We look at the signs, symptoms and physiotherapy treatment of pelvic organ prolapse (POP). The pelvic organs include the bladder, uterus and bowel and they sit upon the pelvic floor in the abdomen. They rely on the strength and integrity of the pelvic floor viscera (muscles, ligaments and fascia) to maintain their position in the abdomen. A weakness in any of these tissues may result in the organs bulging into the vagina. While generally not life threatening, they can be quite bothersome and impact heavily upon a person’s quality of life. They may have reduced abilities or confidence to fully partake in work life, social life, relationships and exercise.

Knowing the subtle early signs and symptoms of the risk factors for pelvic organ prolapse can be very empowering for women and allow for timely interventions that may improve the symptoms of POP. Generally women with pelvic organ prolapse, will complain of a feeling of heaviness within the pelvis, in addition to the sensation of a ‘lump’ coming down into or through the vagina. These symptoms tend to get worse with standing and towards evening time.

There are different types of POP depending on the pelvic organ that is affected. If it is the bladder that is descending or bulging through the front wall of the vagina, it is called a cystocoele. A cystocoele is often associated with urinary symptoms such as urgency- ‘the sudden fear of leaking urine’, frequency (voiding > 8 times per 24hrs) and perhaps the sensation of incomplete emptying of the bladder. For some with cystocoele, a recurrent urinary tract infections may also be a symptom.

If the back wall of the vagina is bulging down, it may be the rectum of the bowel causing the bulge. This type of pelvic organ prolapse is called a rectocoele. A rectocoele can be accompanied with symptoms such as difficulty to empty the bowels, a feeling of rectal fullness and a sensation that the bowel is not emptying completely. The third type of POP is a uterine prolapse which occurs when the uterus loses its height and slips downwards in the vagina. Pelvic organ prolapse may be one or a combination of these presentations. Women with POP may also complain of painful sexual intercourse, difficulty inserting tampons and chronic low back pain.

The common causes of POP include pregnancy, vaginal deliveries in particular when forceps assisted, hormonal changes in the peri-menopausal period, regular constipation or straining, smoking and obesity. The incidence of symptomatic POP in women over fifty is 50%. Pelvic organ prolapse so common that the chance of having surgery to address POP symptoms in life is as high as 10% and the rate of reoperation is as high as 19%.

Thankfully in the last fifteen years, research has been released to support pelvic floor muscle training as a front line treatment for POP. The NICE (National Institute for Health and Care) in the UK published guidelines in 2019 on the ‘Management of Urinary Incontinence and Pelvic Organ Prolapse’. They recommend sixteen weeks of a physiotherapist supervised pelvic floor muscle exercises as first option treatment for symptomatic POP.

The pelvic floor muscles act like a muscular hammock, closing off the bottom of the pelvis. Regular targeted pelvic floor exercises that fatigue the pelvic floor muscles will result in a strengthening of the muscles. This may improve the height of the pelvic organs and alleviate the symptoms of POP.

Chartered Physiotherapists in pelvic health have undergone specialised training to assess POP, your individual risk of development, pelvic floor muscle strength and function. They can advise on correct exercise technique and progression to ensure that the pelvic floor muscles are functioning optimally for pelvic organ support.