Prolapse: Exercises to Avoid
Proper function of the pelvic floor is essential to counteract the forces that occur during exercise. So, what happens when there’s a dysfunction like prolapse in the pelvic floor? Can you exercise? What should you avoid? What is “safe”? Prolapse: Exercises to Avoid is an article devoted to answering these questions and so much more.
Understanding Pelvic Organ Prolapse
Between 1 in 3 and 1 in 4 women are affected by pelvic floor dysfunction, such as pelvic organ prolapse, urinary incontinence, or anal incontinence.
Pelvic organ prolapse is a loss of support of the muscles and/or connective tissue in the pelvic floor, resulting in the downward descent of the female pelvic organs (vagina, uterus, bladder, rectum) into or through the vagina. For a more thorough discussion on prolapse, common causes, symptoms, and staging, check out this article.
Women who seek treatment in my office tell me they experience:
Pressure and heaviness in their vagina
Leaking urine when they sneeze, cough, laugh, and exercise
Discomfort and pain during sex
Constipation and difficulty with bowel movements
They’re sick and tired of their symptoms and the extra energy of:
Packing extra clothes in case they leak at work
Making sure their running route has access to bathrooms every 10 feet
Sensation of their vagina falling out during CrossFit class
Yet another urinary tract infection because they leaked without knowing and the moisture accumulated bacteria
Feeling like they’re losing sexual connection with their partner because their symptoms are uncomfortable or embarrassing
Being exhausted and not themselves because they are NOT exercising anymore
Physical Activity, Intra-Abdominal Pressure, and Ground Reaction Force
During physical activity, intra-abdominal pressure and ground reaction forces increase. The pelvic floor muscles and connective tissue (like ligaments and fascia) help counteract these forces. Pelvic floor muscles are made of slow twitch type I endurance fibers and fast twitch type II power muscles and are anticipatory, meaning they contract in anticipation of movement. They are skeletal muscles, thus can be contracted under your command.
Try it: imagine you have to pee really bad but need to hold it for the moment. Feel your muscles contract to hold in your pee.
Intra-abdominal pressure (IAP) is the pressure inside your belly. It changes throughout the day and increases when you change positions, move, breath, and when you tighten your stomach muscles. It helps stabilize and support your spine.
Ground reaction force (GRF) is the force the ground pushes up when something pushes down on it. Physics tells us this force is equal in strength to the force that is applied to the ground.
Here is some fascinating data, illustrating the ground reaction forces counteracted by the pelvic floor during different activities:
Running 3-4 times body weight
Double back flip landing 9 time body weight
Jumping 5-12 times body weight
Long jump 16 times body weight
Strength and weight training exercises are typically short-duration, with high increases in IAP and low GRF. Contracting the pelvic floor muscles before or during strength training may help decrease leaking during these activities.
High impact exercises like running, jumping, and double-under jump roping, usually require high impacts from both GRF and IAP, although probably smaller IAP in comparison. The repetitive and multi-tasking nature of these activities makes it challenging and impractical to attempt to contract the pelvic floor muscles before or during. A more automatic contraction makes more sense theoretically but further research is needed to substantiate.
Exercise and Prolapse
Certain exercises may increase your symptoms of prolapse. What does this mean? It means the combination of IAP and GRF overcomes the current ability of the pelvic floor support structures. As the pressure against your organs increases and they descend into the vagina, you may feel heaviness and leak urine/feces/gas.
The primary “offenders” for increasing symptoms tend to be:
Double-Unders
Deadlifts
Running
Jumping
Front Squats
Cleans
Push Press
Before you STOP doing these very efficient, functional, and FUN exercises (OK, interrupting with a personal request: will someone please help me with double-unders so I can consider them FUN?!), know that research is very conflicting. For very good reasons, too:
Everyone has unique responses in IAP to every given task
COUGHING generates a higher IAP than most exercises
Standing up from a chair requires a higher IAP than lifting 20 pounds (9.08 kg)
Stopping movement is rarely ever the answer. Sometimes we benefit from putting guardrails up or giving our body a therapeutic window, but those are usually very specific considerations. We’re not going to stop standing from a chair or the toilet and when we have to cough ... Well, we’re going to cough!
Although this article is titled Prolapse: Exercises to Avoid, I have a hard time telling you to avoid any specific exercises! I don’t know what exercises increase YOUR symptoms, what your story is, what breathing strategy you use, how your pelvic floor muscles are contracting, etc. It would be irresponsible for me to make these assumptions and tell you what to avoid!
Instead, I’ll share some tips for exercising with prolapse. These are often very helpful general tips. If they’re not helpful for you, schedule an appointment with me and we’ll figure out what is!
Tips for Exercising With Prolapse
It starts with your A-B-C’s (also D & E)
Alignment: Head over heart, heart over pelvis and weight evenly distributed between both feet. Eyes level, shoulders relaxed.
Breathing: Inhale air→lungs expand, rib cage widens laterally (put your hands on your ribs and feel this happening!)→diaphragm drops down→IAP increases→pelvic floor acts like a trampoline that has just been jumped on. LET THIS HAPPEN!
Coordinate your breathing with your core, including your pelvic floor: Exhale→pelvic floor muscles contract and support, diaphragm moves up to its resting position→rib cage comes in→lungs deflate. Exhaling before or during movement helps provide support to prolapse! Too confusing? Just try not to hold your breath.
Do an at home return-to-run readiness screen. Dr. Carrie Pagliano, amazing physical therapist and human, put together a free clickable and fillable screen to help you assess your strength, balance and stability, and ability to handle impact along, with pelvic floor symptoms and past injuries at https://course.carriepagliano.com/R2Rreadyscreen. You can easily complete this screen at home. I recommend recording each exercise on your phone, so you can review!
Exercise below where your symptoms are and build up from there.
Experiencing your symptoms when you run at a certain pace for 20 minutes? Try running that pace for 10 minutes, walking for 1 minute, then running that pace for 10 minutes. What happens then? Still experiencing symptoms, try 4x (5 minutes running with 1 min walking recoveries).
Lift 80% 1-RM and leak? What if you try lifting 60% and increase the reps? Or continue lifting the same amount of sets and reps at 80% but increase your recovery time between sets? If you’re not getting symptoms with these modifications, then build up from there!
When to Seek Professional Help
If your symptoms are stopping you from doing things that you love, adding to your mental/emotional load, or concerning you in ANY way, schedule an appointment with me or a provider near you through https://pelvicglobal.com/.
Pelvic floor physical therapy is the first line of treatment of prolapse! This article describes the pelvic floor examination and common treatments for prolapse.
Conclusion
Prolapse is experienced by a lot of women and it’s common to have symptoms, but they CAN be treated. You don’t have to put up with them and you don’t have to stop the activities you love (if someone tells you that you do, please get more opinions!). There is no evidence at this point to support “prolapse: exercises to avoid.”
I’d love to help you at my clinic! If you are looking for pelvic and sports physical therapy services and you are located in the Colorado Springs, CO area, schedule your appointment today.
Conveniently located in Woodland Park, CO, I specialize in treating endurance sports injuries, pelvic health concerns, and integrative dry needling. Video appointments are also available.
Next on your reading list:
Can I Exercise With Prolapse? (coming soon!)
Does Running Strengthen the Pelvic Floor (coming soon!)
Recovery from injury, getting back to the sports that fill your soul, and
achieving peak performances ARE in your future!
Resources:
Bø, Kari, and Ingrid Elisabeth Nygaard. “Is Physical Activity Good or Bad for the Female Pelvic Floor? A Narrative Review.” Sports medicine (Auckland, N.Z.)vol. 50,3 (2020): 471-484. doi:10.1007/s40279-019-01243-1
Prevett, C. and Moore, R. “Nuances of the Valsalva Manoeuvre and Bracing with Regard to Resistance Training Performance and its Effects of the Pelvic Floor.” Journal of Pelvic, Obstetric and Gynaecological Physiotherapy, Spring 2024, 134, 31–41. doi:10.62399/YXRS8863
Tian, Tania et al. “Assessing exercises recommended for women at risk of pelvic floor disorders using multivariate statistical techniques.” International urogynecology journal vol. 29,10 (2018): 1447-1454. doi:10.1007/s00192-017-3473-6
Bø, K., Berghmans, B., Mørkved, S., Van Kampen, M. Evidence-Based Physical Therapy For The Pelvic Floor. 3rd ed., Elsevier, 2023.
Bø, K., Anglès-Acedo, S., Batra, A. et al. Strenuous physical activity, exercise, and pelvic organ prolapse: a narrative scoping review. Int Urogynecol J 34, 1153–1164 (2023). https://doi.org/10.1007/s00192-023-05450-3