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The Gist: What is Pelvic Organ Prolapse?

Also known as: pelvic pressure, pelvic heaviness, "feels like my vagina is falling out"

Pelvic organ prolapse is the pressure or heaviness felt in the pelvis caused by the descent of one or more pelvic organs into the vagina or anus.

You may experience feelings of heaviness or pressure in the vagina, or it may feel as if something is in your vagina or that your vagina is "falling out". Symptoms are typically worse at the end of the day or with prolonged activity. You may also experience changes in your symptoms during your menstrual cycle.

The Anatomy of Pelvic Organ Prolapse

One of the functions of the pelvic floor is to support the reproductive organs, bowel and bladder. The bladder and urethra (front), uterus (top), and rectum (back) all lie within the pelvis and are supported by the pelvic floor.

Pelvic organ prolapse is the descent or bulging of one or more organs of the vaginal vault and rectum. This can include the anterior vaginal wall (bladder and urethra), the posterior vaginal wall (rectum and small intestine), the uterus and cervix, and the vaginal vault. With anterior or posterior vaginal wall prolapse, it is not the actual organs descending into the vagina, but rather the involved vaginal wall is being pressed into the vagina by the organ(s). Rectal prolapse is the descent or bulging of the rectum into the anus.

Who gets Pelvic Organ Prolapse? When does it occur for women?

Prolapse is caused by inadequate support of the organs and tissues in the vaginal vault and rectum. It is often caused by laxity or weakness of the pelvic floor muscles (PFM) and the connective tissue of the pelvis, in conjunction with an increased pressure on those structures.

During a vaginal delivery, a woman must birth a baby out of her vagina by "bearing down" or pushing. This is the same action you must perform when passing gas or having a BM, but on a much larger scale. During childbirth, a woman may be pushing for hours, and every push puts more pressure on the PFM. This prolonged pressure can decrease the integrity and elasticity of the PFM and surrounding structures. As a result, the PFM and connective tissue of the pelvis can no longer support the contents of the vaginal vault and rectum, causing a prolapse after delivery.

Prolapse can also be caused by a chronic increase in intra-abdominal pressure, which is increased pressure within your abdomen due to poor breathing mechanics and/or holding your breath. Some examples of this are COPD, repetitive heavy lifting, and chronic constipation. Later in life, prolapse can be the result of deceased tissue integrity from estrogen deficiency due to menopause.

Congenital causes include Ehlers-Danlos syndrome and Marfan syndrome, both of which cause collagen defects that decrease the elasticity and durability of the tissues of the pelvis impairing its ability to support the pelvic organs.

The Origin Way: Physical Therapy for Pelvic Organ Prolapse

At Origin, we look at your entire history, not just your most recent delivery. We take a comprehensive approach that includes not only addressing the pelvic floor, but the way you breath and manage pressure in your abdomen as well. If you can manage the pressure on your pelvic floor, you can help control the forces contributing to your prolapse. Additionally, your Physical Therapist will ask you about your bowel habits and stool consistency so they can provide recommendations to further reduce the pressure on your pelvic floor.

Typically, prolapse occurs because the pelvic floor is weak or compromised, but we do not assume that just because the PFM are weak, they are loose. The PFM may be too tight (hypertonic) or too loose (hypotonic) with poor PFM muscle coordination. Thus, we treat prolapse with a combination of manual therapy to the pelvic floor, coordination and retaining exercises, and the appropriate strengthening exercises. Other tools like vaginal weights or pelvic floor trainers may be used if your Physical Therapist thinks it is the right approach for you. Research shows that pelvic floor physical therapy can reduce a prolapse by 1 grade. Your Physical Therapist may refer you for a pessary if they think you would benefit from one.

How long does it take?

Your symptoms may take up to a few months to improve, but your progress depends on the grade of your prolapse as well as your compliance with the exercises and activity modifications your Physical Therapist prescribes. Furthermore, every woman is different, so your improvement not only depends on your symptoms, but also how they feel to you. What may bother some women, others don't notice.

What to expect in the future

You may have to keep up with your exercises in some capacity in the future. Like any other muscle group, you need to exercise your pelvic floor to keep it strong. Symptoms may increase again if you don't do your exercises for a few months, and improve once you've resumed. You may experience symptoms during subsequent pregnancies, but the exercises don't change.

Additional Reading and Sources

Brækken, Ingeborg Hoff, et al. "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, vol. 203, no. 2, 2010, doi:10.1016/j.ajog.2010.02.037.

Hagen, Suzanne, et al. "Individualised Pelvic Floor Muscle Training in Women with Pelvic Organ Prolapse (POPPY): a Multicentre Randomised Controlled Trial." The Lancet, vol. 383, no. 9919, 2014, pp. 796 - 806., doi:10.1016/s0140-6736(13)61977-7.

Wiegersma, Marian, et al. "Predictors of Success for Pelvic Floor Muscle Training in Pelvic Organ Prolapse." Physical Therapy, vol. 99, no. 1, 2018, pp. 109 - 117., doi:10.1093/ptj/pzy114.

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