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Pelvic Organ Prolapse: What It Is, Symptoms, Causes & Treatment
If you've recently been told you have pelvic organ prolapse, you may have immediately gone down the Google rabbit hole.
Or maybe you're noticing pressure, heaviness, a bulge, changes in how your tampon fits, or something just feels different down there—and you're wondering if you could have prolapse.
Either way, you're probably looking for a simple answer to a not-so-simple question:
What exactly is prolapse, and what am I supposed to do about it?
Let's start there.
What is pelvic organ prolapse?
Pelvic organ prolapse (POP) happens when one or more of the pelvic organs move downward from their usual position because the tissues supporting them have changed.
The organs that can be involved include the:
Bladder
Urethra
Uterus
Rectum
Upper portion of the vagina
Small intestine
Your pelvic organs aren't rigidly fixed in one spot, but they're also not floating freely around your pelvis. They're surrounded by fascial compartments and supported by connective tissue, ligaments, pelvic floor muscles, and the structures around them.
This support system gives your organs some normal mobility while keeping them supported within the pelvis.
With prolapse, that support system has changed, and the organs descend farther than they did before.
The amount of movement can also change depending on your position and what you're asking your body to do. When you're lying down, gravity isn't placing the same downward demand on the tissues as it does when you're upright. Standing, walking, exercising, lifting, and even spending a long day on your feet can place different demands on the support system.
This is one reason prolapse can feel different at different times of the day.
What are the different types of pelvic organ prolapse?
The type of prolapse depends on which pelvic organ is shifting downward or which area of the vaginal wall has lost some of its support.
You may hear terms such as:
Cystocele: the bladder pushes into the front wall of the vagina.
Rectocele: the rectum pushes into the back wall of the vagina.
Uterine prolapse: the uterus moves downward toward the vaginal opening.
Apical or vaginal vault prolapse: the upper portion of the vagina moves downward. This can occur after a hysterectomy or with other changes in pelvic support.
Enterocele: part of the small intestine pushes into the upper vaginal area.
You can have more than one type of prolapse at the same time.
What are the stages of pelvic organ prolapse?
Prolapse is often described using stages from 1 to 4. The stage is based on how far the vaginal wall or pelvic organ has moved downward during an exam.
Stage 1: The prolapse is relatively high in the vaginal canal.
Stage 2: The prolapse has moved farther down into the vaginal canal and may be closer to the vaginal opening.
Stage 3: The prolapse extends beyond the vaginal opening.
Stage 4: The vaginal wall or pelvic organ is significantly outside the vaginal opening.
The stage tells you about the position of the prolapse during the examination, but it doesn't tell the whole story about how you'll feel or what you'll be able to do.
Someone with a higher-stage prolapse may have very few symptoms, while someone with a lower-stage prolapse may be quite bothered by pressure, heaviness, or changes in how things feel.
Your symptoms, goals, and how your body functions matter just as much when we're figuring out what kind of support you need.
What does pelvic organ prolapse feel like?
Some people have prolapse and don't have any symptoms.
Others notice changes that can be subtle at first.
Common pelvic organ prolapse symptoms include:
A feeling of heaviness or pressure in the pelvis
A sensation of something falling, dropping, or bulging
Feeling or seeing extra tissue at the vaginal opening
Feeling like something is different down there
Trouble keeping a tampon or menstrual cup in place
Urinary leaking
Feeling like you need to pee again shortly after urinating
Difficulty emptying your bladder
Changes in bowel movements
Needing to use a finger to help empty your bowel
Pelvic, hip, or low back discomfort
Discomfort during sex
Symptoms that increase with prolonged standing or activity
You may also notice that your symptoms change throughout the day.
You might feel relatively good in the morning and notice more pressure, heaviness, or bulging later in the day. You may notice more symptoms after being on your feet, lifting repeatedly, exercising, coughing, or straining with a bowel movement.
Then things may feel better after you've been lying down for a while.
That doesn't necessarily mean you've permanently made the prolapse worse during the day. Your position and the demands you've placed on your body can change how much support your pelvic organs are receiving at that moment.
What causes pelvic organ prolapse?
There isn't one single cause of prolapse.
It's usually a combination of factors that influence the tissues supporting your pelvic organs.
Pregnancy and childbirth
Pregnancy itself places increased demands on the pelvic floor and surrounding connective tissues as your baby grows.
Vaginal birth can add another layer because the tissues need to stretch to allow your baby to pass through the birth canal.
Certain birth factors, including forceps or vacuum assistance, larger babies, multiple births, and very fast births, may increase the risk of tissue injury or changes in pelvic support.
This isn't about blaming the way you gave birth. Vaginal birth is simply one risk factor among others.
And having a Cesarean doesn't mean you're immune from prolapse especially if there was some pushing for birth prior to the cesarean.
Pregnancy can change your abdominal wall, pelvic floor, posture, breathing mechanics, and pressure management regardless of how you deliver. A C-section can also add scar tissue and affect how the abdominal wall, diaphragm, and pelvic floor coordinate.
Connective tissue and genetics
Your connective tissue matters.
Some people naturally have connective tissue with more stretch and less recoil than others. Genetics can play a role in how your tissues respond to the demands of pregnancy, birth, and everyday life. Certain connective tissue disorders, such as Ehlers-Danlos syndrome, can also increase the risk of pelvic organ prolapse.
This is one reason two people can have similar pregnancies or births and have very different pelvic floor and prolapse experiences.
Hormonal changes
Hormonal changes can play a role too.
There are seasons of life when estrogen is lower, including postpartum, breastfeeding, and menopause. Lower estrogen can contribute to vaginal tissues becoming thinner, drier, and less elastic (less “springy”), which can affect the tissues supporting the pelvic organs.
Pressure and straining
Your pelvic floor doesn't work in isolation.
Repeated increases in pressure—such as from chronic coughing, constipation, or regularly straining or bearing down with bowel movements—can place additional demands on the tissues supporting your pelvic organs.
Heavy lifting can also be a factor when the load is beyond your current capacity or when you're using a strategy that creates more downward pressure and brings on symptoms.
This doesn't mean coughing, lifting, exercising, or having a bowel movement is inherently harmful. Your body is designed to handle pressure. The question is whether your current support system and movement strategies can manage the demands you're placing on it.
Is prolapse caused by a weak pelvic floor?
This is where things get more complicated than simply saying, “Your pelvic floor is weak.”
Sometimes pelvic floor strengthening is part of treatment. But prolapse isn't simply a strength problem.
Your pelvic floor needs to be able to both shorten and lengthen. It also needs to coordinate with your breathing, abdominal wall, pelvis, hips, and the demands you're placing on your body.
Someone can have a pelvic floor that feels weak or doesn't function well without actually needing more squeezing.
For example, your nervous system may respond to pain, pressure, fear, or a perceived lack of stability by keeping your pelvic floor muscles more contracted or guarded.
The muscles may be working hard, but they're not necessarily moving well.
That's why I look at pelvic floor function rather than simply labeling a pelvic floor as weak or tight.
And yes, sometimes that means strengthening. But it's rarely ever, just do Kegels.
Other times it means improving coordination, mobility, the ability to lengthen the pelvic floor, breathing mechanics, pressure management, or how the pelvic floor works with the rest of your body.
Often, it's some combination.
Can you exercise with pelvic organ prolapse?
Yes. Prolapse does not automatically mean you need to stop exercising.
Your exercise program may need to be adjusted based on your symptoms, your current capacity, your mechanics/form and how you're managing pressure.
For example, a heavy lift may be completely reasonable for one person but too much for another person right now.
The issue isn't necessarily the weight itself.
If an activity consistently brings on increased pressure, heaviness, bulging, or leaking, that's useful information. It may mean the demand is currently greater than your body can comfortably manage.
That gives us something to work with.
Rather than deciding that you'll never lift heavy again or that running is off the table, we can look at how to modify the activity and gradually build your capacity.
And also look at the mechanics of that activity to see what is aggravating or provoking the issue.
What can pelvic floor physical therapy do for prolapse?
Pelvic floor physical therapy isn't just about doing Kegels.
When I assess someone with prolapse, I'm looking at the whole body.
I'll look at things like:
Rib cage movement and breathing
Abdominal function
Pelvic position
Posture
Hip and pelvic mobility
Foot and lower-extremity mechanics
Pelvic floor coordination
Strength and motor control
How you manage pressure during lifting and exercise
Bowel and toileting habits
The activities that bring on your symptoms
Your pelvic floor is part of a larger system, and I want to understand how that whole system is working together.
Treatment might include pelvic floor strengthening, but it may also include breathing work, mobility, coordination, posture, movement changes, pressure-management strategies, exercise modifications, or building strength in other areas of your body.
The goal isn't necessarily to make the prolapse itself disappear. It's to improve how your body supports your pelvic organs, reduce symptoms, and help you get back to the things you want to do.
For some people, that may mean symptoms become much less noticeable throughout the day. Others may have long periods where they don't notice symptoms at all.
What about a pessary?
A pessary is a device that sits inside the vagina and provides additional support for the pelvic organs. They're like a sports bra for the pelvic organs.
For some people, a pessary can make a significant difference in symptoms and allow them to exercise or participate in daily activities more comfortably.
A pessary is simply another tool for supporting prolapse. Using one doesn’t mean you’ve failed at physical therapy or that your body can’t get stronger. It can be a helpful addition to PT, and it’s not just for women over a certain age. Pessaries can even be used during pregnancy when appropriate, properly fitted, and monitored. As always, check with your doctor to make sure it’s right for you.
A pelvic floor physical therapist or medical provider can help you determine whether a pessary may be appropriate for you.
Does prolapse mean I need surgery?
No.
Many people with prolapse manage their symptoms without surgery.
Treatment depends on your symptoms, the type and degree of prolapse, your goals, and how your body is functioning.
Surgery is an option for some people, particularly when the grade of prolapse is high and/or symptoms are significant or conservative treatment hasn't provided the results they need.
If surgery is recommended, that doesn't mean you've done something wrong or failed at conservative treatment.
Pelvic floor physical therapy can also be useful before and after surgery to address strength, coordination, breathing, pressure management, movement patterns, and the activities you want to return to.
When should you get evaluated for prolapse?
You don't have to wait until you have a visible bulge or severe symptoms.
If you've noticed:
New pelvic pressure or heaviness
A feeling of bulging or something falling
Changes in how your tampon or menstrual cup fits
Urinary or bowel changes
Symptoms that worsen with exercise or prolonged standing
A feeling that your pelvic floor isn't supporting you the way it used to
it's worth getting evaluated.
And if you've already been diagnosed with prolapse, you don't need to assume that your diagnosis means you have to give up the activities you love.
Prolapse is common and it's not automatically dangerous. There are many things you can do to improve symptoms and function.
You don't have to figure this out alone.
If you've been told you have pelvic organ prolapse—or you're wondering if your symptoms could be related to prolapse—you don't have to spend your days worrying about whether you're making things worse.
A pelvic floor physical therapy assessment can help you understand what's happening in your body and what may be contributing to your symptoms.
We'll look beyond the pelvic floor and consider how your breathing, rib cage, abdomen, pelvis, hips, feet, posture, mobility, strength, and movement patterns are working together.
You don't need to know exactly what's wrong before you make an appointment. That's what the assessment is for.
Whether you're newly postpartum, years out from having kids, newly diagnosed with prolapse, or simply wondering if what you're feeling is normal, you can get help understanding what's going on and figuring out what your body needs.
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