Condition guide
Do you have a feeling of heaviness in your lower tummy, a sense of something coming down in your vagina, or a feeling like sitting on a small ball? The womb, bladder or bowel can slip down from their normal position and bulge into the wall of the vagina. This is very common and is not life-threatening. For mild and moderate prolapse, the first treatment option is pelvic floor exercise with a physiotherapist for at least 16 weeks; small changes to everyday habits can also ease symptoms.
Some women have no symptoms at all; the prolapse is found during an examination done for another reason.
These can happen together; severity is usually graded from 1 (mild) to 4 (severe). Pregnancy and childbirth (especially a long or difficult birth, a large baby or a multiple birth), ageing and the menopause, being overweight, long-term constipation or coughing, having a hysterectomy and jobs involving heavy lifting all raise the risk. Conditions affecting connective tissue, such as joint hypermobility, can also raise the risk.
In POPPY, the largest trial, 447 women with newly diagnosed, symptomatic stage 1–3 prolapse were divided into two groups. One group was taught individualised pelvic floor exercises in 5 sessions over 16 weeks; at home they aimed for ten 10-second contractions and up to 50 fast contractions three times a day, and also practised tightening the muscles before moments of strain (“the knack”). The other group was given only a lifestyle leaflet. At 12 months, the prolapse symptom score had fallen more in the exercise group (an average of 3.77 vs 2.09 points), and 57% vs 45% said their prolapse was better.
The Cochrane review included four trials (857 women) comparing pelvic floor exercise with no treatment. All the trials that reported symptoms favoured exercise; in the combined result of two trials, exercise increased the chance of the prolapse stage improving by 17%. Some of the trials were small and at risk of bias.
Working the pelvic floor muscles correctly is not easy at first. If you cannot feel the muscles, or the exercises make your symptoms worse, you can ask for an assessment by a physiotherapist who works in pelvic health.
Exercises at home
The target doses for the first four exercises come from the home programme in the POPPY trial. It is normal to start with less; hold for as long as you can and build up over the weeks. For a tool that guides you second by second, you can use the pelvic floor timer.
Lie on your back with your knees bent. Draw your pelvic floor muscles in and up as if holding in wind and urine at the same time, squeeze as strongly as you can and hold, then relax fully. Do not hold your breath; do not squeeze your buttocks or tummy.
Target: ten 10-second squeezes, three times a daySit upright. Squeeze the same muscles quickly and let go straight away. Fast squeezes help the muscles switch on quickly during sudden strains such as a cough or sneeze.
Target: up to 50 fast squeezes, three times a dayOnce you can do them easily lying down and sitting, try the squeezes standing up too. You can do them while washing up or waiting in a queue.
Long and fast squeezes, three times a dayJust before you cough, sneeze, laugh or lift something, squeeze your pelvic floor muscles and hold until the movement is over. This lets the muscles give support when pressure inside the tummy rises.
Before every moment of strainIf you have to lift something, squeeze your pelvic floor first, keep the load close to your body and do not hold your breath; breathe out as you lift. Split heavy loads into lighter parts and carry them in several trips.
Every time you liftInstead of activities where both feet leave the ground, such as running, jumping and trampolining, you can choose lower-impact exercise such as brisk walking, cycling, swimming, Pilates or a cross-trainer.
Most days of the weekThey can ease the symptoms. In the POPPY trial of 447 women in the UK, New Zealand and Australia, women who did 5 sessions of pelvic floor exercise with a physiotherapist over 16 weeks had a greater reduction in prolapse symptoms than those who received only an information leaflet. At 12 months, 57% in the exercise group and 45% in the leaflet group said their prolapse was better. The difference was significant but modest. In the Cochrane review, pelvic floor exercise also increased the chance of the prolapse stage improving by 17% compared with no exercise.
For stage 1–2 prolapse, NICE recommends supervised pelvic floor training lasting at least 16 weeks as the first option, and asks that it be continued afterwards if the programme helps. Muscles take time to get stronger; keep going regularly even if you do not notice a difference in the first weeks.
A pessary is a plastic or silicone ring placed in the vagina to support the organs. NICE says it can be considered for symptomatic prolapse, on its own or together with pelvic floor exercises. More than one fitting may be needed to find the right size, and the pessary should be removed at least every 6 months. In the TOPSY trial of 340 women, women who learned to remove and insert their own pessary had a similar quality of life to those cared for in clinic, and reported fewer problems.
Surgery may be offered to women whose symptoms have not improved with non-surgical treatment, or who do not want it. The decision can be made together with your doctor, after talking through the options, expected benefits, risks and the chance of the prolapse coming back. In England’s National Health Service (NHS), operations placing mesh inside the vagina are no longer done unless there is no other option.
Yes, staying active matters. If your pelvic floor muscles are weak, high-impact activities such as running, jumping and trampolining can make symptoms worse; lower-impact exercise such as brisk walking, cycling, swimming and Pilates are good choices. Cut down on heavy lifting as much as you can.
Ageing and the menopause are among the risk factors for prolapse. Women with symptoms related to the menopause, such as vaginal dryness and irritation, may be offered oestrogen used inside the vagina as a cream, tablet or ring; it can also be considered before starting a pessary. You can talk to your doctor about this.
For leaking urine when you cough or feel a sudden urge, see the urinary incontinence guide; for the tummy muscles after childbirth, see the tummy muscle separation guide.
Unexpected bleeding from the vagina, especially after the menopause, should not be put down to prolapse and should be checked by a doctor.
Sources
®