Pelvic organ prolapse is when the bladder, uterus, rectum, or any combination of those organs moves down from its original position and bulges into the walls of the vagina or anus. Symptoms vary from patient to patient. Sometimes people have a severe prolapse and they don’t have any symptoms at all. Other times, people have a very minor prolapse and they feel a ton of symptoms. The most common symptom that patients describe is a heaviness or bulging in their vagina or rectum or a feeling like a tampon falling out of their vagina. Some patients can feel a bulge when they reach into their vagina or, in some cases, can see tissue from their body that bulges out of the vagina or anus. With these signs, it’s important to get screened by your doctor or midwife. In some states, such as California, where you can directly access physical therapy without seeing a heath care provider, you can see a physical therapist right away.

There are many factors, and we don’t know all of them, but they can be distilled into two categories: things that increase pressure on the pelvic floor and things that directly weaken the pelvic floor. Pregnancy, chronic coughing, chronic constipation, excess upper body weight, GI distress, heavy weight lifting with improper technique, and a history of bulimia and vomiting all create increased pressure on the pelvic floor and can contribute to the development of pelvic organ prolapse.

And pelvic floor muscles can weaken with a vaginal birth, which is one of the major contributors to developing pelvic organ prolapse. Genetically, some people have looser fascia, which affects the strength of the pelvic floor. And as we age, muscles can atrophy due to less estrogen, particularly during the postmenopausal period. I’ve even noticed that in some of my patients, their prolapse can worsen during menstruation, when estrogen levels are the lowest.

Yes, I encourage my patients to perform self-checks. They serve as a good baseline indicator, so you know when something is off. To do a self-check: In a sitting position, place your fingers inside your vagina. Feel the front, back, and side walls of the vagina and reach further up to your cervix. Generally, you shouldn’t feel any bulging or that something is pushing into your vaginal wall.

Training the pelvic floor how to relax and contract muscles intentionally during pregnancy is how we set people up for good recovery afterward. Ideally, we want to discover the best birthing position for the pelvic floor. Every birth is different. When treating people during their pregnancies, it’s helpful to show them how to relax their pelvic muscles because it’s not always intuitive. It’s not like seeing your arm in the mirror and getting visual feedback that your arm is relaxed. With physical therapy, we can help people recognize what it feels like to tighten and relax these muscles, and we can adjust to their unique birth needs. For example, someone’s vaginal wall could be really tight on the right side and relaxed on the left side. We can work on relaxing the right side and practice birthing positions that accommodate the difference—lying on their left side could be a better position for them to deliver the baby and have less damage to their pelvic floor.

One major thing is to manage the pressure in their body. It’s very common for pregnant people getting out of a chair to hold their breath as they’re pushing up. When you hold your breath, that pressure is going into your belly area, causing more pressure on your pelvic floor. Instead of holding your breath before you change positions, exhale first. So before you roll over in bed, pick up a child, get out of a chair, or stand up, start exhaling. This is a simple thing that can be done during pregnancy or early postpartum to protect the pelvic floor.

Another thing is to try to have regular and softer bowel movements. Harder stool and constipation can put extra strain on the pelvic floor muscles, so it’s important to talk to your midwives and doctors about managing this, whether it’s through more hydration, different foods, or different supplements.

It varies from patient to patient, but in general, a combination of pelvic floor physical therapy and sometimes pessaries. Pessaries are medical-grade silicone devices inserted into the vagina that provide support for the pelvic floor and help position the muscles so they contract better. They come in different shapes and sizes—a doctor or midwife can help you choose the right fit for you. Pelvic floor therapy trains the pelvic floor and supporting muscles in a way that decreases symptoms and allows patients to be more active. Sometimes a prolapse cannot be managed by pessaries and physical therapy. In these cases, there are surgical options.