and controlled delivery of your baby’s head, which also lowers the risk and severity of tearing. Sometimes healthcare providers instruct you to stop actively pushing during crowning so the perineum can stretch gradually. Again, these birth practices are often seen in a midwifery model of care. For more information on protecting your perineum in childbirth, refer to Evidence Based Birth here. Always talk to your healthcare provider about your birth preferences.

Additional Strategies:

How to Manage POP During Exercise: 

• If you feel symptoms of POP when exercising, try reconnecting to your abdominal and pelvic floor muscles during the exercise (see “Core Coordination” above)
• If you’re still experiencing symptoms of POP, try adjusting the exercise to decrease the weight, duration, or intensity of the exercise.
  • Weight: try using lighter weights or bodyweight only.
  • Duration: decrease the length of time or number of times you do an exercise. For example, instead of holding a wall sit for 60 seconds, try 30 seconds, or instead of 15 squats, try 10 squats.
  • Intensity: try using a lower impact modification to decrease intensity. For example, instead of jump squats, try air squats. 
• Use of a pessary may be another helpful tool to provide additional support for you during exercise.

Both The Prenatal Academy and The Postnatal Academy workout programs teach you how to build up your strength safely, while preventing injury and appropriately managing pressure on your pelvic floor. 

How to Manage POP During Daily Activities:

• When doing your daily activities, consider how your body feels and how it is managing the pressure. If you feel symptoms of POP, try one or more of the following:
  • Take more frequent breaks during the activity. This will minimize the amount of accumulated pressure and may decrease the impacts of the activity on your pelvic floor. For example, vacuum one room at a time, instead of your entire house at once.
  • Break the activity up into smaller parts. For example, if you need to carry a bunch of laundry from your basement up to the second floor of a house, break this up so that you carry from the basement up to the main floor in the morning, and then from the main floor up to the second floor in the afternoon.
  • Decrease the amount of weight you’re lifting if possible, or alternatively get assistance to complete the task. You may want to invest in lighter weight equipment (strollers, car seats, etc.).
• Use of a pessary may be another helpful tool to provide additional support for you during daily activities.

In addition to the physical strategies explained above, we can’t forget about other lifestyle factors that play a role in both prevention and management of POP, including: 

• managing stress/anxiety/depression, 
• balancing hormones, and 
• optimizing nutrition, hydration and sleep. 

These factors can affect all aspects of your pregnancy, birth, and recovery postpartum, and should always be addressed to optimize your pelvic health. We have an interdisciplinary team of practitioners that can address all these lifestyle factors at the WOMB in Vaughan.

References:

1. Sigurdardottir T, Bø K, Steingrimsdottir T, Halldorsson TI, Aspelund T, Geirsson RT. Cross-sectional study of early postpartum pelvic floor dysfunction and related bother in primiparous women 6-10 weeks postpartum. Int Urogynecol J. 2021 Jul;32(7):1847-1855. doi: 10.1007/s00192-021-04813-y. Epub 2021 May 3. PMID: 33938963.
2. Vergeldt TF, Weemhoff M, IntHout J, Kluivers KB. Risk factors for pelvic organ prolapse and its recurrence: a systematic review. Int Urogynecol J. 2015 Nov;26(11):1559-73. doi: 10.1007/s00192-015-2695-8. Epub 2015 May 13. PMID: 25966804; PMCID: PMC4611001.
3. Blomquist JL, Muñoz A, Carroll M, Handa VL. Association of Delivery Mode With Pelvic Floor Disorders After Childbirth. JAMA. 2018 Dec 18;320(23):2438-2447. doi: 10.1001/jama.2018.18315. PMID: 30561480; PMCID: PMC6583632.

Images:

1. London Health Sciences Centre. (2023). Pelvic Organ Prolapse. [Image]. https://www.lhsc.on.ca/women-s-health/pelvic-organ-prolapse

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Note: This post is for educational purposes only and does not replace medical advice or treatment from your healthcare provider. Always follow the advice of your primary care provider when making decisions about your health and well-being.