All Things Pelvic Organ Prolapse: Symptoms, Self-Exams, Exercises, Surgery & Soooo Much More

You know you’re a pelvic floor physical therapist when you’re targeted with an ad for a sweatshirt (or coffee mug or sticker or banner…so many options, the world was my oyster!) that says “do something that would make a 1960’s man think your uterus would fall out”. Did I not-so-silently giggle to myself when I saw it? Yes. Did I almost buy it? Also yes. Well done, algorithm…well done. PS – Here it is if you wanna take a peek and/or purchase 😉

Then, as the real life algorithm seems to work, the subject of pelvic organ prolapse started popping up everywhere – at my pelvic health clinic, in my online virtual consults, podcasts I was listening to, social media, conversations with friends – aaaaand there was a theme. Very few women *truly* understand 1) what a prolapse is, 2) what causes it, 3) their treatment options, and 4) how to prevent it. So I’m breaking ^^that^^ all down today…and more!

I have a structural Grade 2 rectocele (you’ll know what that means here in a minute!) after a severe vaginal tear while birthing my daughter and I treat women with pelvic organ prolapse every day. Despite these particular qualities, I don’t consider myself a prolapse “expert” by any means. But between personal experience and hundreds of patient encounters, ya girl does know a thing or two on the topic.

As always, this is a holistic approach to pelvic health with intentional information, actionable advice, and realistic results on the other side. Whether you know you have a prolapse and could use a little help, think you might have one but are getting mixed reviews, or just want to prevent a prolapse in the future, this is EV-ERY-THING you need to get started. Girl scout’s honor.

You know I love to start with an anatomy lesson…

I firmly believe education is at least 50% of health and healing. When you understand how the body works and what’s “normal”, you’re clearer in your needs and can take more confident action moving forward. [This] is why I begin nearly every blog post with a quick anatomy review – because your success kiiiiiinda depends on it.

The pelvic floor is a sling of muscles that sit in the bottom of the pelvis. It’s job includes sphincter control of the bowel and bladder, sexual function, and stabilizing the spine, hips, pelvis, and…you guessed it!…pelvic organs. Moving from front to back (or left to right in this picture), the female pelvic organs include the bladder, uterus, and rectum. Each organ also has multiple ligaments that connect it to the pelvis for extra support.

Sooooo…what exactly is a pelvic organ prolapse (and do YOU have one)?

A pelvic organ prolapse is when the bladder, uterus, rectum, or small intestines start to fall from their normal resting position. Each type of prolapse has its own name according to what organ is affected and which canal it’s collapsing into. The prolapse is then given a grade based on the distance the organ has descended. It’s very possible to have more than one prolapse and for the grade to change (for better or worse) over time.

TYPES OF PELVIC ORGAN PROLAPSE

Remembering the fancy names of each prolapse is 100% unnecessary, but these are words I’d love for you to recognize moving forward in your pelvic health journey. And if looking at this list feels intimidating or confusing, please appreciate that labeling your prolapse type is helpful but also 100% unnecessary to get value from this blog post and begin the healing process.

Cystocele – bladder into vaginal canal
Urethrocele – urethra into vaginal canal
Urethrocystocele – bladder & urethra into vaginal canal
Uterine Prolapse – uterus into the vaginal canal
Enterocele – small intestines into the vaginal canal
Rectocele – rectum into the vaginal canal
Rectal Prolapse – rectum into the anal canal

PROLAPSE GRADES

Knowing your prolapse grade can be important when determining the effectiveness of conservative care…liiiiiiiike the things I’m beyond excited to nerd out on here. Research shows pelvic rehab provides promising results for Grades 1 & 2, but the probably of improvement declines as the prolapse grade increases. Prolapse grades should be tested in multiple positions (laying down, standing, even squatting), at various times of day (it can change as the day goes on) and both at rest and when bearing down.

Grade 0 – absent, no prolapse
Grade 1 – more than 1 cm above the hymen (or vaginal entrance)
Grade 2 – 1 cm above or beyond the hymen
Grade 3 – more than 1 cm beyond the hymen
Grade 4 – complete retroversion of the organ

**WHERE DO YOUR ORGANS “FALL”?**

There are multiple ways to determine if you have a prolapse, the type of prolapse you have, and its severity. (PS – Simply relying on symptoms is not always accurate as less than 10% of women complain of prolapse signs, but up to 50% will have one on exam. Wild…I know!) An assessment by a pelvic floor physical therapist or gynecologist is the most accessible option. Imaging is also available such as a urodynamics test if a bladder prolapse is suspected, defocography study for a rectocele or rectal prolapse, and MRI.

The easiest place to start is by examining yourself…all you need is a handheld mirror (or a phone with the camera on “selfie” mode)! Here’s whatcha do –

1. Get in a position where your vaginal opening is exposed. This could be laying on your back with your head propped up, sitting with your back against a headboard, wall, or bathtub, on the toilet, or in a deep squat. I honestly recommend looking in more than one position as your prolapse grade may change with and without gravity.

2. Using one had to spread your labia majora and minora (or vaginal lips) and the other to hold the mirror or phone, look inside your vaginal opening. Take note of any bulging or abnormal lumps of tissue taking up space in the vaginal canal. If there’s no bulging, you may not have a prolapse. If there is, it can be worth noting:

What it looks like at rest
What it looks like when you hold your breath and push down like you’re trying to poop
What it looks like in different positions
How far above or below your vaginal entrance the bulge stops, both at rest and when bearing down (this will give you the grade of your prolapse)
Where the bulge is coming from – the front of your vagina (bladder prolapse), straight above your vagina (uterine prolapse), or the back of your vagina (small intestine or rectal prolapse)

3. Not all doctors are able to/choose to/know to test for prolapse in various positions and at different times of day. Consider taking pictures of what you find in your self-exam to show your trusted medical professional.

Signs & symptoms of pelvic organ prolapse

As I mentioned earlier, many women have a prolapse but no telltale signs to suspect it. Those sneaky SOB’s. And honestly, many of the common symptoms I’m about to share aren’t exclusive to a prolapse diagnosis either. If you resonate with anything in the following lists, consider it your signal to check for or confirm your concerns of pelvic organ prolapse…and take the next steps.

(GENERAL) SIGNS OF PROLAPSE

Visible, palpable, or noticeable lump or bulge in the vagina or rectum
Pelvic heaviness, pressure, or pain that often worsens with increased activity, at the end of the day, after going to the bathroom, or on your period
Pain or difficulty with vaginal insertion, can feel like there’s something in the way

SIGNS OF CYSTOCELE (BLADDER PROLAPSE), SPECIFICALLY

Bladder leakage & urgency, occasionally present with intercourse
Recurrent urinary tract infections (UTI)
Weak or prolonged urinary stream that improves with change in position
Incomplete bladder emptying & post-urinary dribble

SIGNS OF RECTOCELE (RECTAL PROLAPSE), SPECIFICALLY

Low back pain
Bowel leakage & urgency
Incomplete or difficulty emptying that improves with change in position or splinting (pushing on the perineum or rectum) with bowel movement
Constant sensation of constipation

Let’s talk about common causes

Like most pelvic floor problems, there is *always* an underlying cause – the body never freaks out for funsies. And when you can identify the culprit, fixing the issue becomes infinitely easier. There are standard sources of prolapse every woman should be aware of, but the goal is not that you proceed to tiptoe through life or anticipate the worst. I’m sharing these regular reasons because the “why” naturally leads to the “how”…the whole reason you’re here!

POSTURE

Picture your pelvis like a bowl filled with water…and fish! That fishbowl needs to stay on a flat, horizontal surface to keep the water and fish in the bowl, right!? In the same way, a neutral or level pelvis is optimal for supporting the pelvic organs. If the pelvis leans too far forward (anterior tilt) or backward (posterior tilt) or consistently orients to one side (lateral tilt), there will be a change in muscle length and tension, and ultimately affect pelvic floor function. AKA – The water and fish will fly right outta the bowl and hellooooooo prolapse!

INCREASED ABDOMINAL PRESSURE

The pressure inside the abdomen naturally varies throughout the day with changes in activity and position. And because that pressure primarily pushes downward (thank you, gravity!), a persistent or prolonged increase in said pressure can promote pelvic organ prolapse. Repetitive coughing or sneezing (due to illness, allergies, smoking, or asthma), chronic constipation (and the pushing that tends to come with it), and heavy lifting (especially with breath holding and/or poor form) all have a negative effect on abdominal pressure and can create a prolapse over time.

PREGNANCY & CHILDBIRTH

Not every woman who has a baby will have a prolapse, and there are also those who develop a prolapse prior to or without ever having babies at all. But just the weight of a baby sitting on the pelvic organs is enough to raise the risk. Combine that with multiples, more than one pregnancy, prolonged labor, high-grade tearing, a forceps or vacuum-assisted delivery, and the probability multiplies even further.

HYSTERECTOMY

Many believe the uterus is only for monthly periods and makin’ babies, but because of its position between the bladder and rectum, the uterus also provides support to its surrounding structures. Therefore, when a woman has a hysterectomy and the uterus is removed, the bladder and rectum are compromised and become more likely to prolapse into the vaginal canal.

MENOPAUSE & ESTROGEN DEFICIENCY

Every woman who lives long enough will go through menopause (whether naturally or surgically), and with menopause comes a drop in estrogen and therefore muscle mass, both of which do not discriminate from the pelvic floor. Estrogen gives muscles and tissues their bulk & strength & elasticity, and a loss of those properties in the pelvic floor and vaginal wall can contribute to pelvic organ prolapse.

PELVIC FLOOR DYSFUNCTION

I dare to argue that all the risk factors mentioned here would be farrrrrrr less…well…risky if they were combined with optimal pelvic floor strength, coordination, and control. But when there’s underlying muscle weakness, tightness, and/or subpar pelvic health habits, those poor pelvic organs don’t stand a chance. While we might not be able to control some of the common prolapse causes, [this] is where proactivity can make the biggest difference.

Allllllll the treatment options (& where you should start)

If ya scrolled right to this money makin’ info, I don’t blame ya! It’s fun to share the eye-opening facts, but the real flex is moving forward with informed, cut-the-fluff effort. I’ve found that many women think (because they are unfortunately told) surgery is the only solution for pelvic organ prolapse, and that couldn’t be further from the truth. Is surgery sometimes warranted? Yes! But you’re reading a blog post by a pelvic rehab therapist, m’kay!?…so the *other* options are what I’m most excited to enlighten you on today.

WHERE SHOULD Y-O-U START?

Like most health concerns, there are medical remedies that span the conservative to invasive spectrum. When it comes to prolapse, the effectiveness of each level of care depends on the grade or severity of the descending organ. To repeat myself from earlier – research shows pelvic rehab provides promising results for Grade 1 & 2 prolapse, but the probably of improvement declines as the prolapse grade increases.

Another determining factor is the nature of the prolapse, beyond which organ is falling and to what grade. Prolapses can be functional, structural, or a combination of the two:

Functional prolapse – caused primarily by pelvic floor dysfunction, specifically muscle tightness and/or weakness
Structural prolapse – caused by tissue laxity due to loss of nerve, muscle, ligament, or fascia integrity
Mixed prolapse – signs of both functional and structural components

A functional prolapse is more likely to respond to conservative care than a structural one. You can determine which one you have by testing the prolapse both at rest and with bearing down as described above. If the organs are sitting where they’re supposed to at rest but descend with bearing down, this is likely a functional prolapse. If the organ is already situated lower at rest, it’s probably a structural prolapse.

Even if your prolapse is structural and/or higher than a Grade 2, I always recommend starting with pelvic floor physical therapy first. Sure, I miiiiiiiight be bias, but 1) it will also improve surgical outcomes if you eventually decide to go that route, 2) it’s recommended after surgery anyway, so why not get a head start, and 3) a healthy pelvic floor never hurt nobody!

PELVIC FLOOR PHYSICAL THERAPY

No shade at MD’s, but general practitioners know a little bit about a lot. Gynecologists and urologists have a more specialized education, but at the end of the day…they’re surgeons who will, more often than not, recommend surgery. Physical therapists know a lot about a little bit (a fact that I’m actually quite proud of), and if you want to address those primary causes of prolapse like poor posture, increased abdominal pressure, and pelvic floor dysfunction, pelvic floor physical therapy is your best bet.

Posture. For every five-degree increase in thoracic kyphosis (or rounded back posture), there’s a 1.35x likelihood of uterine prolapse. And we’ve already touched on the effect anterior and posterior pelvic tilt have on pelvic floor muscle length and strength. Simply being more mindful with posture is a great place to start; strengthening your core, back, and glutes will remedy that bad posture for good.

Breathing. Keeping the stomach sucked in or breath holding during daily life increases abdominal pressure and can contribute to pelvic organ prolapse over time…and both are overall quick to correct. Belly breathing stabilizes abdominal pressure and optimizes pelvic floor length and strength in the process. Breathing out on the hard part of movements (like bending, lifting, pushing, pulling, squatting) supports the core and pelvic floor and prevents downward pressure on the pelvic organs.

Pelvic floor relaxation. When we think of prolapse, we often picture loose, hanging, sagging pelvic floor muscles flapping in the wind (lovely, I know). But in more cases than not, many women with pelvic organ prolapse have muscle tightness, and this must be resolved before trying to strengthen. You wouldn’t give someone a stress ball to squeeze if their hand was stuck in a fist, would you!? Learning to relax the pelvic floor is almost always the first, best, most necessary place to start, and the four steps in this free guide will help optimize muscle length, coordination, and control.

Pelvic floor strength. Only once the pelvic floor muscles are relaxed and posture and breathing are under control do I recommend working on pelvic floor strength. Kegels (or repetitive pelvic floor contractions) and deep core exercises are vital in the process of improving the grade and severity of symptoms for pelvic organ prolapse, and everything you need to know about them is right here in this free guide.

Pelvic floor control. Pelvic floor strength is lovely, but if you don’t know when and how to use that strength, it’s practically pointless. One of my favorite quick wins for pelvic organ prolapse is “the knack”, a two-second trick you can try TODAY which provides an added layer of support when the prolapse is placed in a compromised position.

How to do “the knack” –

1. Right before an activity that places pressure on the pelvic floor – coughing, laughing, sneezing, lifting, bending, pushing, pulling, squatting – perform a quick and strong kegel (or pelvic floor contraction) to brace your pelvic floor.

2. Hold the kegel through the activity.

3. Fully release the kegel once you’re done with the activity.

4. Please note – “the knack” should not be done with prolonged movements like running or jumping rope (even if you have prolapse symptoms with those activities).

Splinting. Bowel movements can be especially difficult for someone with a rectocele or rectal prolapse as they create a pouch where stool can get stuck. This often contributes to constipation, the sensation of incomplete emptying, and excessive pushing. While it doesn’t necessarily fix a prolapse, placing external pressure on the perineum (the tissue between the vaginal and anal opening) with your fingers or putting a finger in the vagina and pushing backwards on the perineum can temporarily minimize the rectal prolapse pouch and make bowel movements easier.

In the name of truthfulness and transparency, there are some cases, especially with a structural and/or high-grade prolapse, that completely resolving a prolapse with conservative care like pelvic floor physical therapy is impossible. But with the strategies above, many prolapses can improve or at least become asymptomatic, and that’s a win in my book.

If you could use a little help through this process and prefer a more personalized approach, I’m just a click (or three) away. My one-on-one online consults have proven effective for pelvic organ prolapse again and again, and I’d love to help you achieve your pelvic health goals from your favorite corner of the couch.

PESSARY

A pessary is a minimally invasive, removable device that’s placed in the vaginal canal to support the pelvic organs. They’re often made of silicone and come in multiple shapes and sizes. Many health practitioners (i.e. primary care doctors, nurse practitioners, gynecologists, urologists, and pelvic rehab therapists) have specialized training to properly prescribe and fit a pessary. This can be a great short or long-term solution for those who don’t respond well to pelvic floor physical therapy, who don’t want surgery, who are waiting for surgery, who want more babies, or who aren’t surgical candidates for whatever reason.

When choosing a pessary, it’s important to note that many women have to try multiple shapes and sizes before finding the right fit. And when I say “right fit”, I mean it shouldn’t be painful (in fact…it really should feel like there’s nothing there at all), there should be no rubbing or bleeding, nor should it easily fall out. You will likely need to try a pessary for a few hours if not days to be sure it’s the perfect one for you.

While a downside of a pessary is that they require ongoing care, once you learn how to insert & remove & clean it, it simply becomes a part of daily life. Some women wear it all day every day, others only use it as needed, often with higher intensity or prolonged activity. Pessaries can be removed and cleaned as often (or not) as you like, at least once every two weeks.

SURGERY

In all honesty, I’m not a huge fan of surgery for pelvic organ prolapse. I believe it should be a last resort and reserved only for severe cases that fail both pelvic floor physical therapy and pessary placement. This isn’t just because of a pride in my profession…it’s because I’ve seen far too many “prolapse surgery gone wrong” cases in my clinic, and the chronic post-operative pain, bowel and bladder issues, and further sexual dysfunction likely could have been prevented.

On that note, I did promise to give allllllll (I think I got all the “L”s?) the available options for pelvic organ prolapse, and surgery is most definitely one of them. Sure…there are plenty of positive outcomes, but you ~must~ weigh the risk with the reward. The obvious reward – no prolapse. The risks? Well, that’s what I’ll share here too.

Colpocleisis. The vaginal canal is shortened and closed off to raise the pelvic organs back into the pelvis. Penetrative vaginal intercourse is no longer possible after this surgery. It can be performed on women who have or have not had a hysterectomy and with various types of prolapses.

Suspension/fixation. Stitches are used to shorten the ligaments and raise the organs back to their normal resting position. These stitches are often placed in surrounding ligaments or muscle in the pelvis.

Mesh sling. A piece of mesh is attached at the front and back of the pelvis to create a sling and support the organs.

Hysterectomy. In the case of a uterine prolapse, some will opt for a hysterectomy to remove the uterus altogether. While this does take care of the uterine prolapse, there is now increased risk for bladder and rectal prolapse as they are missing a vital organ for structural support.

Surgery is often thought of as the quickest, easiest fix for prolapse, and they’re right!…a few hours on an operating table is overall fast and easy. But when mesh is brought into the mix, tissues are tugged and tacked in unnatural places, and vital organs are removed or closed off…complications occur. And when the underlying causes of pelvic floor dysfunction aren’t addressed…prolapse symptoms persist or return.

A hot take – pelvic floor physical therapy is recommended after prolapse surgery to prevent complications and optimize outcomes, so why not just start there and see what happens before surgery? “I wish I would have known” is one of the most heartbreaking things to hear as a clinician…but now you do.

11 word document pages later…

Whew! Sometimes I forget that when I take on these big topic kinda posts, I’m going to be writing for a while. But that’s ok, because now this resource exists on the world wide web, and I’m so happy you found it! Obviously this is written from the perspective of a pelvic rehab therapist, and my biases tend to be quite big, but my goal is that this post leaves you taking informed action, no matter what that action is. I might know the prolapse terms and latest research, but you know your body better than I ever will, and when you combine information with intuition…you’re unstoppable.

Forget “do something that would make a 1960’s man think your uterus would fall out”. I’m half tempted to make us shirts that say “do something that will prevent your uterus from falling out”, and I hope you found exactly what that “something” is here today.

– Amanda

Disclaimer: The content provided here does not constitute medical advice, nor is it a substitute for personalized healthcare. I’m a doctor, but I’m not your doctor. If you have concerns about a medical condition, diagnosis, or treatment, you should consult with a licensed healthcare professional.