“Why Does it Feel Like My Insides are Falling Out?” (Part Two)

(Continued from Previous Blog:)

The symptoms of POP are uncomfortable and unpleasant.  One of the primary symptoms of POP is a feeling of heaviness in the uterus or pelvic floor, possibly even accompanied by the sensation of an organ descending or falling out.  Women may also experience pelvic pressure, low back pain, urinary urgency, urinary frequency, urinary incontinence, post-micturition dribble (leaking a small amount of urine after having just voided), straining with bowel movements, and incomplete emptying of the bladder and bowel.  The force of gravity works against the pelvic floor organs and further pulls them in a downward direction.  Therefore, symptoms are often worse after periods of prolonged standing or at night, after having been on one’s feet all day.


Fortunately, research has shown that pelvic floor physical therapy can help reduce POP.  POP is a condition that is similar to pelvic floor muscle weakness and incontinence in the sense that it too requires an uptraining program.  Pelvic floor exercises (Kegels) increase strength, endurance, and support of the pelvic floor.  Furthermore, a routine exercise program can prevent POP from worsening and can decrease the severity of symptoms.  Pelvic floor muscle training should first occur in a gravity assisted position (ex. with the buttocks resting atop pillows or a wedge pillow).   This position allows one to take advantage of the downward pull of gravity and to utilize it in one’s favor.  Performing Kegel exercises with the buttocks resting atop the elevated portion of the wedge helps pull the organs into a better position.

Image result for wedge hips elevated prolapse


Not only is the wedge a useful tool during exercises, but it is also a a helpful item that can be utilized for positional relief of prolapse symptoms. Women often report that their POP feels worse at the end of the day, after they have been standing on their feet and gravity has been pulling the organs down further.  By lying on the pillows or a wedge properly, gravity can be used in one’s favor to pull the organs superiorly (upward). Women who enjoy yoga may find the same relief from the downward facing dog position which also pull the organs into improved alignment.


In addition, certain lifestyle changes are important to reduce prolapse.  Education about avoiding Valsalva maneuver (exhaling with a closed windpipe) is crucial.  Instead, exhalation should be performed through the mouth during activities involving heavy lifting.  Furthermore, discussion about avoiding constipation and straining as well as proper muscle activation patterns while lifting or coughing (including inward abdominal contraction with upward pelvic floor muscle contraction) are important.


If exercise alone does not satisfactorily reduce POP symptoms, a pessary may be a helpful tool to successfully manage POP rather than resorting to surgery.  A pessary is an orthotic device that can be inserted (on a temporary or permanent basis, depending on the individual’s needs) to lift the POP.  There are many different shapes and sizes on the market, so practitioner guidance is extremely helpful to determine one’s needs and how to best address them.


A pessary is placed in the cervix, behind the pubic bone, in the same location as a contraceptive device.  An individual may prefer using a pessary only during specific activities (ex. during an exercise class), or they may choose to keep it inserted for longer periods of time.  In this case, it is recommended that one visit her doctor every three months for pessary removal and cleaning.  As with all other medical decisions, it is important to discuss options with one’s physician.


If you or someone you know can relate to the aforementioned POP symptoms, pelvic floor physical therapy might be the perfect solution for you.  We at Revitalize Physical Therapy are dedicated to helping you, and we would love the opportunity to do so.

“Why Does it Feel Like My Insides are Falling Out?” (Part One)

As a pelvic floor physical therapist, I am often asked this question by concerned women who may be experiencing pelvic organ prolapse (POP), a weakness disorder of the pelvic floor.  POP is defined as “the descent of one or more of the anterior wall, posterior vaginal wall, the uterus (cervix) or the apex of the vagina (vaginal vault or cuff scar after hysterectomy)” by the International Continence Society.

There are several different types of POP, including:

  • Uterine/cervix prolapse- when the uterus prolapses directly down through the vagina
  • Cystocele/anterior prolapse- when the front vaginal wall is pushed down by the bladder
  • Rectocele/posterior prolapse-when the back vaginal wall is pushed down by the rectum
  • Rectal prolapse- when the rectal tissue prolapses through the anus. This is often related to chronic pushing and straining

Ordinarily, the pelvic floor organs are held in their upright position via intact endopelvic fascia and suspensory ligaments, especially the uterosacral ligament.  Furthermore, the hammock-like levator ani (deep pelvic floor) muscles rest below the organs and prevent them from descending.  Similar to postural muscles, the levator ani muscles provide continuous dynamic support to the pelvic floor, and they contract prior to movement to support the organs during movement.  The ligaments serve as primary support from above and the pelvic floor muscles serve as backup support from below.

Many factors contribute to POP development.  One such cause is pregnancy and childbirth.  In fact, after an individual’s third vaginal delivery, the relative risk for POP development increases significantly.  This risk rises even higher if instruments (forceps or vacuum) were used during delivery.  Even those who have underwent C-section delivery are not necessarily in the clear either.  Pregnancy alone even without vaginal delivery increases the risk of developing POP.  This is due to the loosening effects created by the hormone relaxin which circulates in the blood at increased levels during pregnancy.

Other factors that contribute to POP development include chronic straining (ex. history of constipation), activities involving increased intra-abdominal pressure (ex. jobs that involve heavy lifting), obesity (which increases POP risk 30-50%), lower abdominal surgeries (which may disrupt the ligaments which provide support to the organs), aging, race (POP is seen more frequently in Hispanic women and less in Black/African American), and genetics.

POP severity is graded on a scale from zero (no prolapse) to four (the organ has completely extruded from the body, which is rare and requires surgery).  Approximately 50% of women who have given birth experience POP at some point during their lives, and it is one of the leading reasons for women to undergo hysterectomy.  In fact, 11.1% of community dwelling women undergo POP or incontinence surgery, however physical therapists are aiming to decrease these numbers through education about conservative treatment.


To Be Continued…