Let’s talk about Prolapse

Pelvic organ prolapse or POP, as it’s often written, is a really important topic to talk about because it has many myths and taboo’s surrounding it.

Want to know, WHAT IS A PROLAPSE?

We need to take a look INSIDE our pelvis to answer this question. Within the pelvis, we have three organs: the bladder (which we pee out of), the uterus (where we have periods/babies grow) and the rectum (which we poo out of).

I love this hammock analogy.

The hammock represents your PELVIC FLOOR MUSCLES.
The yellow shape is your BLADDER organ.
The pink shape is your UTERUS organ.
The brown shape is your RECTUS organ.

One of the hammocks jobs is to keep the organs uplifted in the pelvis. It is a dynamic structure that is designed very well to adapt to the loads placed on it. It can stretch, support and tense. Think of your pelvic floor muscles like a trampoline; springy that can withstand heavy loads.

However, if the hammock gets damaged or becomes weak, it can lose its ability to support the pelvic organs and the strength to maintain its upright positions.

The pelvic organs may descend into the hammock via the vaginal walls as a result.

An anterior prolapse or cystocele is when the BLADDER descends into the FRONT wall of the vagina.

A posterior prolapse or rectocele is when the RECTUM descends into the BACK wall of the vagina.

A Uterine prolapse is when the UTERUS descends into the VAGINAL CANAL apically (from the top).

In this section you will find out;

What a prolapse is | Why they occur | What are the signs and symptoms to look out for | Ways to manage your symptoms | Where to get help | Stages of prolapse |
Prolapse treatment suggestions | Prolapse and periods |
Prolapse and sexual function | Different ways to try pelvic floor exercises

A boat in a dry dock

⁣I love a good visual and here is one that we are taught as physiotherapist’s to help explain pelvic organ prolapse to patients.

The boat in the dry dock analogy was created by Prof. Peggy Norton who first suggested pelvic organ prolapse is due to more than one structure in the pelvis.

The boat = pelvic organs,
The water = the pelvic floor muscles,
The cables = pelvis ligaments.
The arrows = external forces (Eg. cough, laugh, lifting heavy weights).

In optimal function, all these structure work in harmony and the boat floats nicely on the water in the dock.

When there is damage or a weakness to the pelvic floor muscles, the water depletes and leaves the cables taking all the strain to support the weight of the boat. Eventually, the boat sinks down into the dock just like your pelvic organs do with prolapse.

Hence prolapse is known as “the boat in a dry dock”. This visual helps people to understand their pelvis mechanics better and can help with their perception of prolapse.

@popuplift is a brilliant account to follow on Instagram if you want more information about prolapse that is uplifting.

Prolapse Stats

1:3 ladies who have had one or more children WILL develop PROLAPSE. That is a staggering amount! That’s people in their 20’s after their first pregnancy, or people who hit menopause and their obstetric history catches up with them.

It’s not just old ladies that prolapse happens to.

IT ALSO AFFECTS WOMEN WHO HAVE NOT HAD ANY CHILDREN! Especially if they lift heavy weights, are overweight or smoke or suffer with a chronic cough.

So, prolapse is COMMON, but it’s NOT NORMAL and you don’t have to put up with it!

Knowledge is power. Prevention is key. Treatment is available and help is at hand with pelvic health physiotherapists – take a look at How to find a physio near you 

How do I know if I have a prolapse?

⁣Could you have a prolapse?

The common signs and symptoms may include a sensation of “heaviness”, “dragging down”, “hanging down”, “bulging”, “bulky” feelings in your lower pelvis/vaginal canal area or even your lower back region.

It may feel worse towards the end of the day.

Your bladder function may alter in one of the following ways:

  • Slow flow when passing water
  • Incomplete emptying
  • Going to the toilet to wee more often (Frequency)
  • Urgent desire to void your bladder (Urgency)
  • Leakage when you cough, sneeze, laugh, jump (Incontinence).

Your bowel function may alter in one of the following ways:

  • Constipation
  • Incomplete emptying
  • Needing to press the back of the vaginal wall to fully empty the bowel.

You might find when you insert a tampon for your period it falls out or won’t stay in properly.

A feeling of discomfort during sexual intercourse.

Prolapse is common, but it is not normal.

Not sure what to look for when checking for a bulge?⁣

I’ve been asked a lot of questions about different stages of prolapse.

This visual is perfect again by the fabulous @mypelvicfloormuscles 💕🙏👏

  • Mild bulge: generally difficult to see on self inspection ⁣
  • Moderate bulge: a pinkish “ball” that does not go past the entrance of your vagina ⁣
  • Severe: a pinkish “ball” that does go past the entrance of your vagina⁣

    Even though it may be the bladder or the rectum that is bulging, the bulge will be pinkish- it’s the colour of your vagina because what you are seeing IS your vagina. ⁣

    Why is that? Let’s use the bladder as an example. The bladder AND the vaginal wall are both dropping. The bladder isn’t staying in it’s lane and it’s taking the vaginal wall down with it. It has dropped into the lane next to it which is the vagina. ⁣
    Pelvic heaviness, pelvic pressure, and a bulge in the vagina are common symptoms of pelvic organ prolapse (POP). ⁣⁣⁣
    1. This “what to look for” post does not determine whether or not you have pelvic organ prolapse.⁣
    2. Your women’s health provider generally uses a test called the “POPQ” during your annual exam to see if you have pelvic organ prolapse. There are multiple calculations and measurements that determine what type and what grade of prolapse you may have. ⁣⁣⁣
    3. Your symptoms may vary by day. Some days a bulge may not be visible and other days it is. ⁣⁣⁣
    4. Your symptoms may vary by time. Some times of day a bulge may not be visible and other times it is. ⁣⁣⁣
    5. Positions and activities may affect your symptoms. ⁣
    6. There are many successful interventions for POP. A strong and coordinated pelvic floor is important for long term successful management of POP. ⁣⁣⁣
    7. I have happily and successfully lived with POP for 19 years! Most days I’m symptom free but not always. Overall I’m pleased with my quality of life and I’m doing everything that I want to do! This is the first time I’ve publicly shared this Jeanice”

Love myPFM page check it out if you have any pelvic health “bothersome bits”

How is a prolapse treated?

There are non-surgical and surgical options for the treatment of prolapse.

A prolapse can happen during pregnancy, just after childbirth or many years later and even to people who do not have pregnancies or give birth.

The majority of women (40%) have minor prolapses which have minimal or no symptoms. Many people experience different symptoms with the same size of prolapse. For some, it may affect their every move and for others, they may not notice it for the majority of time.

How ‘bothersome’ your prolapse symptoms are, normally defines your treatment.

Here are your options:

DO NOTHING – if your prolapse is not affecting your day-to-day quality of life and is not bothering you – leave it alone. You can make lifestyle adjustments to maintain this. You should follow a graded exercise programme that allows you to lift heavy gradually and under the supervision of a pelvic health fitness trainer. Manage your bowels and avoid being constipated as repetitive straining/bearing down through your pelvic floor muscles are likely to cause you to feel symptoms.

Try HYPOPRESSIVE exercises – This is where you learn to decrease your intra-abdominal pressure which can help with prolapse management. Many ladies I have met in Europe swear by this exercises to help reduce those bothersome symptoms of heaviness in the vagina or a bulge felt down there.

Use a PESSARY – A pessary is a ring/cube that inserts into your vagina that allows mechanical support to the inside of the vaginal walls. There are many different shapes and sizes so it can be trial and error to get a good fit. Pessaries will help reduce symptoms if they fit correctly and they can allow you to continue with normal activities of daily living and exercise. A pelvic health physiotherapist may be able to fit you one or a gynaecologist or GP. Ask for a referral and do some research. These are NOT for old ladies!

PELVIC FLOOR EXERCISES – Evidence from the NICE guidelines now confirms that regular strengthening programmes of our pelvic floor muscles will help improve or prevent prolapse symptoms from getting worse. It’s all about timing, motivation and technique as like any muscle they can take 6 – 12 weeks to strengthen.

If you struggle to remember to fit them in then be sure to download my free e-booklet: 10 Super quick ways to fit pelvic floor exercise into your day 

A 16-week programme of pelvic floor strengthening is recommended as the first line of treatment for prolapse management under supervision of a pelvic health physiotherapist.

SURGERY – Based on your age, severity of prolapse and your general health your gynae surgeon will discuss appropriate surgical options for you. Generally, there are two types of surgery: reconstruction or vaginal closure which depend on the severity of your prolapse and if you are sexually active or not. Recently there have been lots of headlines about the MESH scandal. As always, discuss all your treatment options benefits, side effects and choices with your chosen health care provider.

Finally, don’t ignore your body’s symptoms.

Your body is AMAZING at keeping you HEALTHY and it is telling you something you need to address.

Prolapse & Periods, lets talk about it…

It is not fully understood why you may feel your prolapse symptoms at certain times of your monthly cycle but here are a few theories;

1. Your uterus will change size during your menstrual cycle as the lining thickens after ovulation in preparation for a potential fertilised egg (or not) and then sheds it’s lining if no egg is fertilised or there like in an anovulatory period. (See period page for more info on this). It is likely before your period your uterus is heavier in bulk therefore prolapse symptoms may be felt more.

2. The pelvic organs are dynamic structures that change in their size according to when they are full or empty (think full bladder, needing to poo, or when you are on your period). They are not held in rigid positions inside our pelvis which could contribute to bothersome symptoms.⠀

3. During your menstrual cycle huge hormonal changes occur which are likely to alter your symptoms.

So please keep in mind:

  • You are not doing anything wrong and with time and rehab to your pelvic floor muscles your symptoms may even go away.
  • Strengthen your pelvic floor muscles holistically. Use them in different functional positions and not just sitting down/standing up. Gradually increase the load and impact to see big changes and preferably under guidance of a pelvic health physio.
  • If you notice you don’t have any bothersome symptoms for the majority of your cycle then rejoice and plan your calendar for extra self care before/during/after menstruation.
  • You’re not doing anything wrong. Your body’s natural rhythm of it’s monthly cycle is doing it’s thing.
  • Acceptance (and knowledge of the why) helps massively with healing.

Have you noticed a pattern? Track your cycle to find out. Write down each day if you notice any prolapse symptoms or not.

A simple ✅ = yes, and a ❌ = no. You might even want to write one word with it like mild, mod, severe, heavy, dragging, to help you then see a pattern.

Looking for patterns can reassure you and empower you to make decisions about exercise commitments or social engagements. You can plan to avoiding heavy lifting workouts or having a drinking catch up with friends at that time of your cycle which can help calm any anxiety you have and help you to feel in control.

The magic is in writing it down every day or using an app to capture your body’s info.

It’s highly empowering and I encourage all people with a uterus to do this!

Let’s talk about period products and prolapse as you may find these need to alter slightly.

This can be one of the first signs of a prolapse when your tampon will no longer stay in. Perhaps its due to reduced pelvic floor strength or tone which can be improved over time with pelvic floor reeducation exercises.
There are many options now to try in terms of size, brand and style. Many prolapse people prefer a shorter, wider tampon, but we are all different and trial and error here is key.

There has been news suggesting menstrual cups can cause prolapse and are not advised to use, but this isn’t 100% true. A menstrual cup can act as a sort of pessary in that it provides mechanical support to your vaginal walls as suction occurs to keep it in place. As long as you break the seal before you remove it to empty, then they are safe to use. Many prolapse people prefer a wider, shorter cup with a shortened stem. Again, there are many different ones out there for you to try if menstrual cups are your preferred period device.

Can you use a pessary on your period? If it’s comfortable then yes you can.
A support pessary (like a ring) can be used with a tampon, always ask your provider if you are unsure about this. Ideally you need to be able to remove the pessary daily to wash it during your period for hygiene reasons. Many people find the correct sized tampon on it’s own does provide adequate support.

Also, it is important to mention that some people feel fine when on their periods with a prolapse but others struggle and you are not alone if that is you. Ask your healthcare provider for options (GP/ gynaecology cons/pelvic health physio).

Help is out there, please do reach out and ask.

Sex and prolapse, are you worried about this?⁣

This topic is very rarely talked about so let’s bust some myths!

Will having sex make my prolapse worse?
In one word, no.

It is safe to have sex and it will not damage your bladder/uterus or bowel. You may need to experiment with different positions or use a lubricant to make things more comfortable. The main message is it’s ok to try new things out. If you have pain though do discuss this with your GP to find out about other treatment options.

Will my partner feel my prolapse?
In a word, no.

It’s highly likely that they won’t even know you have a prolapse. ⁣⁣⁣⁣If you feel unsure about it get investigative. Try inserting your finger(s) into your vagina and see what you can feel.
Be reassured that the penetrating object is less likely to be able to tell what it is feeling compared to your fingers.

Will sex be painful with a prolapse?

It is difficult to say on paper as it depends on a number of variables that are different for each of us. Factors that may affect your comfort levels can be reduced oestrogen (breastfeeding can reduce your libido and natural lubricant levels) vaginal dryness, irritated tissue in and around your vulva and vagina, overactive pelvic floor muscles and more.
Will I still be able to orgasm?
Yes there’s no reason not to.

Top tips from Jeanice from @mypelvicfloormuscles on instagram:
1️⃣”Try it out on your own first. Insert a couple fingers or a favorite sex toy. ⁣⁣
2️⃣Use lubricant.
3️⃣Tip your pelvis to let gravity help you- your pelvis is like a bowl. Tipping it can be done many ways- lying on your back with a pillow under your hips, on all fours with hips in the air (drop onto your elbows), lying on stomach with pillow under hips- and the list goes on!⁣⁣
4️⃣Remember to stimulate your clitoris. Most females are unable to achieve orgasms without clitoral stimulation. ⁣⁣
5️⃣If it hurts, get help! Pelvic health physio’s specialise in helping your intimate parts do the right thing at the right time!!⁣⁣”

Pelvic floor exercises with a prolapse: a great position to start with…and then progress to upright!


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Instagram accounts to follow:

@popuplift | @mypelvicfloormuscles | @clarebournephysio | @hypopressiveguru


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Please visit my Pelvic Health page for more useful resources