Pelvic Organ Prolapse

Other names for organ prolapse

• Pelvic prolapse
• Genital prolapse
• Bladder prolapse (cystocele)
• Rectal prolapse (rectocele)
• Uterine prolapse (hysterocele)

What is organ prolapse (pelvic prolapse)?

Organ prolapse is the descent of one or more pelvic organs (bladder, uterus, rectum) into the vaginal canal. This condition occurs when the muscles and ligaments of the pelvic floor weaken and can no longer adequately support these organs.

The pelvic floor consists of several layers of muscles and connective tissue that form a sort of hammock at the bottom of the pelvis. These structures support the bladder, uterus, and rectum, while allowing the urethra, vagina, and rectum to pass through. The pelvic floor is a group of muscles that serves several functions, including supporting the pelvic organs. Contracting the pelvic floor helps control urination and stabilize the pelvis.

About 50% of women over the age of 40 experience pelvic organ prolapse. Bladder prolapse (cystocele) is the most common type. Younger women can also be affected, particularly after one or more childbirths. Organ prolapse is one of the most common forms of pelvic floor disorder, along with urinary incontinence, pelvic pain, and sexual dysfunction.

Organ prolapse is not dangerous to your health, but it can significantly impact your quality of life. Some women experience no symptoms, while others have significant daily symptoms.

What are the types of organ prolapse?

There are four main types of pelvic prolapse. Cystocele (bladder prolapse) is the most common. Rectocele involves the rectum, hysterocele involves the uterus, and enterocele involves the small intestine. Several types can coexist in the same person.

Prolapse Grading System

Healthcare professionals use a grading system to assess severity:

What causes organ prolapse?

Organ prolapse occurs when the supporting tissues (muscles, ligaments) weaken or become damaged. The main causes include pregnancy, vaginal childbirth, menopause, and aging. Repeated straining and certain medical conditions also increase the risk.

• Pregnancy and Vaginal Delivery: The stretching of tissues during pregnancy and the baby's passage through the birth canal can damage the muscles and nerves of the pelvic floor
• Aging: Tissues naturally lose their elasticity and strength as we age
• Menopause: Declining estrogen levels affect the quality of supportive tissues
• Chronic Constipation: Repeated straining increases pressure on the pelvic floor
• Chronic Cough: Repeated abdominal pressure weakens the supporting structures
• Pelvic Surgeries: A hysterectomy can affect the supporting structures
• Connective Tissue Disorders: Ehlers-Danlos Syndrome and Marfan Syndrome Increase the Risk

What are the risk factors?

Some women are at higher risk of developing pelvic prolapse. Advanced age, multiple childbirths, obesity, and chronic constipation are important factors.

What are the symptoms of organ prolapse?

The main symptom is a feeling of heaviness or pressure in the vagina, as if something is descending. Other signs include urinary or bowel difficulties, a sensation of a lump in the vagina, lower back pain, and discomfort during sexual intercourse.

• Feeling of heaviness or pressure in the vagina
• Sensation that something is descending or coming out of the vagina
• Visible or palpable lump at the entrance of the vagina
• Difficulty urinating or completely emptying the bladder
• Urinary leakage (incontinence)
• Constipation or difficulty emptying your bowels
• Needing to support your perineum to have a bowel movement
• Lower back pain
• Discomfort or pain during sexual intercourse

• At the end of the day
• After standing for a long time
• During physical activities
• During straining or pushing efforts

Some women experience no symptoms, especially when the prolapse is mild.

How is organ prolapse diagnosed?

Diagnosis involves a pelvic physical exam performed by a healthcare professional. A pelvic floor physiotherapist or doctor will visually and manually assess the degree of prolapse. Additional tests are rarely needed.

• Medical History: Questions about your symptoms, pregnancies, deliveries, and lifestyle
• Physical Examination: Visual and Manual Assessment of the Vagina and Perineum
• Push Test: You are asked to push to observe how the systems respond
• Muscle Assessment: Testing the Strength and Coordination of Your Pelvic Muscles

Imaging tests (ultrasound, MRI) are sometimes prescribed for complex cases, but a clinical exam is usually enough to make a diagnosis.

How does pelvic floor physiotherapy help?

Pelvic floor physiotherapy is the first-line treatment for pelvic prolapse. It strengthens the pelvic floor muscles, improves organ support, and reduces symptoms. Studies show a significant reduction in the prolapse grade with this treatment.

Pelvic floor exercises supervised by a professional are a treatment option being studied for organ prolapse. A large randomized clinical trial, conducted among women with prolapse, evaluated an individualized pelvic floor strengthening program.

A supervised pelvic floor strengthening program can help with mild to moderate pelvic organ prolapse. The results depend on a well-structured exercise regimen supervised by a professional.

What your physiotherapist will assess

Recommended treatments

Based on the assessment results, your physiotherapist will be able to:

• Teaching you pelvic floor strengthening exercises
• Showing you the "perineal lock" technique to use before straining
• Correcting your posture and breathing
• Giving you advice on managing abdominal pressure
• Mobilize tissues if necessary
• Use biofeedback to improve muscle awareness

A proper pelvic floor contraction involves both squeezing and lifting, without tightening the glutes or thighs. A common mistake is to tighten those other muscles instead.

You can't assess a pelvic floor contraction just by looking at it from the outside. An evaluation by a professional, tailored to each individual, helps correct technique and identify the right exercise.

The pelvic floor works in conjunction with the abdominal muscles, the rib cage, and the diaphragm—never on its own. Rehabilitation therefore focuses on the entire core, not just isolated contractions.

What is a pessary and when should you use one?

A pessary is a silicone device inserted into the vagina to support prolapsed organs. It can be used daily or occasionally for certain activities; it is an effective non-surgical option when physical therapy alone is not sufficient.

• Non-surgical and reversible solution
• Can be removed and reinserted by the patient
• Helps maintain daily activities

A pessary is a flexible device placed in the vagina to support prolapsed organs. It is a non-surgical option that can relieve the sensation of heaviness or a lump.

A trained professional (physiotherapist or doctor) adjusts the pessary, and regular follow-ups are required.

When to consult a physiotherapist?

Consult a pelvic floor physiotherapist if you experience symptoms of prolapse or have risk factors. You do not need a medical referral. Preventive consultation is also recommended, especially after childbirth or during menopause.

Pregnancy and childbirth place strain on the pelvic floor. After childbirth, a Canadian guideline recommends daily pelvic floor exercises and emphasizes that instruction on proper technique from a physical therapist provides the greatest benefits.

• Feel a heaviness or pressure in the vagina
• Feel like something is descending
• Experience urinary or bowel difficulties
• Have urinary leaks
• Experience discomfort during sexual intercourse

• After a vaginal delivery
• During menopause
• If you have multiple risk factors
• Before or after pelvic surgery

You do not need to see a doctor before consulting a physiotherapist. If your condition requires further medical evaluation, your physiotherapist will guide you.

What to do at home to relieve symptoms?

Several home strategies can relieve prolapse symptoms. Lie down with your pelvis elevated for immediate relief. Use a small stool in the restroom to help with bowel movements. Avoid straining and manage constipation.

To relieve the feeling of heaviness

• Lie on your back with your pelvis elevated on one or two cushions
• Your hips should be slightly higher than your shoulders
• This position uses gravity to help your organs move back into place.

To make bowel movements easier

• Place your feet on a small stool in front of the toilet
• Keep your knees higher than your hips
• Lean slightly forward
• Avoid straining

Habits to adopt

What is the recovery time?

Improvement in symptoms requires a pelvic floor rehabilitation program that is followed regularly, often over several weeks. Progress is gradual and depends on continuing the exercises. Strengthening the pelvic floor requires consistency. The exercises often need to be continued over the long term to maintain the benefits.

• The initial stage of prolapse
• The consistency of your exercises
• Following the recommendations
• Participation in supervised sessions

Studies show that supervised training with a physiotherapist is more effective than relying solely on written instructions. A personalized program and regular follow-up greatly improve your chances of getting better.

If conservative treatments are not enough, your physiotherapist will discuss other options with you, such as a pessary or a referral for surgery.

To learn more

You can listen to the podcast "Parle-moi de santé," created by one of our physiotherapists, Alexis Gougeon. Episode #23 features Jennifer Lévesque discussing perineal and pelvic rehabilitation.

Find the episode on YouTube, Spotify or Apple Podcasts.

Sources

• Nygaard I, Barber MD, Burgio KL, et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA. 2008;300(11):1311-1316.

• Braekken IH, Majida M, Engh ME, Bø K. Can pelvic floor muscle training reverse pelvic organ prolapse and reduce prolapse symptoms? An assessor-blinded, randomized, controlled trial. Am J Obstet Gynecol. 2010;203(2):170.e1-7.