What is Pelvic Organ Prolapse?

Pelvic organ prolapse is the descent of one or more pelvic organs (the bladder and urethra, uterus/cervix, rectum, or vaginal vault after hysterectomy) into or beyond the vaginal canal, due to loss of support from pelvic floor muscles, ligaments, and fascia.

The International Continence Society (ICS) and International Urogynecological Association (IUGA) define POP as:

“The descent of the anterior vaginal wall, posterior vaginal wall, the uterus (cervix), or the vaginal vault (after hysterectomy), such that the organ protrudes into or beyond the vaginal canal, and may be associated with symptoms such as a vaginal bulge, pelvic pressure, or bladder, bowel, or sexual dysfunction.” (Haylen et al., 2016).

It can also be understood as a hernia through the pelvic floor. The hernial opening is called the levator hiatus, which is the gap in the pelvic floor muscles (levator ani) that allows the urethra, vagina, and rectum to pass through.

When the levator hiatus becomes overstretched or weakened, often after pregnancy and childbirth, it provides less support to the pelvic organs. This allows them to move downward from their normal position and bulge into or through the vaginal canal (in the case of uterovaginal prolapse), or into the anal canal (as with rectal prolapse or rectal intussusception).

According to the Royal Australian College of General Practitioners (RACGP), pelvic organ prolapse is the “downward displacement of pelvic organs (bladder, uterus or rectum), resulting in herniation of those organs into or through the vagina or anal canal.”

How common is prolapse?

How common POP is depends on how we measure it, by medical examination, by symptoms, or by looking at who eventually needs surgery.

1. Prolapse found on examination

• When women are examined by a doctor or physiotherapist using standardised tools such as the Pelvic Organ Prolapse Quantification (POP-Q) system, between 30% and 50% demonstrate some degree of prolapse (stage ≥1).  
• Many of these cases are asymptomatic, i.e. most of these women do not notice symptoms, especially if the prolapse is mild.
• For example, the large Women’s Health Initiative study of over 27,000 women found that about 41–50% of women had prolapse when examined, even though many had no complaints (Hendrix et al., 2002).
• A recent worldwide systematic review and meta-analysis reported a global prevalence of 30.9%, with examination-based studies showing a higher rate (41.8%) than questionnaire-based ones (Hadizadeh-Talasaz et al., 2023).

2. Symptomatic prolapse

• Only 3–12% of women report bothersome symptoms like a vaginal bulge, heaviness, or dragging sensation.
•  Symptomatic POP is defined as women reporting a sensation of vaginal bulge or pressure, often assessed with validated questionnaires such as the Pelvic Organ Prolapse Symptom Score (POP-SS) or the Pelvic Floor Distress Inventory (PFDI-20).
• In population studies, there is a clear gap: far more women have prolapse visible on exam than those who actually feel symptoms.
• For example:
  • Swift et al. (2003) found only 3% of women reported symptoms, compared with 24% who had prolapse on exam.
  • In the U.S. national survey, Nygaard et al. (2008) reported 7% of women experienced bulge symptoms.

3. Lifetime risk of surgery

• Prolapse is not always severe, but some women will eventually need surgery. 
• The lifetime risk of surgery for prolapse or incontinence is estimated at 11–20% by the age of 80.
• Olsen et al. (1997) first estimated this at 11%, while more recent U.S. data suggest it is closer to 20% (Wu et al., 2014).

Summary

• Prolapse on exam: common, seen in up to half of women.
• Prolapse with symptoms: much less common, about 1 in 10 women.
• Surgery: required in about 1 in 5 women across their lifetime.

This shows that while prolapse is very common, not all women will notice symptoms, and only a proportion will ever need treatment.

What does a prolapse feel like? Prolapse Symptoms

The common symptoms of prolapse include a vaginal lump or bulge (whether visible or not), a feeling of heaviness or dragging sensation, feelings of vaginal laxity or looseness and pain before, during or after vaginal intercourse.

There may also be a range of accompanying conditions such as urinary incontinence, straining to void or intermittent stream, trouble having bowel motions or incomplete emptying, recurrent urinary tract infections and pain or lack of sensation during sex.

These are the physical symptoms. Women living with prolapse can alos experience a wide range of emotional symptoms including feelings of despair, grief and frustration.  

If you are experiencing any symptoms of prolapse, please don’t self-diagnose. Get support from a qualified pelvic health physiotherapist, obstetrician, or gynaecologist. 

Can I fix a prolapse myself? Prolapse treatment without surgery 

How your body feels, functions, and looks at six weeks postnatal is completely different to how it will be at 12 months or beyond. The same goes for your pelvic floor. In the early stages of postnatal recovery, it looks and feels very different compared to 18 months postpartum. The pelvic floor and pelvic organs need time to heal, regain strength, and return to their normal position.

According to prolapse classifications, many women assessed internally at six weeks postnatal would be considered to have a pelvic organ prolapse. But at this stage, your body is still in a physiologically and anatomically altered state. When we reassess these same women months later, prolapse symptoms have often improved significantly, or resolved altogether.

It is important to have hope, but we also believe it is important to be realistic. Whilst you might not be able to completely heal your prolapse in the sense of your body and pelvic floor returning to its pre-pregnancy state, there is so much you can do to reduce your symptoms and improve your quality of life. Recovery takes time and consistent work, but the long-term results are worth it.

Mild to moderate prolapse can often be managed without surgery using conservative treatments like pelvic floor rehab, movement retraining, and pressure management.The degree of recovery you may experience will depend on a number of factors. 

• Body Type: Your body type will affect your rate of recovery. Everything from body shape to muscle bulk and connective tissue will affect rates and degrees of healing.

• Connective Tissue Types: Our bodies have different types and ratios of connective tissue, some of which create more rigidity or others of which create more elasticity. These ratios can affect the amount of organ support provided at rest and the degree of distensibility.

• Pelvic floor Muscle Weakness  The levator ani forms an important role in supporting the organs. When the pelvic floor muscles are weaker and not functioning well, this can reduce support and increase the risk of prolapse.

• Pelvic floor Muscle Damage As the baby crowns and passes through the pelvic outlet, it is not uncommon for the pelvic floor muscle to undergo micro or macro trauma (an avulsion). When this occurs, there is a deep tear in the attachment point of part of the pelvic floor to the pubic bone, which is unfortunately irreversible. This tear results in an increased hiatus width and increased prolapse risk.

• Endovaginal Fascial Damage Between each organ is a strong web of fascia that supports and helps to suspend the organs. When this is damaged or overstretched, the degree of pelvic organ support reduces.

• Biomechanics and Load Management How well you move in daily life and place loads through the abdominal and pelvic area can play a role in prolapse symptoms, especially with respect to intra-abdominal pressure.

• Weight, Diet, and Fatigue Prolapse recovery takes a whole-body approach, and this includes optimising diet, reaching a healthy weight range, managing stress, and ensuring you are getting enough rest and downtime.

• Risk factors such as obesity, constipation, heavy lifting, and chronic cough increase the likelihood and severity of prolapse (Vergeldt et al., 2015; Dheresa et al., 2018).

• Family History If you have a family history of prolapse, research shows us you are likely to have an increased risk of prolapse. There are many possible reasons, but the most likely would be a genetic predisposition due to body type and connective tissue.

The postpartum or postmenopausal body is forever changed. And whilst we would love to tell you that you can fix your prolapse, the truth is that you are probably always going to live with some degree of increased movement in your pelvic organs. And you will probably always have to be more mindful of your pelvic floor than you were pre-children. However, some steps can be taken to manage your symptoms and prevent further progression.

What causes prolapse after birth?

Prolapse after birth is primarily caused by pelvic floor muscle damage, connective tissue stretching, and the pressure of pregnancy and vaginal delivery.

Vaginal childbirth is consistently identified as the biggest single risk factor for prolapse.

After vaginal delivery, women are more likely to have:

• Levator ani muscle injury/avulsion: detachment of the levator ani muscle from pubic bone.
• Wider levator hiatus; results in reduced support for pelvic organs
• Stretched fascia and ligaments: these changes reduce the “hammock” support of the bladder, uterus, and rectum, increasing the chance of descent.

References: Dietz & Lanzarone, 2005; Shek & Dietz, 2010; Kearney et al., 2006

•  The risk and severity of POP rise with the number of vaginal deliveries.
•  Forceps deliveries and large baby size further increase the risk by placing more strain on pelvic tissues.

References: Kearney et al., 2006; Gyhagen et al., 2013 (20-year longitudinal study).

•  Women who only deliver by caesarean have lower rates of prolapse compared with vaginal deliveries.
•  However, caesarean does not fully protect against prolapse because pregnancy itself also stretches and weakens pelvic tissues.

References: MacArthur et al., 2011; Shek & Dietz, 2010.

Prolapse can happen for a variety of reasons. Genetic factors, a history of chronic constipation, collagen types, biomechanics, hormones, weight, a history of high-impact movement, pregnancy, and birth can all contribute. There is no single defined reason that one individual will develop prolapse; it is usually a combination of cumulative factors.

The largest contributing factor, however, is pregnancy and vaginal birth. During pregnancy, the body starts to prepare for what is required during the birth, which is essentially to propel the baby towards the pelvic outlet and allow it to pass through into the world towards its first breath.

The body's inbuilt wisdom knows that in 9 months' time, it will require strong uterine contractions (the preparation for this is Braxton Hicks), an opening of the pelvic bones (the preparation for this is softening of the pelvic ligaments) and an opening of the pelvic outlet (the preparation work is a lengthening and weakening of the pelvic floor).

Once the baby has entered the pelvic outlet and is crowing, the levator ani will then need to stretch up to 3 times its normal length, which is the length at which almost all skeletal muscle would rupture. In most cases, the changes that have occurred during pregnancy allow this to happen without major injury however, in around 10-20% of births, it struggles with this lengthening, reaching its maximum point of stretch before the pelvic floor has to give way, tearing at the bony attachment point (a levator avulsion).

As the levator ani is one of the major organ supports, it’s no surprise that we have strong evidence to show the link between a levator avulsion and risk profile for prolapse. It is important to note that the statistic for levator avulsion actually increases to 30-65% when forceps are required during labour (Friedman et al 2019).

Of course, there is more to a prolapse than simply a weakened or damaged pelvic floor. Other factors, such as poor biomechanics and movement patterns, an inability to manage and distribute pressure throughout the core and increased tension or tightness in other areas of the body ca,n all contribute to the development of pelvic organ prolapse over the long term.

Pelvic organ prolapse treatment. Do Kegels help with prolapse? 

Prolapse isn’t caused solely by a weak pelvic floor, and Kegels aren’t the only answer. However, the research shows that strengthening the pelvic floor muscles through pelvic floor muscle training (PFMT) can be an effective non-surgical treatment option for managing the symptoms of pelvic organ prolapse.

Healing prolapse takes a whole-body and mind approach. In addition to your pelvic floor muscle training, the following factors will contribute to your prolapse recovery.

An overview of the research on Pelvic Floor Muscle Training and Prolapse includes

• Supervised pelvic floor muscle training significantly reduces prolapse symptoms and improves quality of life in women with stage I–III prolapse (Hagen et al., 2014; Hagen et al., 2022). 
• Women undertaking PFMT are more likely to report symptom improvement compared with those receiving lifestyle advice alone (Hagen et al., 2017). 
• Imaging studies show that PFMT can cause measurable improvements in pelvic floor support (Braekken et al., 2010).
• Coordinating a pelvic floor contraction with activities that increase abdominal pressure (e.g., coughing or lifting), known as “the knack,” reduces downward force on the pelvic floor and can lessen symptoms (Miller et al., 1998). 
• Combining PFMT with movement retraining and behavioural strategies provides greater long-term benefits than observation alone (Panman et al., 2016).

Overall Management Consensus

• Conservative management, combining PFMT, functional movement strategies, and lifestyle support, is safe, effective, and recommended as the first-line treatment for women with prolapse (NICE, 2019; Hagen et al., 2017; ICS, 2021).
• Surgical options are reserved for women with persistent or severe symptoms when conservative measures are not sufficient.

Overall, the latest research suggests that pelvic floor muscle training can be an effective non-surgical treatment option for managing pelvic organ prolapse. However, the effectiveness of PFMT may vary depending on the severity and type of prolapse, and treatment options should be individualized based on specific needs and symptoms.

Healing prolapse takes a whole-body and mind approach. In addition to your pelvic floor muscle training, the following factors will contribute to your prolapse recovery.

1. Maintaining a healthy weight: Excess weight can put additional pressure on the pelvic organs and weaken the supporting muscles, which can contribute to prolapse. Where possible, maintaining a healthy weight through a balanced diet and regular exercise can help reduce the risk of prolapse or prevent further progression, especially in the case of posterior wall prolapses.
2. Avoiding heavy lifting with poor technique: Lifting heavy objects can strain the pelvic muscles and exacerbate symptoms of prolapse. It is unrealistic and misguided to advise women to stop lifting weights altogether. What is important is to train your body to lift heavy objects and weights well. This may involve re-training motor patterns and breathing strategies as well as being more mindful in your day-to-day life of the impact of lifting heavy items.
3. Treating constipation: Straining during bowel movements can put a large amount of pressure on the pelvic organs and can worsen prolapse symptoms. Eating a high-fibre diet, staying hydrated, using stool softeners or laxatives, and learning to defecate correctly can help reduce straining and the load during bowel movements. Management of chronic bowel and respiratory issues can reduce pelvic floor symptoms and support conservative management (Subak et al., 2010).
4. Sleep and Immunity: Chronic coughing can significantly affect your ability to heal. And whilst getting sick is a part of life, investing in your immune health and ensuring that you are getting as much sleep as you can (especially if you are in those early postpartum days) will support your prolapse recovery.
5. Full Body Strength: Building full body strength will result in less load being transferred through your core and pelvic floor. So ensure that you are doing at least 2 pelvic floor safe full-body strength sessions a week.
6. Using pessaries: A pessary is a medical-grade silicone device that is inserted into the vagina to provide support for the pelvic organs. It can be a temporary or long-term solution for managing prolapse symptoms. 

While prolapse may not fully “go away,” symptoms can dramatically improve. With EMP’s expert-designed programs, you’ll get the education, tools, and movement guidance you need to reclaim your confidence and quality of life.

Exercise and Prolapse

At the Empowered Motherhood Program, we are deeply passionate about supporting women with pelvic organ prolapse (POP) to move safely, rebuild strength, and feel empowered in their bodies again.

Through our Prolapse Safe Program, we combine expert education, real-life insights, and POP-safe Pilates, strength, and cardio workouts—designed to help you return to exercise with confidence. 

We believe that with the right movement patterns and technique, almost all forms of exercise can be modified and performed safely, even with a prolapse diagnosis.

Recovery Looks Different for Everyone

When it comes to prolapse recovery, there’s no one-size-fits-all. Every woman is different. Each person’s journey is shaped by a unique combination of factors, including:

• Type of birth (vaginal or C-section) 
• Physical or emotional birth trauma
• Overall health and fitness
• Sleep quality
• Body type
• Level of support at home 

And how you recover will depend on a myriad of factors, including your birth, how much sleep you are getting, your level of general health and fitness, your body type, how much support you have and whether you experienced physical or emotional birth trauma.

In the EMP, we focus on the following approach to prolapse-safe exercise: