Exercise with Prolapse: what people and providers need to know
Exercise with Prolapse: Here are some common questions I get:
Are there “good” and “bad” exercises to do with pelvic organ prolapse?
How do I know an exercise is “safe” with pelvic organ prolapse?
Should I have my patients start only with low-level, anti-gravity exercises?
Does heavy weight lifting and running make a prolapse worse?
Should I be doing kegels (pelvic floor muscle strength exercises)?
As a provider, what kind of things can I do with people who have prolapse to help them?
I’m going to cover these topics and more, but if you want to start with the basics about pelvic organ prolapse, check out my blog post How to Fix Pelvic Prolapse (and what that even means?)
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What is pelvic organ prolapse?
The most recent clinical definition of pelvic organ prolapse from the IUGA is as stated:
“Anatomical prolapse with descent of at least one of the vaginal walls to or beyond the vaginal hymen with maximal Valsalva effort WITH the presence either of bothersome characteristic symptoms, most commonly the sensation of vaginal bulge, or of functional or medical compromise due to prolapse without symptom bother."
In other words, pelvic organ descent + bothersome symptoms or medical compromise = pelvic prolapse
Things that can exacerbate or increase the risk of developing pelvic organ prolapse
Pelvic organ prolapse results from changes, most commonly caused by pregnancy and childbirth, to the ligaments, muscles, and fascia that support the pelvic organs. Genetics, age, repetitive straining/constipation with bowel movements, chronic cough, and repetitive heavy lifting in the workplace are also associated with prolapse.
Vaginal childbirth - the first one is a more significant impact than subsequent births and forceps delivery increases the risk
Older age - pelvic and surrounding muscles lose strength and elasticity
Chronic constipation - regular straining during bowel movements can increase pressure and, over time, exacerbate prolapse
Chronic coughing - repetitive straining to the pelvic floor muscles
Genetics - maternal family history may be somewhat linked
Levator hiatus avulsion (from vaginal childbirth) and someone with a larger levator hiatus area (GH+PB - genital hiatus + perineal body length) is at a greater risk
When working with people at risk of pelvic organ prolapse, or who already have symptoms, considering risk factors, along with other information such as parity, postpartum recovery, prior and current fitness level, and current exercise routine can help when creating or modifying a treatment plan.
Specific Objective Information for Providers
Internal or External Pelvic Floor Assessment with Movement:
Palpate the internal pelvic floor or the perineum externally while they do a movement or exercise to feel if they are “bearing down” or straining
Assess in different positions: supine, side-lying, prone, standing, sitting, etc.
Many exercises and movements can be assessed this way, such as bridge, crunch, dead bug, push-up, squat, lunge, deadlift, etc.
If the person is straining or “bearing down” during an exercise or movement, as a provider, can you offer suggestions for doing that movement differently to make a change? More on this later!
Exercise with Prolapse
Are there “good” and “bad” exercises to do with pelvic organ prolapse?
Should I have my patients start only with low-level, anti-gravity exercises?
How do I know an exercise is “safe” with pelvic organ prolapse?
People need to generate intra-abdominal pressure to do everything in life! Increased intra-abdominal pressure happens automatically with movement and can help stabilize the spine and reduce the risk of injury. Studies have shown that the amount of intra-abdominal pressure varies from person to person for the same movement or exercise. Here are some interesting findings:
Basic daily movements such as getting up from a chair, getting on the floor, and getting up from the floor, on average, generate more pressure than many exercises such as bench press, squats, arm curls, crunches, stairs, Pilates (mat and reformer), lifting under 20# from the floor, etc.
There is variability within the same person for a repeated task. In other words, we don’t do repeated movements the exact same way with the same intra-abdominal pressure each time.
No differences in intra-abdominal pressure have been found between recommended and discouraged versions of the same exercise. In other words, there is not necessarily a “good” and “bad” way to do an exercise when it comes to intra-abdominal pressure.
Cobb et al. 2005, Weir et al. 2006, Tian et al. 2018, Niederauer 2022
If getting out of a chair, coughing, or getting up off the floor creates more intra-abdominal pressure than most exercises, why are we telling people that there are “good” or “bad” exercises? Limiting certain exercises for all people with prolapse doesn’t make sense. If they spend their day chasing after or repeatedly picking up their child, why are we only letting them do low-level, anti-gravity exercises, to be “safe”? This doesn’t train them for the daily requirements of pressure management needed to perform activities of daily living and taking care of kids.
A Word About Breathing:
I recently heard a seasoned pelvic floor PT say that she has all of her patients with a prolapse “exhale with exertion because this will decrease the pressure”. There are two problems with this:
1) I’ve felt patients bear down into their pelvic floor as they exhale (many times).
2) People who lift heavy, a closer percentage to their 1RM (the maximum amount of weight a person can lift for a single repetition of exercise), need to hold their breath in order to brace and create the core stability required to lift the weight.
Rather than villainize intra-abdominal pressure, we need to assess each person’s ability to manage the amount of intra-abdominal pressure that a certain activity generates, and if it’s not managed well (symptoms show up or worsen), teach them to try a different way.
We need to meet people where they’re at and offer education and training that applies to their current activity requirements with a progression of difficulty that matches their goals.
Exercise with Prolapse: Running and Weight Lifting
If I have a prolapse, should I avoid running?
There is limited research on pelvic prolapse and running. In a couple of studies, the prevalence ranges from 5-12.7% (Yi et al. 2016, Forner et al. 2021). However, we also know that up to 75% of people self-select out of exercise due to symptoms of prolapse, so accurate numbers may be tricky. To my knowledge, we don’t have any studies that show running makes prolapse worse (symptoms or stage) other than transient pelvic floor muscle fatigue.
Because we have such limited research, strategies and recommendations should be given on an individual basis. Some things that may be worth considering:
Overall fitness level: strength, endurance, balance, muscle deficits
Postpartum status and recovery - prior training, current physical fitness, breastfeeding status, sleep, nutritional support, etc.
Targeted muscle training specific to running
When modifications are appropriate, consider the following:
Change in distance, speed, or recovery time
Modifying stride length, assess vertical height, thoracic and arm rotation, body angle
Pre-run exercises that may help: glute or hip exercises, thoracic mobility and diaphragmatic breathing, etc.
Avoid clenching or gripping: tensing your abdominals or pelvic floor muscles can have a negative impact
Change in running surface
Assess your cadence - running at a higher cadence may reduce the overall impact (aim for 160-180 bpm)
Trial of a pessary or supportive garment
Try a post-run recovery position (lying down, pelvis up on pillows or yoga block, legs resting against the wall) for possible symptom relief
If I have a prolapse, should I avoid lifting weights?
We do have a bit more evidence on this. While having a heavy manual labor job can make prolapse symptoms worse, that’s quite different than a specific strength training routine. Here’s what we know:
In one study comparing those who were inactive, those who lifted light weights, and those who lifted heavy (more than 50kg), prolapse symptoms occurred more often in women who lifted light and those who were inactive (Forner et al. 2020). In another study looking at runners and people participating in CrossFit, those who did CrossFit-brand training had 7.8% of people with prolapse symptoms compared to runners at 12.7% (Forner et al. 2021).
As a pelvic health provider, if you are qualified and trained to do so, doing an external or internal assessment of the pelvic floor can allow you to feel if the person is “bearing down” or straining during the movement. If so, you can try the following:
Cue different posture
Cue a different breath (full breath hold vs. half breath hold vs. exhale vs. inhale)
Cue a pelvic floor muscle contraction (maximal, sub-maximal, etc.)
Change what they are doing with their abdomen (more bracing, less bracing)
Change cuing for breath holding/valsalva if lifting heavy (Ex: keep the pressure at the diaphragm or upper abdominals vs. down into the pelvic floor)
Have them build up strength and endurance more slowly with an individualized exercise program managing load, volume, intensity and increased overall recovery and rest time in between sets
Assessing the pressure that goes into the pelvic floor with an exercise or movement, and having the person try different strategies if needed, can help them better manage pelvic pressure during exercise. Changes and modifications should be explored before cutting someone off from an activity or exercise they love.
If you work with people who do heavy weight lifting or CrossFit, I highly recommend taking Antony Lo’s “The Female Athlete Course”, which can give way more information and nuance to valsalva vs. straining/bearing down, cuing, etc. @physiodetective
Exercise with Prolapse: Pelvic Floor Muscle Training (aka “kegels”)
Should I be doing kegels (pelvic floor muscle strength exercises)?
Maybe, maybe not. The research is not strong on pelvic floor muscle training being effective. One study showed improvement in symptoms but not anatomical changes, however, it didn’t show clinical significance with improvement in “feeling something coming down”, which is the most prominent reported symptom of prolapse (Hagen et al. 2014). Another study showed statistically significant improvement in anatomical descent (POP-Q) but only for the short term (Wang et al. 2022). Here are some issues that may be limiting the success (in studies) of pelvic floor muscle training with prolapse:
Most studies look at all types of prolapse and group them together although anatomically speaking, a posterior wall prolapse is less likely to improve with pelvic floor muscle training due to the anatomical attachments and action of the puborectalis muscle.
Studies look at physiotherapy or pelvic floor physical therapy treatments but aren’t specific about the treatments or the parameters or they vary widely so you can’t compare them in a meta-analysis.
Studies typically look at results in the short term. Are people continuing to do their exercises? Assuming one had improvement from doing pelvic floor muscle training, logic says that the exercises should continue to see ongoing benefits. This makes sense - I can’t get “buns of steel” from a great glute exercise program and then expect to maintain the results if I don’t continue to do it, right?
What’s the training dosage? Ask 10 pelvic floor physical therapists and they will give you 10 different answers. If we have no consensus on training the pelvic floor, it makes it hard to compare studies and measure effectiveness.
When to not kegel:
There are many people with prolapse in which doing pelvic floor muscle training might make them feel worse. Why? Think about it: a small group of tiny muscles is trying to contract all day long to hold things up, over-working past its normal capacity, can lead to increased muscle tone and pain. I’ve seen this happen with patients of mine! So, we need to be nuanced on this. How can we figure out who to give kegels to and who not to give kegels to? No research, but here’s what I have found clinically:
Doing a pelvic floor internal assessment, how do their muscles feel?
Do they feel like they have increased tone (less give)
Are there multiple areas on both sides that are tender/painful with light pressure?
If so, I’m most likely not going to start with isolated pelvic floor muscle contraction exercises. This may be more helpful later on after their muscles have improved.
Conservative Treatment Options to Consider for Providers
Manual Therapy:
Can be helpful with: increased tone, pain, and improving awareness and coordination.
Manual therapy can improve the connection between the pelvic floor muscles and the brain, which may help facilitate this.
There is also a biotensegrity-focused hypothesis that prolapse symptoms are worse with taut pelvic tissue and that releasing pelvic tension (doing manual therapy) will improve symptoms of prolapse. I have found this to be true for many people and have found manual therapy to be a huge asset in treatment. If you want to learn more about biotensegrity-focused therapy, check out this paper from Crowle and Harley, 2020.
Exercise and Movement Re-Training:
Ongoing assessment of pelvic floor function during exercise and movement as you progress exercise difficulty
Graded exposure to movement and exercise and progressive resistance training
Other sport-specific muscle training, especially if deconditioned or postpartum
Pelvic floor muscle training exercises (possibly)
Hypopressives: Hypopressives are a series of breathing and postural exercises aimed at improving posture and strengthening the core and pelvic floor. Studies of hypopressive exercises are mixed for demonstrating improvement with pelvic prolapse, but I personally have had some patients find significant symptom relief with doing these, so it may be worth learning more about. If you want to investigate this further, I highly recommend checking out @hypopressives.can or @dr.tamararial.
Lifestyle Changes, Education, and Self-Help:
Bowel retraining and education to avoid/prevent constipation and straining.
Splinting with bowel movement, manually or with a splinting device, for posterior vaginal wall prolapse.
Education on how to reduce pressure on the pelvic floor with activities of daily living with external or internal palpation assessment.
Teach people to avoid sucking in their belly all day long and with movement and exercise.
Reduce load from manual labor jobs involving heavy lifting and carrying or advise on modifications (if possible).
For those with a high BMI/obesity, losing weight may help with prolapse progression (BMI is not currently linked to initial prolapse onset).
Increase physical activity - some studies show being physically fit is more beneficial than being sedentary for prolapse symptoms.
Symptom relief options: rest breaks in a reclined, hips elevated position throughout the day
-Lying on the floor with pelvis elevated by a large pillow or yoga block, legs in the air and resting against a wall, allowing gravity to draw the prolapse up and in and relax the pelvic floor muscles.
Support Devices:
Pessaries: Using a pessary can help a person achieve or maintain their desired exercise/activity goals. Pessary fittings can be performed by any skilled medical provider (PT as well) who has had special training to do so.
More About Pessaries:
Will my pelvic floor get weaker over time if I use a pessary? No. In fact, some evidence shows that wearing a pessary and then doing pelvic floor muscle training may yield better results than pelvic floor muscle training alone. (Cheung et al. 2016). Even without exercise, there is some evidence that long-term use of a pessary may help reduce symptoms and POP-Q measurements. (Boyd et al. 2021). One study showed improvement in puborectalis function and improved resting hiatal area in those who has used a pessary for 3 months (excluding those with levator avulsions). (Manzini et al, 2021).
Even if there are no substantial changes anatomically, using a pessary can help a person achieve or maintain their desired exercise/activity goals, which can contribute to cardiovascular, muscle, and bone health, improved mental health and quality of life, decreased frailty, etc. as they age.
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Supportive garments: may help give support and improve symptoms during activity and exercise (Hem Support Wear and this Pelvic Support Belt are two examples).
Education about physical support of the perineum with ongoing cough or respiratory illness, especially if newly postpartum.
Education for Your Patients:
Mild anatomical descent may be normal
Prolapse stage often isn’t correlated with symptoms
Changes in symptoms can be achieved even without anatomic changes
Many factors influence symptoms and anatomy fluctuations
Prolapse does not automatically limit people in the activities or exercises they enjoy. Some people may need to modify, some may not.
If symptoms do increase with an activity, this does not necessarily mean that the prolapse is “worse” as these changes may be transient and short-lived.
Helpful Tips for Providers:
Let your patients tell their stories and validate their feelings and beliefs.
Get consent before doing an assessment and discuss the pros and cons of this assessment and results beforehand.
Consider screening for other factors that influence their experience of prolapse: Central Sensitization Inventory (CSI), stress, anxiety and depression (DASS 21), sleep quality/quantity, etc.
Have them clarify their goals and what a good outcome means to them:
Are they expecting anatomic changes? What if that doesn’t happen?
What is that important to them? What do they worry about?
Are their symptoms stopping them from doing any physical activity? How does this impact their life?
Discuss a realistic timeline of symptom changes, severity and duration, and progression of activity and exercise
Referrals:
Consider discussing your findings with your patient’s OBGYN or urogynecologist (with prior patient consent), especially if you are referring them back to their provider for a pessary fitting.
Consider referring to a mental health therapist if appropriate and have a list of local people in your area who specialize in different areas. I have a list that is divided by specialists in prenatal/postnatal/maternal issues, chronic pain, and sexual health.
Another option for referral is to a person trained and specialized in nutrition support for postpartum people, athletes, and peri-menopause. Being depleted in calories, vitamins, minerals, protein, etc. is more likely to exacerbate their symptoms, and working with a professional who specializes in this area can be very helpful for the prevention of future problems (over-use injury, osteoporosis, etc.) which also can limit people’s ability to exercise.
Does your patient utilize a personal trainer or exercise fitness professional? Consider discussing your findings and plan (with prior patient consent) to better serve your patient and work together as a team.
In Summary:
Many people with symptoms of prolapse limit their exercise or stop altogether due to symptoms and fear of making things worse. Due to a lack of research, many uncertainties regarding exercise and prolapse persist. However, blanket statements about “good” and “bad”, “safe” and “unsafe” exercises are not helpful because they don’t apply to everyone. People move and exercise differently from one another. As a pelvic floor physical therapist, I believe a hands-on, individualized, and comprehensive approach can help. We need to meet people where they’re at, reduce fear, and empower them to move and exercise in the ways they love.
For people with prolapse, reach out to a qualified and skilled pelvic floor PT/OT and get help! Ideally, have them check your pelvic floor externally or internally while doing exercise or activity - are you straining/bearing down? If you don’t get the experience you were hoping for, seek out a different provider. We all vary in our skill levels and training, and just like with any profession, sometimes it takes a few tries to find the right fit!
Do you need help with your prolapse symptoms and want to work with me? If you live in the greater Minneapolis, Minnesota area, my clinic is in Edina, MN - let’s work together! Contact me to learn more.
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Disclaimer: The information in this blog post is for general purposes only and is not intended to be used as medical advice, diagnosis, or treatment. Refer to your medical provider for all questions and concerns regarding your individual care.
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