Pelvic Organ Prolapse...Is it all about Strengthening the Pelvic Floor?

Picture this scenario:

A very anxious patient walks into your clinic reporting symptoms of heaviness, dragging and pressure in their vagina. As a pelvic floor physio, a light bulb goes off in your head…’prolapse’…I’ve got this!

You go on to perform an assessment and note some vaginal wall laxity: maybe it’s ‘mild’, maybe it’s ‘moderate to severe’. Either way, this is enough to confirm your hypothesised finding of Pelvic Organ Prolapse (POP) and start to devise a treatment plan for this condition….right?

You get to work designing the patient a strength and endurance program drawing from the abundant evidence based recommendations (POPPY study anyone?), and add in a handout with some advice about lifestyle modification (i.e. don’t run, don’t lift heavy weights, stop Crossfit)…a solid evidence-based treatment plan!

A few weeks later (and a few sessions) later the patient is not improving. In fact, their symptoms have become worse! Their worry and anxiety has increased and they are consumed by their symptoms. You think to yourself “what have I missed here”?

This is a common story that often pops up during our mentoring sessions. Many a time, when pelvic floor physios observe vaginal wall laxity in combination with a subjective report of ‘heaviness or pressure’ in the vulvo-vaginal region, they go into the muscle assessment with their blinkers on and elect to go straight to a strength and endurance program.

A critical finding that is commonly overlooked by physios new to treating pelvic floor dysfunction is the patient’s ability to fully relax the pelvic floor muscles. Some patients, like the case above, have developed a tendency to be ‘bracing’ their pelvic floor constantly throughout the day to instinctively try and lessen the feelings of pressure in the pelvic floor or for fear of everything “falling out”. An intervention focussed on contracting the pelvic floor will usually make them feel worse.

Patients with ‘POP’ may have been told to monitor or stop certain activities which they love such as running or HIIT in order to avoid raising ‘IAP’. Whether this is because a well-meaning health professional has advised this, or it has come from their own research, this advice can have huge knock-on implications for a person’s mental and physical health, often leading to a vicious circle of hyper-vigilance towards the pelvic floor and a increase in protective ‘bracing’ and therefore their symptoms.

So what do I tell these perplexed pelvic floor physios who are faced with a worsening ‘POP’ patient?

Vaginal wall laxity is an assessment finding. We can’t specially target or treat vaginal laxity (as it relates to connective tissue). Pelvic floor physio interventions have the ability to target the muscular support structures around the vaginal wall.

In order to treat effectively, we must spend time understanding what the muscles are actually doing (and not get distracted by what we think we might find). In many cases, management of these cases does not include a strength and endurance program, initially or even at all. 

Another word of advice, don’t give generic advice about decreasing IAP. Any advice you do give must be considered in the context of the person's overall physical and emotional health, as well as their symptoms and pelvic floor findings. Everyone is different, no one POP is the same, no one pelvic floor is the same. As much as we would all love a recipe to roll out and give our patients, it rarely works. 

POP is complex and as for many things in physio, take your time, ask questions and if things don’t add up or don’t seem to be progressing as expected, zoom out and see if you can consider a different approach.

Rebecca Liberatore is the co-owner and founder of Pelvic Floor Physio Mentor. She is passionate about helping physios to implement what they have learnt in the course and clinical reason cases that come into the clinic day in and day out. She has a goal of allowing patients all over the country to access high quality pelvic floor physio treatment by supporting physios to improve their confidence, skills and knowledge through the PPPM program.