Prolapse and Pelvic Floor Muscles

When clients are asked what they hope to achieve with treatment, they invariably say, “I want to learn how to do pelvic floor exercises”. They understand that pelvic floor muscle (PFM) strengthening is an important strategy in resolving and preventing incontinence and vaginal prolapse.

This is certainly a reasonable view, as 2010 research reports that following a 6-month program of PFM strength exercises women can improve or reverse pelvic organ prolapse (POP).

POP is related to pregnancy, birth trauma, a Body Mass Index greater than 25, weak PFM, age, bowel straining, heavy lifting and pelvic surgery. PFM strengthening does not reverse damage to endo-pelvic fascia and ligaments supporting pelvic organs; however strength reinforces sphincter closure and supports the pelvic organs.

This year I’ve seen a higher number of women with POP and chronically tight PFMs. The women were not aware their POP was associated with high tone, weak muscles rather than low tone, weak muscles.

The direction of conservative treatment for POP varies depending on whether the PFMs are high or low tone so the type of muscle dysfunction must be determined early as physiotherapy treatment of prolapse is not generic. For a high tone pelvic floor, initially strengthening the PFMs is counter productive, as the muscles are already tight and stiff.

I find that women with high tone PFMs and prolapse share some common features:

  • Poor ability to locally contract the PFMs; instead, the buttock, leg and trunk muscles activate when a PFM lift is attempted.
  • Long term stiffness in the PFMs. Try bending your elbow (biceps contraction) so the fist is near the shoulder. Imagine walking around with your arm in this position for months or years. Due to stiffness the muscle can’t relax and only produces a weak contraction. That’s similar to what happens with over active PFMs; they fail to effectively lift and hold.
  • Marked stiffness, pain and trigger points in one or both Obturator Internus (OI) muscles, which are palpated vaginally. This muscle is a hip stabilizer that externally rotates the hip but is often a problematic little princess. The Pudendal nerve (supplying the PFMs) runs through the OI, leaving the nerve prone to pressure when the muscle is chronically tight.

The OI shares a common tendon insertion with the piriformis muscle (typically tight when low back or sacro-iliac pain is present).

  • Long-term low back or sacro-iliac joint pain with poor postural contol.
  • Tight upper chest breathing associated with stiff spinal and trunk muscles. Breath holding when attempting a PFM lift is common.
  • Many walk with a strong heel striking pattern rather than sharing the weight bearing through the forefoot and heel. Strong heel striking jars the leg, pelvic and spinal joints.
  • They may have experienced birth interventions (forceps, suction, episiotomy or forced pushing), which damaged the vagina, supporting tissues and PFMs.
  • Past episiotomy is associated with PFM wasting, poor muscle activation and endurance (on the side of the cut).
  • Some degree of rectus abdominis separation may be present, weakening the ability of the trunk and pelvis to fully stabilize during activity.
  • Pain or discomfort with intercourse due to PFM tightness or a lower sitting cervix.

 Solutions for prolapse associated with chronically tight PFMs takes time and involves working through

  • Breath-training to develop abdominal/basal breathing, which promotes diaphragmatic movement. Effectively using the breath assists with pelvic floor relaxation and contraction.
  • Relaxation therapy to improve awareness and ‘letting go’ of muscle tension.
  • Myofascial release for overactive spinal, trunk, rib and pelvic muscles.
  • Specific PFM self - release techniques to reduce muscular over activity.
  • Mobilising stiff joints e.g. rib/spinal joints, inter-vertebral stiffness.
  • Muscle stretching program for tight pelvic, buttock, leg and trunk muscles.
  • Some women benefit from cognitive therapy to change reactions to stress or past trauma/abuse.
  • Postural control and learning to move/exercise with control.
  • Local pelvic floor and core muscle coordination.
  • Optimal position and muscle action for bladder and bowel emptying.
  • Specific pelvic friendly exercises throughout life and remaining active with suitable forms of exercises.
  • Fitting a vaginal pessary to support the pelvic organs. Local oestrogen is often used to improve the quality of vaginal tissues.

If you’re experiencing prolapse symptoms consult an urogynaecologist and women’s health physiotherapist for individual assessment and a program to determine the direction of treatment. Learn which conservative interventions are most effective in controlling your specific type/s of prolapse. Surgical intervention is considered when conservative treatment fails. The following article by Sherrie Palm (Founder of APOPS) addresses issues around surgical repair of prolapse with mesh.