POP- Did something fall out down there?

What is POP?

Pelvic organ prolapse (POP) is defined as the dropping of the female pelvic organs past their normal anatomic position. The organ prolapse is typically described by the organ that is falling into the vagina or out of the pelvic cavity (1).  Wait, WHAT? That can really happen? We know it sounds a bit crazy, but as many women experience, POP is a real phenomenon and is more common than you might think.

In fact, POP may occur in up to 50% of all women who have had a child (2).  Surgical repair is a common medical treatment for POP but as research progresses we are learning much more about the role of pelvic floor muscle function and coordination in reducing the symptoms associated with POP (1-6). 

This month, we will focus on the 4 most common types of pelvic organ prolapse and the common symptoms experienced by women.  We discuss the risk factors that contribute to POP  and how physical therapy can be helpful to return you to your desired activities.  So let’s get started!

Types of POP: Check out some helpful education on the AUGS website

Cystocele: A descent of the bladder into the anterior (front or top wall) vagina

Urethrocele: A descent of the urethra into the vagina

Prolapse of the uterus: A descent of the uterus into the vagina

Rectocele: A descent of the distal rectum into the posterior (back wall) of the vagina

Common Symptoms Associated with POP (1,2):

  • Sensation of pressure or heaviness in the pelvis or vaginal/rectal area
  • Urinary retention, urges and or leakage
  • Fecal incontinence, uncontrolled flatus, constipation, pain with BM, incomplete emptying of bowels and or manual assistance to evacuate stools
  • Vaginal bulging
  • Painful intercourse and/or sexual activities

Risk Factors for Developing POP (8):

  • Pregnancy and vaginal delivery:  

Yep, those amazing offspring can be a major contributor to developing POP.  Constant low load stress to the pelvic floor muscles and connective tissues that occurs with pregnancy may weaken the soft tissue support of the pelvic organs.  Labor and delivery may damage pelvic floor muscles or stretch the pudendal nerve causing the muscles to weaken and reduce their ability to support the organs. Higher risk of POP is associated with the number of vaginal deliveries, larger babies and the use of instruments, such as a vacuum or forceps for delivery.

  • Increased intra-abdominal pressure:

A chronic cough, respiratory diseases, chronic constipation or heavy lifting and straining all increase intra-abdominal pressure.  The increased load on the pelvic cavity from the increased pressure of the abdominal cavity contributes to chronic strain and weakening of the pelvic floor muscles and connective tissues, increasing risk of  pelvic organ prolapse.  

  • Hormone changes

Decreased estrogen levels associated with menopause contribute to weakening  and thinning of the vaginal walls, creating an environment that can contribute to the onset of POP.

  • Other risk factors:
    • Ethnicity- Hispanic and Caucasian women have a higher risk of developing POP
    • Obesity
    • History of Hysterectomy or previous pelvic organ surgeries

Role of the Pelvic Floor Muscles (1,2,3,5):

The pelvic floor muscles (PFM) are the main muscular support of the pelvic organs. They provide support the pelvis and it’s contents from the front to the back of the pelvis (from pubic bone to tailbone) and side to side from sitting bone to sitting bone (ischial tuberosities) to form a muscular hammock or sling.  

 The PFM work in concert with a group of muscles- the integrated core-  to support the organs and manage your intra-abdominal pressure.  The integrated core consists of the breathing diaphragm, abdominal wall, pelvic floor muscles and your spinal multifidi muscles. The coordinated efforts of your pelvic floor, deep abdominal wall muscles and spine muscles as your exhale helps manage your intra-abdominal pressure and support your organs with all your activities – from house chores to exercise.  

Activities that increase your intra-abdominal pressure (1,8):  

  • Breath holding with activities and exercises
  • Heavy lifting
  • High impact activities and exercises
  • Chronic cough
  • Chronic straining with bowel movements

Easy tips and tricks:

  • Exhale with exertion
  • Modify exercises or activities that bulge your abdomen
  • Use a squatty potty or lean forward for bowel movements

The upside: It’s never too late to retrain your core, and physical therapy can help alleviate the symptoms of POP (9)!

We’re here to help you get back to your activities safely and without pressure, heaviness, or pain. Our physical therapists can design a personalized core exercise program to reduce your risk of POP or progression of an existing POP.  If you have symptoms of prolapse and you are in the Triangle area, call us at 919-571-9912 and schedule your first visit or free phone consultation today! 



  1. Saunders K. Recent advances in understanding pelvic-floor tissue of women with and without pelvic organ prolapse: considerations for physical therapists. Physical Therapy 2017;97:1-9.
  2. Hagen S. Stark D. Conservative prevention and management of pelvic organ prolapse in women. [ Update of Cochrane Database Syst Rev.  2006; 4:CD003882; PMID:  17054190]. Cochrane Database Syst Rev. 2011;4:CD003882.
  3. Li C, Gong Y, Wang B. The efficacy of pelvic floor muscle training for pelvic organ prolapse: a systematic review and meta-analysis. Int Urogynecology J. 2016;27:981-992.
  4. Due U, Brostrom S, Lose G. The 12- month effects of structured lifestyle advice and pelvic floor muscle training for pelvic organ prolapse. Acta Obstet Gynecol Scand. 2016 Jul;95(7):811-9.
  5. Boyle R, Hay-Smith EJC, Cody JD, Morkved S. Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database Syst Rev. 2012;10:CD007471.
  6. Hilde G, Staer-Jensen J, Siafarikas F, et al. Postpartum pelvic floor training and urinary incontinence: a randomized controlled trial. Obstet Gynecol. 2013;122:1231-1238.
  7. Bo K., Pelvic floor muscle training in treatment of female stress urinary incontinence, pelvic organ prolapse and sexual dysfunction. J Urol. 2012;30:437-443.
  8. Kuncharapu, I, Majeroni B, Johnson D. Pelvic Organ Prolapse. Am Fam Physician. 2010 May 1;81(9):1111-1117.
  9. Hagen S, Stark D, Glazener C, et al. Individualised pelvic floor muscle training in women with pelvic organ prolapse (POPPY): a multicentre randomised controlled trial. Lancet. 2014; 383 (9919): 796-806. Accessed August 21, 2017.