Exercises for pelvic organ prolapse
Exercising with pelvic organ prolapse (POP) can feel a little scary, and there is a lot of misinformation online about exercising with prolapse. In this blog post I’m going to talk about exercises to reduce pelvic organ prolapse symptoms (and so much more!)
First, what is pelvic organ prolapse?
Pelvic organ prolapse is the descent of one or more of the anterior vaginal wall (bladder or urethra), posterior vaginal wall (rectum or small intestine), the uterus, or the apex of the vagina (vaginal vault or cuff scar after hysterectomy). Some patients may also experience a rectal prolapse.
Symptoms of POP include pelvic pressure or heaviness, a bulging sensation in the vaginal canal, low back ache, bleeding or discharge, symptoms improve when lying down or elevating pelvis, and symptoms worsen with straining or bearing down (such as having a bowel movement). Urinary symptoms may also be present such as leaking, incomplete emptying, or post void dribbling. Some types of prolapse may also make emptying bowels difficult.
I know that pelvic organ prolapse can sound scary, but many patients with pelvic organ prolapse are (or can become) asymptomatic. When defined by symptoms, evidence has shown that the prevalence of pelvic organ prolapse is around 3-6%, however when based on vaginal exam it may be up to 50%. This means that by medical definition, many women meet the definition of prolapse but do not have any symptoms. You can learn more about the different types of pelvic organ prolapse and what causes prolapse in this blog post.
Is exercise safe with pelvic organ prolapse?
The short answer is YES. I actually believe that when prescribed properly, exercise plays a major role of reducing symptoms caused by POP. Before I share any specific exercises, I want to be clear about a few things when it comes to exercising with POP.
1) If you have symptomatic prolapse, I highly recommend working with a pelvic floor therapist in person. It is important that you have an individualized assessment to determine what is contributing to your symptoms, if there are manual therapy techniques that may help, and what type of day to day habit and activity modifications may help you.
2) Kegels are not pelvic floor therapy, and are not the answer to prolapse. A kegel is an isometric contraction of the pelvic floor muscles. First of all, being able to isometrically contract your pelvic floor is not functional. Your pelvic floor muscles should automatically lift and lengthen with movement. If your pelvic floor muscles are weak and disconnected, there are a lot of other exercises that can work on pelvic floor coordination that are more effective than just doing kegels. Second, many people with pelvic organ prolapse actually have tension in their pelvic floor muscles. Squeezing a tight muscle over and over again is not going to help the muscle lengthen and function better. So needless to say - you won’t see kegels as one of my recommended exercises for prolapse!
3) Breathing and stretching is also not the answer to prolapse. Breathing and doing stretches like “happy baby” can help to reduce prolapse symptoms temporarily, however they are not going to help you be able to lift, walk, run, jump, etc without prolapse symptoms.
4) Exercises need to be progressive. You may need to start with body weight exercises, breathing techniques, and mobility work. Over time exercises should get more challenging, including gradually increasing resistance and impact. If you aren’t sure how to progress, a pelvic floor therapist can help (I work with clients in Memphis and virtually on proper exercise progressions!).
5) Exercises and mobility techniques that reduce symptoms are great tools to have on hand. I love when patients have a few go-to techniques if their symptoms flare. I’ll share a few of my favorites below.
6) Monitor your symptoms as you work towards your goals. If you do a work out and notice increased symptoms during or immediately following, it is likely that you may have progressed a little too quickly. However, it’s also important to look outside your exercises to see if something else may have flared your symptoms. Did you do more walking or lifting than normal? How has your sleep been? Have stress levels been elevated? All of these factors may affect your prolapse symptoms.
What exercises should I do with prolapse?
Of course the answer is - it depends! It is important to get assessed to find out where your body needs the most support. Below I’m going to share a few things I commonly assess with patients with symptomatic prolapse, and some of the exercises I prescribe.
1) Rib cage mechanics. Many of my patients think diaphragmatic breathing is “belly breathing”. They take a big inhale into their belly, which actually puts a lot of pressure down on their pelvic floor. This can happen because belly breathing just simply isn’t a good cue for them, or because they have some restrictions in their rib cage.
Some women present with a rib flare in the front, meaning that the angle of the rib cage from their breastbone is wide. This happens a lot in my postpartum patients. They are stuck in what is known as an “inhalation” position. If you are stuck in this wide angle, it is hard for the ribs to expand further as your diaphragm is resting at a lengthened position. This also affects how well you are able to manage pressure in your abdomen. If you feel like your bras have been tighter postpartum, or notice your ribs flare forward in the front, give this exercise a try.
Strengthening your oblique muscles can help to reduce rib flare, but it is also important that you are able to expand your ribs in the back. Many of my patients (whether they have rib flare or not!) tend to have tension through their thoracic spine and posterior rib cage. If this sounds like you, give this back expansion breathing exercise a try.
Improving rib mechanics and breathing mechanics can play a key role in helping you better manage pressure placed on your pelvic floor, which can in turn significantly improve POP symptoms.
2) Hip mobility and strength. Your hips have a major affect on your pelvic floor function, and vice versa. One muscle that is often a problem in patients who have pelvic floor dysfunction (including POP) is your obturator internus. The obturator internus is a deep hip rotator that needs to be able to lengthen and lift alongside your pelvic floor muscles in order to support your pelvic organs. Give this exercise a try to work on hip rotation strength.
Hip strength and stability is also important in force absorption. If your hips are unable to absorb forces during activities like running and jumping, your pelvic floor muscles have to work much harder. In some cases, this may make your POP symptoms worse. Single leg strengthening exercises like step ups and lunges can help build hip strength. Progressing to yielding exercises like this one can help with hip strength and force absorption.
3) Foot strength, mobility, and midfoot pronation. The word “pronation” has gotten a bad rep over the last decade, however midfoot pronation is actually very important when it comes to force absorption and pelvic floor muscle function. I am talking about your midfoot (near your arch) being able to lengthen and lift with weight shifting, walking, and running, not your ankle. (Over-pronating at your ankle can be problematic for some people). If your midfoot is unable to pronate, your pelvic floor will have to absorb a lot more force. If your pelvic floor is unable to handle that force, your POP symptoms could worsen.
Give this midfoot mobilization exercise a try. Once you feel ready, you can advance to this version with a lunge.
4) Pressure management. I mentioned pressure management above when discussing rib cage mechanics, but I want to dive in to some other things to consider when it comes to exercise and pressure management.
First, lets talk about breathing with exercise. I am not saying that you should never do a Valsalva. If you are a powerlifter or someone who wants to test and train your 1 rep max, there is a time and place for using a Valsalva technique (yes, even if you have prolapse). However, for most of my patients if they are in the early rehab stages with POP, we will work on breathing through exercises to help reduce pressure down on your pelvic organs. Often exhaling through the hardest part of a movement is most helpful, but you can play around with your breathing technique with different exercises to see what feels best.
What you shouldn’t feel is a lot of pressure down on your pelvic floor. If you feel like you are bearing down on your pelvic floor (as if you were trying to have a bowel movement), you likely aren’t managing your pressure well to help reduce POP symptoms. Again, if you would like to eventually progress to being able to Valsalva for lifting without increasing your POP symptoms, I highly recommend that you work one on one with a performance based pelvic floor therapist.
5) Organ mobility. Tension throughout the thoracic cavity, abdominal cavity, and pelvis can affect how well your organs are able to move, and can also affect your ability to manage pressure on your pelvic floor. Visceral manipulation can be really helpful in balancing any tension and reducing pressure on your pelvic floor, while also reducing POP symptoms. Check out this blog post to learn more about organ mobility and pelvic health.
Working with a Barral trained visceral practitioner can be really helpful in addressing specific tissue tensions. If you are unable to find someone in your area or want to try some general techniques yourself, check out this self bladder release, and this side lying release on the coregeous ball. If you have had a c-section or have any other abdominal scars, check out this scar mobilization technique. Keep in mind these techniques are a lot more general than what we do in office!
6) Down-training/relaxation exercises and techniques. I see a lot of patients who have been taught down-training and relaxation exercises to reduce their POP symptoms. I think these exercises are a great tool if you have a flare in your symptoms, or if they are helpful to utilize at the end of the day to keep your symptoms down. However, as a treatment for POP I do think they are incomplete. You still need to be addressing all of the above points in order to reduce POP symptoms!
Some of my favorite down-training and relaxation techniques include hips elevated breathing and marching, legs up on the wall, and back expansion breathing.
If you want to get back to higher impact exercises, like running and jumping, I still recommend starting with some of the above exercises if you are symptomatic. However, eventually you will need to work on adding more impact. Check back for a future blog post specific to running with prolapse!
Questions about exercise and prolapse? You can contact me directly at alexis@absolutekineticspt.com or schedule your in-person or virtual appointment with me here.
Blog post written by Dr. Alexis Hutchison, PT, DPT, OCS, PCES
Core Confidence: Reclaim Your Strength Postpartum (& Beyond)
A program designed to help postpartum women regain the confidence to return to exercise, an active lifestyle, and caring for their children without limitations.
Pregnancy and childbirth are major physical events, and postpartum moms deserve evidence-based guidance and proper rehabilitation. I created this program to help postpartum women confidently rehab, decrease pelvic floor symptoms, and be able to access personalized guidance from anywhere.