Comprehensive Pelvic Organ Prolapse Treatment
What is pelvic organ prolapse (POP)?
Pelvic organ prolapse (POP) occurs when one or more parts of the vaginal wall descend toward the vaginal opening. This may involve tissue near the bladder, rectum, cervix/uterus, or the vaginal cuff following hysterectomy.
Pelvic organ prolapse is not uncommon, and its severity can vary widely. Some people notice symptoms such as pressure or bulging, while others may be told they have a prolapse during an exam and feel no symptoms at all.
What causes pelvic organ prolapse?
Pelvic organ prolapse develops when the connective tissue and muscular support of the pelvis can no longer manage pressure effectively.
Anterior vaginal wall prolapse (bladder involvement)
When the front wall of the vagina drops, the bladder or bladder neck may descend. This often relates to weakness or injury of the pubocervical fascia—a connective tissue layer extending from the perineum to the cervix. Urinary leakage or difficulty emptying the bladder can occur.Posterior vaginal wall prolapse (rectal involvement)
Weakness or injury of the rectovaginal septum—the tissue between the vagina and rectum—may allow the rectum or small bowel to press into the vaginal wall. This can contribute to constipation or incomplete bowel movements.Apical prolapse (uterus, cervix, or vaginal cuff)
When the top of the vagina descends, the uterus, cervix, or vaginal cuff may be involved.
Most pelvic organ prolapse cases involve more than one compartment, which is why a comprehensive pelvic assessment matters.
What are the risk factors for pelvic organ prolapse?
Risk factors include:
Increasing age
Number of pregnancies and vaginal deliveries
Forceps delivery
Infant birth weight over 10 lbs
Chronic constipation or straining
Smoking
Connective tissue disorders
Occupations involving heavy lifting
Previous hysterectomy
Chronic physical or emotional stress
What happens if you have a prolapse during pregnancy?
Pelvic organ prolapse during pregnancy can be alarming, but it is often managed conservatively. Hormonal changes, increased abdominal pressure, and connective tissue adaptation can temporarily worsen symptoms.
In many cases:
Symptoms fluctuate throughout pregnancy
Prolapse does not automatically worsen long-term outcomes
Pelvic floor physical therapy can help manage pressure, heaviness, and function
Surgery is not recommended during pregnancy
If you notice new pelvic pressure, bulging, or the sensation that something is falling out of your vagina during pregnancy, a pelvic floor physical therapist can help guide safe strategies and symptom management.
Pelvic floor prolapse symptoms
Pelvic organ prolapse symptoms vary and do not always correlate with severity. You may have a mild prolapse with significant symptoms—or a more advanced prolapse with very few.
Common symptoms include:
A sensation of bulge, heaviness, or pressure in the vagina
Feeling like you are “sitting on a ball”
Feeling like a tampon is coming out of your vagina
A sensation that something is falling out or protruding from your rectum
Additional symptoms may include:
Urinary urgency or frequency
Difficulty starting your urine stream
Incomplete bladder emptying
Leaking urine after peeing
Constipation or incomplete bowel movements
Needing to press on the back vaginal wall to empty the rectum
Fecal or urinary incontinence
Pain with penetrative sex
It’s important to note that pelvic floor muscle dysfunction alone can mimic prolapse symptoms, even when prolapse is mild.
What would a pelvic physical therapy exam be like for prolapse?
If your prolapse symptoms worsen during your menstrual cycle or when your pelvic floor is fatigued, scheduling your exam during that time can help ensure accuracy.
Your pelvic physical therapy exam may include:
External inspection of the genital tissues
Assessment of the vaginal opening and urethra
Screening for tissue estrogenization and scarring
Discussion of bladder or bowel habits
Possible use of questionnaires or a bladder diary
Referral for urodynamic testing if needed
The exam is collaborative, consent-based, and tailored to your comfort.
What does it mean to consider surgery for pelvic organ prolapse?
Surgery is not appropriate or necessary for everyone.
Research shows that up to 44% of patients develop urinary incontinence after prolapse surgery, often because the prolapse was masking pelvic floor dysfunction. Overactive bladder symptoms may improve after surgery in moderate to severe cases.
Surgery is typically considered when:
Symptoms are significantly bothersome
Conservative management has been fully explored
Childbearing is complete
Pelvic floor physical therapy is often recommended before and after surgery to optimize outcomes.
What is pelvic floor physical therapy treatment like for prolapse?
Pelvic floor physical therapy focuses on restoring function—not just general strengthening.
Your care may include:
Education about pelvic anatomy and intra-abdominal pressure management
Strategies to reduce strain from constipation, coughing, and lifting
Guidance on pelvic floor exercises for prolapse
Nervous system regulation and breath coordination
Referral for topical estrogen if vulvar tissues are symptomatic
Management may also include observation when symptoms are mild.
If symptoms are minimal, continue monitoring and contact your provider if you notice:
Urinary retention
Severe bowel dysfunction
Hydronephrosis
Does pelvic floor therapy work for pelvic organ prolapse?
Yes. Evidence supports pelvic floor muscle training as a first-line, non-surgical treatment for stages 1–3 pelvic organ prolapse.
“Pelvic floor muscle training, either self-directed or under the guidance of a therapist with specialty training, is typically suggested as an initial non-surgical modality.”
“Therapist-guided training demonstrates superior results, with significant improvement in symptoms and POP-Q staging.”
(Bureau & Carlson, 2017)
What about pessaries?
Pessaries can be helpful if you are significantly bothered by symptoms but wish to avoid surgery or plan future pregnancy.
40–60% of patients continue use beyond 6–12 months
Possible side effects include discharge, irritation, constipation, or unmasking stress urinary incontinence
Topical estrogen is often recommended when appropriate