Navigating Pelvic Organ Prolapse (POP)
By Dr. Terri Robertson Elder, PT, DPT, WCS @terri.elder.dpt
What Is POP? | Types of POP | What Can I Do About POP? | Common Questions About POP | Navigating Exercise With POP | Resources & More Info
But first…Why is Street Parking talking about this “personal” stuff?
POP and other pelvic health complaints are very common and can be significant barriers to staying consistent with exercise. We hope this resource will empower individuals and their support networks with high-quality and straight-forward information to navigate circumstances that can get in the way of consistency. We hope you are here for it, too. Yes, even for that stuff.
Pelvic Organ Prolapse (POP) is the descent of one or more of the pelvic organs into and sometimes out of the vagina. Common symptoms include the sensation and/or appearance of a vaginal bulge and heaviness or pressure. POP results from changes to the connective tissue, ligaments, muscles, and/or nerves which support the pelvic organs; it’s most commonly caused by pregnancy and childbirth, especially instrumented vaginal delivery. Genetic factors, increasing age, and conditions that cause excessive pressure on the pelvic floor (like chronic cough, constipation, and repetitive heavy lifting in the workplace) are also associated with prolapse. (Interestingly, heavy lifting during exercise has so far NOT been shown to be associated with POP, only occupational lifting!)1
Debunking POP Movement Restrictions:
Providers often give restrictions to avoid lifting, running, and deep squatting to those with prolapse. These restrictions may limit exercise and the well-known benefits associated with activity. Evidence shows heavy lifting at work may contribute to the development or worsening of POP1. However, progressively lifting weights during exercise has not been shown to cause or worsen prolapse. Movement and lifting restrictions like “don’t lift more than 15 pounds” are not only unreasonable (especially for parents, right!?) but can ironically reduce the strength and ability to manage pressure that is actually helpful for navigating prolapse.
"Heavy" is different for each individual. Likewise, each person has different ways they manage pressure. Some movement limitations may be advisable temporarily for someone with a new diagnosis as they learn to navigate symptoms, improve coordination, and build tolerance to their preferred type of exercise. Individuals with multiple risk factors for developing or worsening POP (such as those with birth injuries, genetic conditions, etc.) may choose to use an internal or external support device during heavier exercise. See resources for finding a qualified pro to guide your continuation or return to progressive exercise.
Types:
Anterior Vaginal Wall Prolapse: also known as cystocele or bladder prolapse
Posterior Vaginal Wall Prolapse: also known as Rectocele (the wall between the rectum and vagina is pressing into vagina, different from rectal prolapse)
Apical Prolapse (from above): also known as Uterine or vaginal vault prolapse
Enterocele: small intestine descending into the vaginal wall, more rare
→ Rectal prolapse is considered a separate condition to POP, though there is some overlap with causes and management of both conditions.
Grades/stages: (1-4)
There are different classification systems for POP. Most commonly, grades/stages 1 to 2 are considered “mild” and inside or near the vaginal opening, and stages/grades 3 and 4 protrude beyond the vaginal opening. Stage/grade 1 POP is considered "sufficient" organ support.
First, if you have gotten a diagnosis of POP, please know that it is common to go through a challenging process of trying to figure out “what you did wrong.” You are NOT to blame, these changes are often complex and there is often no way to pinpoint the exact cause. While it's tempting to search online for more in regards to symptoms, you will likely come across outdated and fear-based information. Constantly thinking about and frequently checking on your POP (feeling or looking in a mirror) can be challenging to your mental health and is known to increase symptoms. We suggest taking some time to process in whatever way is best for you, and reach out to us for support and more resources as needed.
Symptom Management:
Reclining/elevating hips as needed.
Splinting during bowel movements (manually supporting your tissues internally or externally).
Managing pelvic floor muscle fatigue with appropriate, individualized exercise programming including recovery periods during exercise, managing exercise load, volume, and intensity.
Use of a pessary, a medical-grade silicone device that’s worn internally and is like a sports bra for your pelvic organs. Some only wear it for exercise, some wear them all the time. There are many different types, sizes, and considerations. Pessaries are fit and managed by urogynecologists and now also many pelvic health physical therapists. Pessaries can help improve symptoms and there is also emerging evidence they may help tissues improve (and therefore POP stage improve) if used consistently3,4.
Interventions targeting stress, anxiety, and depression.
Management of respiratory symptoms in cases of chronic coughing, allergies, etc.
Treatment components listed in the next section can also help to manage symptoms.
During exercise or other activity, doing a set of pelvic floor exercises can help to improve symptoms (such as 5-10 reps of “quick holds” where you contract for 1 second and relax for 1 second, or 5 longer endurance holds where you hold for 5-10 seconds and rest for 5-10 seconds).
Conservative Treatment Options:
Constipation avoidance and optimizing gut/bowel health (it’s so important we bolded it!)
Graded exposure to movement & progressive resistance training
Internal support: Pessaries
External support (EVB shorts, SRC shorts)
Topical products such as estrogen or hyaluronic acid are commonly recommended for those perimenopausal, menopausal, and postpartum/lactating
PFMT (pelvic floor muscle training) with a tailored program from a pelvic PT/OT may be helpful for muscular support and for improving symptoms but is not known to create lasting improvements to connective tissue changes
Research is mixed on the effect of weight loss; avoidance of weight gain may prevent further connective tissue changes
Will this only get worse? Some with POP experience a worsening stage or symptoms, however many do not. It is not considered a "definitively progressive" condition. Mild, asymptomatic POP is so common as to be within the realm of "normal" and does not predict worse prolapse later in life. For mild prolapse with symptoms, consider hormonal changes, vaginal tissue health, and nervous system threat response.
Can it get better? The tissue changes associated with POP may not improve without interventions such as consistent use of a pessary or surgery; however, bothersome symptoms can improve or resolve with conservative treatments. Postnatal individuals may experience a greater improvement in the few years post delivery.
What can I do to prevent it from getting worse? While there are no guarantees, treatments may help to reduce the risk of worsening, especially reducing constipation and straining. See the "conservative treatment" section for a full list of strategies that have been shown to be helpful.
Do I need surgery? This is a personal decision based on many factors. Many individuals with even moderate to severe prolapse are able to manage symptoms conservatively. If surgery is desired, it is still worthwhile to consult with a pelvic physio or pelvic occupational therapist before and after surgery. Likewise, trying a pessary before surgery is recommended in order to trial conservative options and also to rule out urinary incontinence which can be hidden by prolapse and may worsen after prolapse repair5.
What about sex? While it's common for people with POP to experience changes in self-confidence and/or how things feel, many with prolapse lead fulfilling sex lives, even those who use pessaries. To find a provider who may help, access the directories at www.pelvicguru.com and/or www.aasect.org/referral-directory.
I have symptoms of heaviness and the feeling of a "stuck tampon." Does this mean I have POP? Sometimes. Symptoms are not always reliable indicators of changes to anatomy. Research shows the symptom that corresponds best to anatomic prolapse is seeing or feeling a vaginal bulge or protrusion.
Having the guidance of a professional to help navigate return to exercise is incredibly beneficial, if you are able. (See the Resources section for directories and guided programs.)
There are many things to take into consideration with each individual, namely, how someone is managing pressure. Pressure management basically means how you are using your breath, position, and tension in your abdominals, chest, and pelvic floor during movement. Research shows each individual manages pressure differently for the same task, and even the same individual will generate pressure onto their pelvic floor differently on various trials of the same movement! This means that there are a lot of variables to consider that can contribute to how much you are “pressuring down” with various movements. Pressure is not the enemy, but how it is used can make a big impact on symptoms and ability to manage loads during movements and lifts.
Going into each variable is beyond the scope of this blog, but here are our top tips for navigating exercise with POP.
#1: BUILD PROGRESSIVELY
“Progressively” in this context essentially means gradually building up. Figuring out what movement strategies seem best for you is a process, and there is no one-size-fits-all approach! As you learn to navigate symptoms and figure out what options are most appropriate for each movement or mode of exercise, you can gradually increase load, intensity, and complexity of movement as you feel stronger and more supported down below (using the various strategies sprinkled throughout this blog). Here is a very brief example of a return-to-impact progression.
#2: BRACING VS BEARING DOWN: Check in with your pelvic floor.
There are many different strategies for “bracing” (contracting muscles to create stiffness and stability for lifts). How you breathe can also make a difference. Many suggest exhaling as you perform the “hard part” of a lift or movement, and this can be a good strategy. Some individuals may choose to hold their breath during a movement, and this can be a perfectly good option, especially a “submaximal” breathhold (i.e. your lungs aren’t completely full). These variables need to be tested individually to see how your body and performance respond. Try different things, see how they feel!
For more on these concepts, here is an amazing resource with a lot more detail on activating your pelvic floor, bracing vs bearing down, and pelvic floor precontractions during exercise.
#3: CONSIDER FATIGUE AND CAPACITY
You might need to scale back initially in order to monitor symptoms and to allow for being progressive with building strength and capacity. One other important factor to consider is how fatigue may impact your ability to manage pressure. Muscular fatigue, cardiorespiratory demand (👀 looking at you, Vault and Endurance workouts!), as well as overall fatigue (from lack of sleep, the general overwhelm of life, or injury/illness) can reduce your overall capacity to manage pressure.
Likewise, you may notice increased symptoms at the end of the day or after a lot of time on your feet. Use the strategies from the “symptom management” section like resting with your legs up and pelvis elevated for a bit or even doing some pelvic floor exercise to modulate symptoms and allow for recovery.
Check in with how you are feeling before a workout or demanding activity, and adjust the dials on intensity, weight selected, etc., to meet yourself where you are at the moment. Remember, Fitness Freedom and More Than Nothing!
And finally, your coaches want you to know you are not alone in navigating exercise if you are experiencing POP symptoms or a diagnosis. Please don’t hesitate to reach out with questions or for support to mamas@streetparking.com.
Podcast episodes with more information about POP and treatment options:
Find a pelvic health provider:
Course, product links, handouts: www.mypfm.com/prolapse
External support products:
Internal support products: there are few over-the-counter options available, and the options vary depending on your location. Internal support products such as the Impressa, Revive, and Uresta are created to support the bladder and urethra primarily for stress urinary incontinence; however, some with mild prolapse may find these products helpful. Other internal devices such as pessaries come in many shapes and sizes and are best fit by a professional such as a urogynecologist (some pelvic health physical therapists/physios also have specialized training).
References
Deprest JA, Cartwright R, Dietz HP, et al. International Urogynecological Consultation (IUC): pathophysiology of pelvic organ prolapse (POP). Int Urogynecol J. 2022;33(7):1699-1710. doi:10.1007/s00192-022-05081-0
Collins, S. A., O'Shea, M., Dykes, N., Ramm, O., Edenfield, A., Shek, K. L., van Delft, K., Beestrum, M., & Kenton, K. (2021). International Urogynecological Consultation: clinical definition of pelvic organ prolapse. International urogynecology journal, 32(8), 2011–2019. https://doi.org/10.1007/s00192-021-04875-y
Boyd SS, Propst K, O’Sullivan DM, Tulikangas P. 25: Pessary use and severity of pelvic organ prolapse over time: a retrospective study. American Journal of Obstetrics and Gynecology. 2019;220(3):S723. doi:10.1016/j.ajog.2019.01.055
Mendes LC, Bezerra LRPS, Bilhar APM, et al. Symptomatic and anatomic improvement of pelvic organ prolapse in vaginal pessary users. International Urogynecology Journal. 2021;32(4):1023-1029. doi:10.1007/s00192-020-04540-w
Vij, M., Dua, A., Davies, A., & Freeman, R. (2021). Do patients with central sensitivity syndromes have poor subjective outcomes despite anatomical cure from pelvic organ prolapse surgery?. International urogynecology journal, 32(6), 1461–1467. https://doi.org/10.1007/s00192-020-04655-0
Liapis, A., Bakas, P., Georgantopoulou, C., & Creatsas, G. (2011). The use of the pessary test in preoperative assessment of women with severe genital prolapse. European journal of obstetrics, gynecology, and reproductive biology, 155(1), 110–113. https://doi.org/10.1016/j.ejogrb.2010.12.007