“I went to the gym, to my regular boot camp-type class. They had us do a difficult sit up. I stood up afterwards and instantly knew something was wrong. It felt like something was falling out of my vagina.”
Descriptions like this one are very common in my office. Patients often complain of pelvic pressure or like something is falling out. Many are not aware of what this is, or if it can be fixed. Known as pelvic organ prolapse (POP), it affects 40% of women ages 50 and older. Risk factors for POP include increased BMI, age, number of children and vaginal delivery. Many websites, programs and fitness professionals claim to treat POP. If you read their material, the information is full of “Don’t’s and Never’s.” Many of the women who seek help from me are scared to move, let alone exercise or lift their children. They think there is no hope, that surgery is their only option. While doctors perform over 200,000 surgeries each year to correct POP, several studies report that 1/3 of these surgeries fail.
While this may initially present a picture of “doom and gloom” the good news is that evidence shows that the presence of POP does not necessarily mean that a woman will be symptomatic. Many women with mild prolapse have no limitations in function. The evidence also supports exercise that includes pelvic floor muscle training, as an intervention to improve symptoms and quality of life in women with mild to moderate POP. In other words, physical therapy is beneficial for many women who deal with these symptoms. In fact, there are several myths regarding POP that may not be the complete truth:
1. I have a prolapse. It will always be there unless I have surgery
POP occurs because of a combination of events. The pelvic organs are suspended in the body by a group of ligaments and other soft tissue. The pelvic floor muscles (PFM) lie in a hammock-like position to provide support for the pelvic organs. Muscle stretching and lengthening throughout pregnancy may weaken the pelvic support system. During a vaginal delivery, the soft tissue structures become stretched as well. The good news is that mild to moderate prolapses have been shown to improve with retraining the pelvic floor muscles (Hagen, 2014). Learning the correct way to contract and use the PFM can help restore the muscular support system. If muscle strength and function is sufficient it may be enough to overcome the downward pressure of gravity onto the pelvic organs. It is important to realize that this does take time. In the Hagen study referenced, they re-assessed at 6 and 12 months after starting the exercise program. Slow and steady wins the race in this scenario. Working with a physical therapist who can help guide exercises and ensure a safe return to activity is a good idea.
2. I will never run, jump or lift heavy weights again because of my prolapse
This is simply NOT TRUE. There are few instances where I use the word “never.” The truth is, it depends. Every woman is different and every body responds differently to loading with weight and impact. As I mentioned previously, the presence of POP does not necessarily mean that it Is symptomatic. Working with someone who can slowly and safely increase the intensity of your exercise program is paramount. Adding exercises to strengthen your hips, abdomen, and back and to incorporate breathing are key component of an exercise program to improve POP symptoms. Starting a program in a gravity-minimized position that reduces downward pressure is a great place to start and once that is accomplished, moving into more challenging positions must happen. However, having someone who can help you modify your posture, alignment, breath and movement strategies is key to success. In other words, you can’t go from Kegel to Burpees with nothing in between. There is a progression to follow and steps to take that can get you back to most, if not all, activities with or without some modifications. What is most important is that you feel comfortable and confident with loading and impact.
3. If I strengthen my pelvic floor muscles I will be able to cure my prolapse
The truth in this statement lies in the fact that improving PFM function often helps improve symptoms of POP. However, it is only partially true for a couple of reasons. First, as mentioned above, POP occurs in part because of stretching and weakening of soft tissue structures with pregnancy, delivery, menopause and other factors. PFM strengthening will not change the quality of non-muscular tissue. Having said that, many women have a mild POP and are completely functional. The reasoning here comes from looking at the abdominal and pelvic cavity as a canister, with balanced pressure. Muscles and ligaments work together to support our organs. In some cases, improving muscle function can help overcome ligament laxity and loss of soft tissue support. This is why improving PFM strength can be helpful. If the hammock underneath is strong enough, it can withstand the loss of support from above.
On the other hand, what if the pressure from above is too much for the PFM to support the pelvic organs alone? What does that mean? There is a unique relationship between the diaphragm (the muscle that helps us breathe) and the PFM. As the diaphragm contracts, the PFM relax and vice versa. This relationship is designed to help control the increase in intra-abdominal pressure with things like coughing, sneezing, jumping and lifting heavy objects. Posture, breathing mechanics, and habits can affect how the diaphragm moves through the breathing cycle. Like other muscles it can be too short, too long, underactive or overactive. Rapid changes in muscle length and posture (such as pregnancy / delivery) may cause a temporary or more long-lasting change in the coordination between the diaphragm and PFM. What this means is that PFM strength and function is not the only muscular component that may affect POP. Controlling POP is a whole-body activity and multiple muscle groups are involved. Improving PFM function is helpful but depending on the individual it may not be enough.
The take home of all of this Is good news: there IS a way to improve the symptoms of POP. Experiencing POP during pregnancy, delivery or later on in life does not have to mean surgery, or having to stop meaningful activities. Find a physical therapist who specializes in pelvic health. A physical therapist with this knowledge can guide you on a safe, effective return to exercise and other physical activity without worsening symptoms of POP.