Clinical Overview
Pelvic Organ Prolapse (POP) is the descent of one or more pelvic organs—bladder (cystocele), uterus (uterine prolapse), or rectum (rectocele)—into or through the vaginal canal due to loss of support from the pelvic floor muscles, ligaments, and fascia. This is typically a result of levator ani avulsion, connective tissue laxity, or neuropathic injury following childbirth, chronic strain, or aging.
Symptoms include:
- Sensation of vaginal “heaviness” or bulging
- Visible prolapse at or near the introitus
- Urinary hesitancy, urgency, or incomplete voiding
- Constipation or rectal pressure
- Dyspareunia or reduced sexual sensation
Prevalence and Impact
POP affects approximately 50% of parous women, although not all cases are symptomatic (Hagen & Stark, 2011). Its impact on quality of life, sexual function, and mental health can be significant—even in early stages.
Evidence-Based First-Line Management: Physiotherapy
Recent guidelines and systematic reviews recommend pelvic floor muscle training (PFMT) as the first-line conservative management for Stage I–III POP (NICE, ICS).
The POPPY trial (Hagen et al., 2014), a multicenter RCT, demonstrated that individualized PFMT over 16 weeks led to:
- Clinically significant improvement in prolapse symptoms (measured by POP-SS)
- Improvement in POP-Q staging
- Reduction in prolapse severity on examination
- Better sexual function scores compared to control
- No reported adverse effects
Physiotherapy Intervention Includes:
- Digital pelvic floor assessment (Oxford scale, Modified Brink, or EMG)
- Supervised, progressive PFMT tailored to POP-Q findings
- Symptom management education: posture, breath mechanics, bowel/bladder habits
- Intra-abdominal pressure control through breathwork and load management
- Behavioral coaching for voiding, defecation, and sexual activity
- Collaborative pessary fitting (as per gynecologist referral)
Ideal Referral Candidates:
- POP Stage I–III (non-surgical candidates or surgery-averse)
- Postpartum patients with vaginal laxity or pelvic heaviness
- Patients with concurrent stress or mixed urinary incontinence
- Patients requiring pre- or post-operative pelvic floor conditioning
- Those seeking prevention of POP recurrence following prior treatment
Multidisciplinary Collaboration
- Pelvic floor physiotherapists complement gynecologic and urogynecologic care through:
- Preventing progression in early-stage prolapse
- Enhancing surgical outcomes when used pre- or post-operatively
- Reducing surgical burden in healthcare systems
- Educating patients on long-term pelvic health maintenance
Conclusion
High-quality RCTs support pelvic floor physiotherapy as an effective, low-risk, first-line treatment for women with symptomatic POP. Early intervention can delay or eliminate the need for surgical correction in many cases, and it significantly improves functional outcomes and quality of life. Prompt referral for PFMT should be considered standard care for women with mild to moderate prolapse.
References
Hagen, S., Stark, D. (2011). Conservative management of pelvic organ prolapse in women: A systematic review of randomized controlled trials. BJOG: An International Journal of Obstetrics & Gynaecology, 118(8), 868–878. https://doi.org/10.1111/j.1471-0528.2011.02955.x
Hagen, S., Stark, D., Glazener, C. M., Dickson, S., Barry, S. J., & Logan, J. (2014). Individualised pelvic floor muscle training in women with pelvic organ prolapse (POPPY): A multicentre randomised controlled trial. The Lancet, 383(9919), 796–806. https://doi.org/10.1016/S0140-6736(13)61977-7
