August 20, 2020

Pelvic Organ Prolapse

Pelvic organ prolapse is not necessarily a death sentence for your vagina. In many cases, prolapse is completely treatable without surgery, and may even be able to be improved. But to know how to treat prolapse, we first have to understand what it is.

What it is, how it happens, and what can help

A diagnosis

Being diagnosed with pelvic organ prolapse can feel overwhelming. You may feel like you can’t so much as sneeze without risking feeling vaginal pressure and may not know what can even help. There is little guidance, and Dr. Google is typically far from reassuring. But the good news is that not all prolapse diagnoses are created equal. In many cases, prolapse is completely treatable without surgery and may even be able to be improved. But to know how to treat prolapse, we first have to understand what it is.

So, what is it?

Pelvic organ prolapse occurs when one or more of the pelvic organs begins to drop down into the walls of the vagina. This can be anteriorly from the bladder or urethra, posteriorly from the rectum or intestines, and apically from the cervix or cuff scar after a hysterectomy. The symptoms that are often reported by patients with prolapse are vaginal pressure or bulging, feeling that their insides are falling out of their vagina, low back pain that is worse as the day goes on, or pelvic heaviness that is worse at the end of the day. Depending on the location of the prolapse, the patient may also experience difficulty emptying when peeing or pooping, a need to re-position during poops, or urinary leakage. There are also varying stages or degrees of prolapse.

The stages of prolapse

The states of prolapse range from 0 (none present) to 4 (full eversion or lowering of the tissue). Stage 4 occurs when the organ involved is actually protruding out of the vaginal opening, and this does require surgical intervention. However, grades 1 through grade 3 can often be treated with a combination of physical therapy and supportive devices. The primary focus of physical therapy for these patients is often addressing the causative factors that lead to prolapse and supporting the weakened vaginal wall.

Causes of prolapse

While pregnancy and delivery is one known causative factor, it is definitely not the only one. Other causes of prolapse can include: vaginal and/or vulvar trauma via vaginal deliveries, tissue restriction from healing cesarean scars or perineal scars, chronic pelvic floor muscle overactivity, activities that increase pressure in the abdomen (improper breathing with weight lifting, chronic constipation, chronic obstructive airway disease), hormonal changes during menopause, pelvic surgery, congenital factors, and race (Caucasian women are at higher risk). It is also possible for patients to have multiple risk factors, which will increase the likelihood of prolapse.

Where to start with treatment?

Before a pelvic physical therapist performs an internal assessment of pelvic floor muscle and tissues, they take a thorough history. What does the patient’s day to day look like? Do they have a physically taxing job? What is their bowel and bladder function like? Do they have pain with intercourse? How many pregnancies and deliveries have they had, and was there any trauma? What does their exercise routine consist of? These are all questions your pelvic PT should be asking you at your initial evaluation. Gathering this information gives the therapist an idea of the types of stresses your tissue are sustaining on a daily basis, and can help guide treatment.

Kegels may not be the answer

What I find most often in my practice is a mixture of inadequate pressure management with activity, and pelvic floor muscle overactivity with subsequent muscle inefficiency (weakness). Because of this, “just do your kegels” will likely not improve your symptoms and may even make them worse. So, what recommendations are appropriate for these patients?

What you can do

Here is a list of some of the things we commonly recommend for activity modification and treatment. Let’s start with modifications to improve pressure management.

  • Get a squatty potty! The squatty potty is not a gimmick. It actually works. Using the squatty potty to poop AND pee puts your pelvic floor muscles in a more lengthened position which will make pooping and peeing easier. This will reduce the likelihood of straining and therefore reduce pressure on the already weakened vaginal wall.

  • DO NOT PUSH THE PEE OUT! That’s right, straining to initiate the flow of urine is not how our bodies were intended to pee. So, when you sit on the toilet, just let the flow of urine begin on its own. The same applies to “just in case” peeing. You should only be peeing if you have true urgency.

  • BREATHE! More importantly, exhale! How many of you breath hold when you are stressed or when something becomes physically challenging? Breath holding can significantly increase the pressure in your abdomen, on the muscles of your pelvic floor, and your vaginal wall. So, start using a slow exhale (like blowing out birthday candles) when you exert energy (working out, picking up kiddos or pets, at work if you have a physical job, etc).

  • Drink that smoothie… through your vag. Draw in your lower abdomen and pelvic floor as if you were trying to sip a smoothie through a straw in your vagina. By engaging your pelvic floor and lower abdomen (at the same as you exhale), you are supporting the more vulnerable tissues of your vaginal wall.

  • Lastly, modify any activity that causes increased pelvic heaviness or pressure, urine leakage, pelvic or low back pain, or protruding of your tissues out of the vaginal opening.

Next, find a balance between lengthening any overactive pelvic floor muscles and retraining them to improve their strength and motor control.

  • Always incorporate activities that improve pelvic floor relaxation into your treatment plan (walking, gentle yoga, stretching). This will be particularly important for clients participating in HIIT such as orange theory, Crossfit, powerlifting, Pilates, competitive sports and running.

    • Stretches can include: child’s pose, knee to chest stretch, butterfly, pigeon, deep squat, piriformis stretch, cossack squat and spiderman lunge.


Knee to Chest stretch example

Knee to Chest stretch example

Child’s Pose example

Child’s Pose example


  • Perform any one of these relaxation activities before AND after your high intensity activity. This will address any tightness present before the workout to ensure proper muscle function during the workout, and address any tightness that is present because of the workout.

  • Modify exercises that increase symptoms. This may mean decreasing the weight, decreasing the speed or decreasing the intensity.

Pain and symptoms management options

  • External support devices include:

  • Internal Supportive devices include:

    • Poise Impressa (recommend ordering the sizing kit first to determine appropriate size)

    • Pessary (must be fitted by a OB/GYN, Urogynecologist)

    • A regular tampon (If the prolapse is not too significant, a tampon can be used for added support with exercise.)

  • Pelvic elevation at the end of the day. This can be done using a pelvic wedge or multiple pillows under your pelvis (see below), and can help reduce swelling and pressure in the vulvar and vaginal regions. This can be used in combination with a heating pad on your low back if you also have low back pain, or ice to your pelvic floor if you have a lot of vaginal or vulvar pain. We typically recommend you do this for about 10 minutes per day.

  • Work with a Pelvic Health Physical Therapist. We offer online sessions and in-person sessions to help!


Pelvic elevation example

Pelvic elevation example


Emily McElrath PT, DPT, MTC, CIDN is an orthopedic and pelvic health physical therapist with a passion for helping women achieve optimal sports performance. She is an avid runner and Crossfitter and has personal experience modifying these activities during pregnancy and postpartum. She is certified in manual therapy and dry needling. When not working, Emily enjoys time with her husband and two kids.

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