Pelvic organ prolapse (POP) occurs when one or more pelvic organs descend toward or through the vaginal opening because the supporting muscles, fascia and connective tissues are no longer providing adequate support. The anterior vaginal wall and bladder, posterior vaginal wall and rectum, uterus or vaginal apex may be involved. Although anatomical prolapse is common, treatment is primarily guided by symptoms, functional limitation and patient preference rather than anatomical stage alone (American College of Obstetricians and Gynaecologists [ACOG], 2019).

For the general physiotherapist, the aim is not to provide specialist urogynecological management. The key role is to recognise the presentation, identify factors that may increase pelvic-floor loading, initiate appropriate conservative strategies within scope of practice, monitor response and know when specialist pelvic-health or medical referral is required.

Recognising Pelvic Organ Prolapse in General Practice

The symptom most strongly associated with POP is the sensation or observation of a vaginal bulge. Patients may describe heaviness, dragging, pelvic pressure or the feeling that “something is coming down". Symptoms often increase after prolonged standing, lifting, repeated coughing or later in the day.

Bladder symptoms may include incomplete emptying, urinary frequency, urgency or incontinence. Posterior compartment prolapse may be accompanied by difficulty emptying the bowel or a need to change position or manually support the vaginal wall during defecation. Sexual discomfort and reduced confidence with physical activity may also occur. Importantly, the degree of anatomical descent does not always correspond closely with symptom severity (ACOG, 2019).

Risk is associated with factors including pregnancy and vaginal childbirth, increasing age, obesity, chronic constipation and repeated exposure to increased intra-abdominal pressure. Connective-tissue characteristics, previous pelvic surgery and family predisposition may also contribute.

The internationally recognised Pelvic Organ Prolapse Quantification, or POP-Q, system provides a standard method of describing anatomical prolapse. A formal POP-Q examination, however, is generally part of a specialist gynaecological or pelvic-health assessment rather than something every general physiotherapist is expected to perform. NICE recommends documenting prolapse by compartment and POP-Q stage during specialist evaluation.

Assessment: What Does the Generalist Need to Know?

Assessment should begin with the patient's symptoms and their effect on everyday function. Ask about the presence of a vaginal bulge or heaviness, urinary and bowel symptoms, sexual symptoms where appropriate, childbirth and pelvic surgery history, constipation, chronic cough, typical physical activity and occupations or exercise involving repeated heavy loading.

The physiotherapist should also determine which activities actually provoke symptoms. A patient may tolerate walking and resistance exercise well but develop heaviness after repeated high-load lifting, prolonged standing or constipation-related straining. Management should therefore be based on individual load response rather than automatically telling every patient with prolapse to stop exercising.

Observation of breathing, abdominal pressure strategies, sit-to-stand, squatting and lifting can be useful within general practice. Pelvic-floor muscle assessment should be performed according to the physiotherapist's training and local scope of practice. An internal vaginal examination requires specific competence, informed consent and appropriate clinical governance; referral to a pelvic-health physiotherapist is preferable when a detailed muscle assessment is required.

Pelvic Floor Muscle Training: The Main Physiotherapy Intervention

Pelvic floor muscle training (PFMT) is the principal physiotherapy intervention for symptomatic POP. NICE recommends supervised PFMT for at least 16 weeks as a first option for symptomatic stage 1 or 2 prolapse; its broader pelvic-floor guideline similarly recommends at least four months of supervised training when prolapse does not extend more than approximately 1 cm beyond the hymen on straining (National Institute for Health and Care Excellence [NICE], 2019, 2021).

PFMT should be more than simply advising the patient to “do Kegels". The first task is ensuring that the patient can produce a correct contraction: closure around the pelvic openings accompanied by an inward and upward lift, without excessive breath-holding or bearing down. Training can then target strength, endurance, repeated contractions and the ability to recruit the pelvic floor during functional loading.

The programme should be individualised according to baseline muscle function. A typical progression may move from accurate contractions in supported positions to longer holds and repeated contractions, followed by practice in sitting and standing and finally integration into tasks such as sit-to-stand, squatting and lifting. Full relaxation between contractions remains important.

Evidence supports this approach. The multicentre POPPY trial found that individualised PFMT produced greater improvement in prolapse symptoms at 12 months than lifestyle advice alone (Hagen et al., 2014). A later meta-analysis of 13 trials also found improvements in prolapse symptom scores and, in some patients, anatomical prolapse severity, although long-term effects remain less certain (Wang et al., 2022). PFMT should therefore be presented primarily as a way to improve support, symptoms and function, not as a guaranteed method of permanently reversing anatomical prolapse.

Lifestyle and Load Management Without Unnecessary Restriction

Conservative treatment should also reduce modifiable sources of excessive or repeated pelvic-floor loading. NICE specifically recommends addressing constipation, considering weight reduction when BMI is above 30 kg/m² and minimising heavy lifting when relevant (NICE, 2019).

Constipation management is particularly important. Adequate fluid and dietary fibre intake, appropriate medical management when required, a supported toileting position and avoidance of prolonged straining can decrease repeated downward pressure. Persistent constipation should be medically assessed rather than treated solely as a pelvic-floor problem.

Exercise does not need to be universally avoided. Current guidance notes that there is insufficient evidence to say that general activities such as walking or swimming either improve or worsen pelvic-floor dysfunction. The practical approach is therefore symptom-guided modification. If repeated heavy lifting, running or high-impact exercise consistently produces vaginal heaviness or bulging, temporarily reducing load, volume or impact while building pelvic-floor and whole-body capacity is more useful than imposing permanent restrictions.

During functional training, patients can also be taught to avoid unnecessary breath-holding and repeated straining. Coordinating breathing with lifting and gradually restoring confidence in loaded movement helps make pelvic-floor rehabilitation relevant to everyday function.

For postmenopausal patients with associated vaginal dryness, irritation or other genitourinary symptoms of menopause, vaginal oestrogen may be considered medically. It is not a physiotherapy treatment for prolapse itself, but treatment of vaginal symptoms may improve comfort, particularly in patients using pessaries (NICE, 2019).

Where Does a Vaginal Pessary Fit?

A vaginal pessary is a removable device placed inside the vagina to provide mechanical support to prolapsed structures. It can be used alone or alongside PFMT and may be appropriate when symptoms remain troublesome, surgery is undesirable or unsuitable, or the patient wants additional support during daily activity. NICE recommends considering pessary treatment for symptomatic prolapse and does not restrict its use to early-stage POP.

Pessary selection and fitting should be performed by a clinician with appropriate training. More than one fitting may be required before a comfortable and effective device is identified. Patients also need education about removal and cleaning where self-management is appropriate, sexual activity with the selected pessary and possible problems such as discharge, bleeding, expulsion or vaginal erosion.

AUGS and the Society of Urologic Nurses and Associates emphasise structured fitting, follow-up and management of pessary-related complications. Recent evidence also suggests that appropriately selected patients can safely self-manage some types of pessary when adequate training and access to clinical support are provided (Hagen et al., 2023; Hooper et al., 2023).

For the general physiotherapist, the important point is to recognise pessary treatment as a valid conservative option, rather than viewing physiotherapy and surgery as the only alternatives.

Monitoring Progress and Knowing When to Refer

Reassessment should focus on change in symptoms and participation rather than pelvic-floor strength alone. Useful questions include whether the vaginal bulge or heaviness is less noticeable, whether standing or walking tolerance has improved, whether bowel emptying is easier and whether previously provocative exercise or lifting can now be performed without a significant symptom increase.

Referral to a pelvic-health physiotherapist is appropriate when the patient cannot identify a correct pelvic-floor contraction; symptoms fail to improve with a reasonable trial of generalist management; pelvic pain or marked muscle overactivity complicates strengthening; or a detailed pelvic-floor examination is required.

Medical or urogynecological assessment is appropriate for advanced or increasingly troublesome prolapse, significant bladder or bowel emptying difficulty, recurrent pessary problems, unexplained vaginal bleeding or ulceration, or when the patient wishes to discuss pessary fitting or surgery. Acute urinary retention, severe or rapidly worsening pelvic pain, significant bleeding or systemic symptoms warrant more urgent medical assessment.

Conservative treatment is not merely a way of delaying surgery. For many patients, appropriate PFMT, management of contributing factors and pessary support provide meaningful long-term symptom control. The generalist's most important task is therefore to recognise which patients are suitable for conservative care and which require specialist input.

Viva-Ready Summary

Pelvic organ prolapse is the descent of one or more pelvic organs toward or through the vaginal opening because of impaired pelvic-floor and connective-tissue support. The classical symptom is a vaginal bulge or heaviness, sometimes accompanied by urinary, bowel or sexual symptoms.

Conservative management includes supervised pelvic floor muscle training, constipation and load management, appropriate weight-management advice and vaginal pessary use when indicated. PFMT should be individualised, performed correctly and continued for approximately four months before judging its effect. It improves symptoms and pelvic-floor function but should not be presented as a guaranteed anatomical cure. Persistent or advanced symptoms, emptying dysfunction, inability to contract the pelvic floor correctly, pessary requirements or concerning medical symptoms require appropriate referral.

One-line recall:
POP conservative care = identify symptoms → train pelvic-floor support → reduce unnecessary straining → modify provocative loads → consider pessary → reassess and refer when required.

References

American College of Obstetricians and Gynecologists. (2019). Pelvic organ prolapse: ACOG Practice Bulletin No. 214. Obstetrics & Gynecology, 134(5), e126–e142. https://doi.org/10.1097/AOG.0000000000003519

Bø, K., Berghmans, B., Mørkved, S., & Van Kampen, M. (Eds.). (2024). Evidence-based physical therapy for the pelvic floor: Bridging science and clinical practice (3rd ed.). Elsevier.

Hagen, S., Kearney, R., Goodman, K., et al. (2023). Clinical effectiveness of vaginal pessary self-management versus clinic-based care for pelvic organ prolapse (TOPSY): A randomised controlled superiority trial. eClinicalMedicine, 66, 102326. https://doi.org/10.1016/j.eclinm.2023.102326

Hagen, S., Stark, D., Glazener, C., Dickson, S., Barry, S., Elders, A., Frawley, H., Galea, M. P., Logan, J., McDonald, A., McPherson, G., Moore, K. H., Norrie, J., Walker, A., & Wilson, D. (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

Hooper, G. L., Moynihan, L., Leegant, A., Long, J. B., Atnip, S., Bradley, M., Hull, A., & Clemons, J. L. (2023). Vaginal pessary use and management for pelvic organ prolapse. Female Pelvic Medicine & Reconstructive Surgery, 29(1), 5–20. https://doi.org/10.1097/SPV.0000000000001293

National Institute for Health and Care Excellence. (2019). Urinary incontinence and pelvic organ prolapse in women: Management (NICE Guideline NG123). NICE.

National Institute for Health and Care Excellence. (2021). Pelvic floor dysfunction: Prevention and non-surgical management (NICE Guideline NG210). NICE.

Wang, T., Wen, Z., & Li, M. (2022). The effect of pelvic floor muscle training for women with pelvic organ prolapse: A meta-analysis. International Urogynecology Journal, 33(7), 1789–1801. https://doi.org/10.1007/s00192-022-05139-z