The physio take on prolapse: It might not be as scary as you think!
How prolapse became so big and scary
If you search the internet or talk to someone who has dealt with POP in the last twenty years, you’ll hear a lot of scary, restrictive advice: Don't lift heavy. Stop running. Avoid impact forever. Because, they say, those activities will make your POP “worse”.
Ten to twenty years ago, that advice may have been the best we could give at the time, given what we knew then - high-impact exercise, heavy lifting, or being upright for extended periods of time can temporarily trigger symptoms like heaviness or pressure. So we clinicians thought the safest move was telling people to stop or minimize these activities altogether.
The problem?
That advice treated bodies with prolapse symptoms like they were injured or broken. It created massive amounts of fear, shame, and anxiety.
It limited the activity level of people with POP, which likely contributed to muscle weakness, osteoporosis, poor cardiovascular health, and overall decreased health and fitness in the aging female population. Don't women have it hard enough already!?
Fortunately, pelvic health research has shifted significantly. We now know that wrapping yourself in bubble wrap isn't the answer; building strength and tolerance is. However, unhelpful beliefs and worries persist because of this pre-existing narrative. We pelvic health physios are working hard to change that story.
Let’s dig into this!
What is POP, and what can cause it?
Pelvic organ prolapse (POP) is defined as the loss of anatomical support of the uterus, bladder, or bowel, resulting in the downward displacement or drop of pelvic organs from their normal position into or out of the vagina.
This can sometimes result in feelings of heaviness, pressure, or bulge in the pelvis, vagina, or rectum. Symptoms are often felt with lifting, coughing, running, and jumping, and tend to come on later in the day or after prolonged standing or walking. But some people with prolapse feel no symptoms at all.
POP is often associated with pregnancy and childbirth, as it can result from changes after vaginal delivery. It can also result from constant or prolonged straining, such as with constipation or with repeated heavy lifting, or with age- and hormone-related tissue changes.
What makes it worse, and what does "worse" even mean?
Often clients’ first concern is making it worse. When clients ask if an activity will make their prolapse "worse," our first question back is always: What does "worse" mean to you?
For some clients, their priority is to avoid symptoms, because they find them too unpleasant. Other clients don’t mind symptoms, but still prefer to be conservative in their approach because they’re worried about the future. There are also clients who are more concerned about performing their activities and want to be more aggressive with their rehab. All approaches are good ones.
It’s important we know what’s specifically concerning you, and why, so we can tailor and maximize physio to your advantage. We will always tell you if we think there is a clinical reason to adjust or limit an activity temporarily, but you can often do much more than they think. You may experience symptoms that feel worse, but that doesn’t mean they’re doing damage.
Some variables to consider..
Is it a temporary sensation? You feel a heaviness during a workout, but it goes away once you lie down or do a few pelvic floor contractions.
Is it a visual change? You see a bulge in the mirror, but you don’t feel it, and it doesn’t bother you during the day.
Is it a clinical observation? A physio or doctor sees slight anatomical changes during an exam, but your day-to-day life is totally unaffected.
Is it a minor bother? You only notice a mild pressure sensation from time to time, but it doesn’t limit your activities.
Is it a significant and prolonged increase in symptoms? Discomfort or pressure drags on for, days and stops you from functioning normally.
Again, it’s important to understand that a temporary increase in symptoms doesn’t equate with increased damage to the tissues.
Your symptoms can fluctuate based on fatigue, stress, bowel habits, and where you are in your menstrual cycle. It’s important that you work with a professional to unpack all the possible contributors and figure out which ones are factoring into your symptoms (we’re biased, but we think physios are the best at doing this!)
What do you have control over and how can physio help?
When we know more about the landscape of your symptoms, how they show up, and what your priorities are, we can start a rehab journey based on controlling the controllables.
There is a huge toolbox we draw from in our physio approach, and what we do depends on what’s contributing to your symptoms. Here’s a list of things that are helpful to consider;
Too much too soon
Did you simply push your body a bit harder than it was ready for? Increase your weights in the gym or attempt skipping before your body had figured out the coordination or built enough strength to do so?
Taking a few steps back and developing a plan to gradually build up your level of activity is a better plan than just going for it and hoping for the best.
Pressure management
Did you feel an increase in symptoms with heavy lifting because you were holding your breath or bracing excessively?
Your physio can teach you different breathing and bracing strategies for lifting to make sure that you don’t put excess pressure on your pelvic floor.
Decreased pelvic floor support
Is your pelvic floor struggling to keep up?
Your physio can give you specific exercises to make sure that your pelvic floor is functioning optimally and providing adequate support for the pelvic organs.
Menstrual cycle
Are your symptoms worse around your period?
There are hormone fluctuations that can play into this, as well as the increased weight of the uterus right before menstruation; activity modification around this time can be helpful.
Full rectum
Do you notice more symptoms when you’re constipated or have a full rectum?
The added pressure from a full rectum can put more pressure on the pelvic floor and make you feel an increase in symptoms. Sometimes modifying your activity (eg: go for a run after you have a poop) or addressing constipation issues can help alleviate symptoms.
Fatigue
Do you notice more symptoms when you’re sick, tired, or after you’ve been on your feet running around all day?
Our bodies get tired after a lot of activity, our muscles don’t provide as much support as they should, we’re less mindful of our posture, there’s more pressure and strain on our pelvic floor. We know that this strain is short-lived and can be reversed by just getting off our feet and having a rest.
Stress/anxiety
Do your symptoms feel worse when you’re stressed or worried?
It’s not uncommon to feel symptoms more when life is throwing a lot at you and your nervous system is full on in flight/fight. Without getting into the complex physiology, when our nervous system is stressed, it pays extra attention to any sensations in our body that may be considered a threat and turns up the volume on those sensations. Considering your stress state and applying all your helpful stress management tools can sometimes surprisingly help with POP symptoms!
Support products
Can you use an external support like support shorts or a pessary?
There are different products on the market that help to provide support to the pelvic organs either to add to the above management tools or to use when these strategies alone aren’t sufficient. Support shorts like EVB and SRC are essentially compression shorts that provide support to the pelvis. My Pelvic Bra provides external support directly under the pelvic floor. And pessaries are silicone devices inserted into the vagina to provide support for the pelvic organs. Your physio can help you figure out what product may be the best for you.
Working with your physio to learn what you can control and seeing how your management tools can improve your symptoms helps take the “scary” out of prolapse and put you back in the driver’s seat.
Physio isn't about avoiding life to protect your pelvis. It's about figuring out what your body can handle right now, tweaking a few things, and gradually building the load tolerance you need to live your life confidently.
Will my prolapse eventually get better?
The answer is - it depends. And, much like the need to define “worse”, it also depends on what “better” means to you.
For some people, the change in anatomic support of the pelvic organs is temporary. For example, we see anatomical changes decrease over months, or even beyond a year following birth in some postpartum clients. These clients will feel an improvement in their symptoms that corresponds with the anatomical change.
In other clients, their physio treatment results in an improvement in symptoms, but without the corresponding change in their anatomy. The prolapse may still be there, but it’s not causing symptoms or limitations anymore.
In some cases, we don’t see an improvement in the anatomy, and symptoms can linger too. Some clients are happy to self-manage with the tools we have provided, while others might consider a pessary or surgery to get to where they want to be.
The big takeaway is this: while some clients do see the prolapse itself improve, it is possible to have a full recovery in terms of being symptom-free and doing all your activities, even if you still have some degree of prolapse present.
Are there any long-term concerns?
While it’s impossible to predict the future, we do have a pretty good idea of many things that may increase risk for symptomatic POP down the road. Some of these are related to how your body responded to pregnancy and delivery, but others are related to your genetic makeup, whether you have a history of constipation, and what type of occupation you’re in.
We look forward to future research that will likely give us even more insight and guidance. But for now we use what we currently know about risk factors to decide if we take a more conservative approach with someone (eg: suggesting non-impact strengthening activities) versus continuing to push someone’s capacity with impact and lifting exercises. Your physio can advise you on your specific risk factors so you can make your own informed choice.
To wrap up
As you can see, there is no one-size-fits-all approach to managing or preventing POP, which is why getting advice from the internet about POP management may not be your best bet! Working 1:1 with a pelvic physiotherapist to make sure that your management plan is specific to you is the best way to go, particularly:
Making sure you understand all the factors contributing to your symptoms
Learning what your individual risk factors are for your long-term health and considering these in your approach
Building a toolbox full of useful tools to control what you can control
