June is Pelvic Organ Prolapse (POP) awareness month (among other things!). Now, hold on…before you bypass this blog thinking “I don’t do women’s/pelvic health,” consider that 41% of female patients with lumbopelvic pain have been found to have some degree of pelvic organ prolapse.¹ Donaldson et al found that 46% of individuals with pelvic organ prolapse reported comorbid low back pain-for 30% of them, the onset of low back pain and POP occurred simultaneously.² It is extremely likely that if you treat female patients with low back pain, a significant percentage of your patients do in fact have pelvic organ prolapse, whether or not they share that information with you (remember: patients often don’t know there is an association between the two). Thus, I would love to invite you along for the ride even if this is not your primary anticipated patient population.

  Pelvic organ prolapse is defined as the downward descent of the pelvic floor muscles. This most commonly occurs anteriorly (from the bladder) or posteriorly (from the rectum). The cause is multifactorial and not completely understood at this time. Symptoms can include a feeling of pressure or heaviness low in the pelvis; urinary and/or bowel symptoms such as urgency/frequency; incontinence, or constipation; low back pain; hip pain; and pelvic girdle/SIJ pain-and, by the way, it is not uncommon for the primary symptom to be low back or hip pain.

 I had a patient who had severe pelvic organ prolapse, and who had undergone surgical intervention without benefit several times. Her primary complaint was low back pain, which would begin upon standing and then worsen the longer she remained in an upright position until she had to go lie down to relieve symptoms. When she started working with me, her limit for upright activity was approximately 15 minutes, which prevented her from being able to care for her donkeys or participate in her role as a docent at a museum. She was no longer a surgical candidate and truly had no other options besides rehabilitation to try to address her symptoms.

She also had several contraindications to internal pelvic floor assessment and treatment, so the care she received was entirely external in nature. We worked on things like motor planning for transfers and movement, developing better strategies for lifting, and graded exposure to activity. By discharge, she had returned to being able to care for her livestock (including lifting and moving grain and feed) as well as being able to do up to a half day of work as a docent. She happened to be our docent when I took my kids to the museum almost a year later and she had worked up to full time and was enjoying living life free of low back pain.

There is a longstanding myth that people with pelvic organ prolapse need to discontinue exercise, especially exercise involving high impact or lifting heavy weights. However, we actually have quite a bit of evidence that lifting heavy weights (>50 kg) does not increase the likelihood of POP symptoms, and may actually be protective compared to being active but not doing significant strength training.³ Heavy weightlifting has also been assessed to not cause immediate negative changes.⁴ We also know that pelvic floor symptoms are heavily correlated with weakness in the hips and core musculature,⁵ so there is actually reason to suspect that exercise (especially when done with good form) is likely to be beneficial to the pelvic floor and thus pelvic organ prolapse. I also think it is critically important for rehabilitation professionals to remember the MANY benefits of exercise and consider whether a theoretical/not literature supported possible decrease in pelvic floor impact is worth the impacts on the cardiovascular system, bone density, overall well being, and mental health that we know accompanies loss of exercise.

So what are best practices for treating pelvic organ prolapse? Pelvic muscle training is a hallmark-not just isolated Kegels (I see very little benefit in these in most populations), but working on pelvic floor timing and coordination in conjunction with movements-preferably as functional as possible.⁶ Addressing any identified hip and spine mobility and strength deficits is also extremely beneficial-and one really cool thing to know is that by the thoughtful use of breathing and mindfulness/body focus, you can turn literally any exercise into a pelvic floor exercise. Don’t dump the bridges and clamshells-just integrate purposeful breathing and intentional pelvic floor activation and voila! A pelvic floor exercise (seriously, you probably would not be able to tell just by watching their exercises which of my patients have pelvic floor dysfunction). And most of all-work on movement! Our bodies were made to move in all the planes-encouraging more of that tends to help them function better. Finally, having some pain neuroscience education skills is incredibly helpful with this patient population. Very understandably, being diagnosed with pelvic organ prolapse can be scary. It is well established that degree of pelvic organ prolapse is not positively correlated with degree of bother/symptoms, with some studies even suggesting there is a negative correlation.⁷ Since POP is also highly correlated with chronic low back and pelvic pain, there are many applications of pain neuroscience education for this patient population. In particular, addressing sleep issues and kinesiophobia while providing graded exposure to activity can be very powerful for this patient populations.

By the way-the patient I mentioned earlier? She had several contraindications to internal work, so she and I were working together without the use of that tool. Everything I did with her would/should have been in my wheelhouse before I did my pelvic health specific training, but I likely would not have known how to apply what I knew for her specific case prior to that point. She is one of the reasons that I am passionate about helping therapists make the connection between the pelvic floor and the rest of the body. If you are interested in furthering your awareness of how to screen and include the pelvic floor in your care for your patients with low back/hip/pelvic pain (or how to address the spine, hips, and pelvis in your pelvic floor patients), I would welcome you to join us in Pelvic Health 1! This course is available both in person and as a virtual lab and focuses on expanding your toolbox to care for the pelvic floor, the rest of the body, and the intersection of the two. Meanwhile, if you aren’t already, I highly recommend adding some POP screening to your low back evaluation process-and definitely make sure you are assessing the spine and hips in patients who may be referred to you specifically for POP!

1. Dufour S, Vandyken B, Forget MJ, Vandyken C. Association between lumbopelvic pain and pelvic floor dysfunction in women: A cross sectional study. Musculoskelet Sci Pract. 2018;34:47-53. doi:10.1016/j.msksp.2017.12.001
2. Donaldson K, Meilan J, Rivers T, et al. The Incidence of Pelvic and Low Back Pain in Patients with Pelvic Organ Prolapse. Int Urogynecol J. 2024;35(3):609-613. doi:10.1007/s00192-024-05732-4
3. Forner LB, Beckman EM, Smith MD. Symptoms of pelvic organ prolapse in women who lift heavy weights for exercise: a cross-sectional survey. Int Urogynecol J. 2020;31(8):1551-1558. doi:10.1007/s00192-019-04163-w
4. Skaug KL, Engh ME, Bø K. Acute Effect of Heavy Weightlifting on the Pelvic Floor Muscles in Strength-Trained Women: An Experimental Crossover Study. Med Sci Sports Exerc. 2024;56(1):37-43. doi:10.1249/MSS.0000000000003275
5. Foster SN, Spitznagle TM, Tuttle LJ, et al. Hip and Pelvic Floor Muscle Strength in Women with and without Urgency and Frequency Predominant Lower Urinary Tract Symptoms. J Womens Health Phys Therap. 2021;45(3):126-134. doi:10.1097/jwh.0000000000000209
6. Li C, Gong Y, Wang B. The efficacy of pelvic floor muscle training for pelvic organ prolapse: a systematic review and meta-analysis. Int Urogynecol J. 2016;27(7):981-992. doi:10.1007/s00192-015-2846-y
7. Ellerkmann RM, Cundiff GW, Melick CF, Nihira MA, Leffler K, Bent AE. Correlation of symptoms with location and severity of pelvic organ prolapse. Am J Obstet Gynecol. 2001;185(6):1332-1338. doi:10.1067/mob.2001.119078