If any of your clients has ever given birth — and considering that 85 percent of women do, there’s a very strong likelihood that many among your clients have — you should educate yourself about pelvic organ prolapse.
Pelvic organ prolapse (POP) is a condition where the organs of the pelvis descend toward or through the opening of the vagina due to a loss of support from the pelvic floor muscles, fascia, and ligaments. It is also common to hear POP described with terms that refer to the specific structure that is prolapsed:
- Cystocele (bladder)
- Cystourethrocele (bladder and urethra)
- Rectocele (rectum)
- Uterine (uterus)
- Enterocele (small bowel)
- Vaginal vault (where the upper portion of the vagina sags down into the vaginal canal)
The degree and location of the descent determine the grade and type of prolapse. The degree of descent — referred to as grade — is usually defined using a 0-4 scale, with 0 being normal positioning and 4 being the most severe. It is also common to have more than one site that is experiencing a loss of support; many women, for instance, will have a rectocele and a cystocele.
Anything that increases pressure in the abdomen to a significant enough degree can increase the likelihood of pelvic organ prolapse. Pregnancy, labor, and childbirth are cited as the most common causes of POP. The weight of the growing baby during pregnancy places a greater load on the pelvic floor musculature, and labor and childbirth can cause damage to the musculature, connective tissue, and nerves of the pelvic floor, creating an opportunity for decreased support of the pelvic organs.
However, women who have never been pregnant can also develop POP. Other factors that may increase the likelihood of POP include:
- Respiratory concerns like long-term coughing or asthma
- Chronic constipation
- Gynecological cancers
- Heavy physical work
- Family history of POP
- Connective tissue disorders [1,2,3]
Often, women will not notice symptoms of POP until they reach menopause, but it is also common for newly postpartum women to notice symptoms of POP as well, particularly as access to pelvic health physical therapy improves.
Some women with POP will experience few symptoms, if any, while some will find the condition debilitating. The grade of POP does not necessarily dictate the symptoms a woman will experience; some women with mild grades of POP may find their symptoms unbearable and some women with more significant grades of POP will not experience the same symptom severity. Symptoms may be persistent, or may come and go. Many women do not realize they have POP until they are diagnosed by their healthcare provider.
When symptoms of POP occur, they may include:
- Feeling or seeing a bulge or excess tissue protruding from the vagina
- A sensation that something is “falling out” of the vagina
- Heaviness, pressure in the pelvis
- Incontinence (urinary, fecal, gas) or difficulty with urination or defecation
- A feeling of incomplete emptying of bladder or bowel
- The sensation of laxity in the vagina (sometimes noted by “queefing”, or vaginal flatulence)
- Lack of sensation during sex (or painful sex)
- Back pain
Accurate estimates of the prevalence of POP are challenging to obtain, due in part to the fact that not all women report their symptoms, nor are they necessarily seeking treatment from their healthcare providers. When based on findings from vaginal examination, some studies note that as high as 30 to 50 percent of women may experience POP [4,5]. One study noted a prevalence of 93.6 percent in a population of 497 women between the ages of 18 and 82 who were being seen for a routine gynecological exam .
Despite its frequency, POP is not something that is commonly discussed, and the stigma that surrounds POP may prohibit many women from reaching out for help.
If you are a trainer or coach working with women, it is almost certain that you are already, or will in the future, work with women with POP, and it is crucial that you are aware of the considerations you will need to make when working with them.
Many women experience an exacerbation of their symptoms when they exercise. In addition, much of the information readily available to women with POP is extremely conservative and does not necessarily take into account the active nature of many women diagnosed with POP.
Unfortunately, many women with POP will stop exercising entirely due to fear that movement will worsen their POP. It is crucial that the trainer or coach working with a client with POP is clear on the risks and rewards of exercise for their client.
A well-educated trainer or coach working in conjunction with a pelvic health physical therapist (PHPT) can be a huge asset to a client looking to manage POP while navigating their athleticism. Here are five considerations when training women with POP:
1. Make Sure Your Client Has Seen a Pelvic Health Physical Therapist (and That You Understand the Treatment Plan and Your Role In It)
Before working with women who have or are at risk of developing POP, it is important to make sure you have an awareness of your client’s condition and how it is impacted by exercise.
Be aware that many women will not know that they have POP. Asking questions about your client’s birth experience and including a checklist of common symptoms of pelvic floor dysfunction (including POP) is an excellent practice to adopt.
If a client has symptoms that may indicate they have a pelvic floor concern, refer them to a local PHPT for an assessment. If your client is already working a PHPT, you’re one step ahead already! With your client’s permission, it’s a great idea to reach out to their PHPT to get an awareness of what your client’s PHPT recommends.
While there’s certainly no expectation that you, as the trainer or coach, will have the level of knowledge a PHPT has, it’s important that you feel comfortable working with your client with POP and that your client feels confident that you have the requisite education to make smart training decisions. Staying communicative with your client’s PHPT, when appropriate, in addition to maintaining an open and ongoing dialogue with your client about how they’re feeling, will give you the feedback you need to guide your programming decisions.
Some women will use a rubber or silicon support device called a pessary to support the pelvic floor. Pessaries come in many shapes and sizes, are usually prescribed by a urogynecologist, and can be a very effective at managing symptoms. Some women with POP will decide that surgery is the best option for treating their POP. The recommendations will vary, depending on the surgeon, and the client’s unique situation. Women with a pessary or who have had a surgical repair still need to learn to manage pressure and use their deep core system to the best of their ability. When in doubt, make sure to get in touch with their PHPT to check in.
2. Pelvic Organ Prolapse Is Not a One-Size-Fits-All Condition
Every client with POP is an individual and it is important to keep in mind that they are more than their pelvic floor. Women with the same grade of POP may have completely different symptoms, pelvic floor function, and athletic abilities, making it impossible to create a generic “POP-safe” program that will meet the needs of each woman with POP.
Additionally, symptoms can vary depending on the time of month (many women who are menstruating find that their symptoms correspond with ovulation, or the beginning of their menstrual cycle), the time of day (many women find their symptoms more bothersome at the end of the day), or the type of activity in which a woman is engaging. The importance of an individualized approach cannot be overstated!
Checking in at the beginning of each session is a practice that any fitness professional should adopt, especially when working with a client with a chronic condition. While trainers and coaches needn’t pester a client for feedback after every single rep, an ongoing dialogue about symptoms or what the client is experiencing can provide valuable information that guides the rest of the session. Many clients will hesitate to share that they’re feeling uncomfortable and so asking direct and specific questions regarding symptoms and sensations can be helpful.
When your client is experiencing more symptoms, regressing the programming can be a smart choice. Many women with POP will experience an increase in symptoms during ovulation or at the start of their menses and dialing down the intensity, impact, and load is often indicated. Focusing on movement that is less taxing on the pelvic floor decreases the likelihood of further exacerbating their symptoms.
Ultimately, a woman with POP is just like any other client in the sense that a progressive program that focuses on their goals, current capabilities, and concerns is paramount.
Instead of becoming terrified to work with women with POP, trainers and coaches should become as educated as they can, really listen to their client, build a supportive alliance with the rest of their client’s team (primarily, a PHPT), and adhere to the basic principles of exercise science while prioritizing the function of their unique pelvic floor and body.
3. Not All Exercises Are Created Equal
While the individuality of each woman’s experience of POP makes it impossible to give absolute “safe” and “unsafe” lists of movement, there are some movements that are more likely to lead to POP symptom aggravation and that may increase the risk of worsening the grade of POP.
Movements like running and jumping are associated with increases in ground reaction forces. Ground reaction forces are approximately 1.5 times body weight during walking, three to four times body weight during running, and as high as five to 12 times body weight for jumping .
While a well-supported and optimally-functioning pelvic floor can likely cope with the increased demand, many women with POP will find that high-impact activities increase their POP symptoms. It is essential to make sure that clients who aspire to partake in high-impact exercise while managing POP are working with a physical therapist (PT) who can address their pelvic floor function internally. With guidance from their PT, a trainer or coach can work to incorporate a progressive return to higher impact.
Heavily Loaded Exercises That Encourage Bearing Down
Simply saying that “heavy lifting” is contraindicated for women with POP doesn’t tell the whole story. For instance, 25 pounds may feel heavy for one woman and equivalent to a paper weight for another.
Instead of trying to quantify “heavy”, it may be more helpful to discuss the impact of load when it becomes difficult to manage without straining and bearing down (forcefully pushing out) on the pelvic floor.
When moving large loads, the increase in intra-abdominal pressure (IAP) can lead to a tendency to bear down on the pelvic floor, potentially contributing to POP symptoms and increasing their severity. There are some strategies that can mitigate these effects, but dialing down the resistance to make sure the pelvic floor is able to sufficiently meet the demands being placed on it is a wise decision.
Women with POP should learn to meet the demands of more manageable loads (for example: they can breathe through the rep, they don’t feel like they’re straining) before moving on to higher resistance, if that’s something they’re interested in. Some PTs are able to assess a client’s pelvic floor function while they perform a weighted movement, which can give extremely valuable feedback on their tendencies (do they bear down? Does their pelvic floor lift?), from a pelvic floor perspective.
While heavier loaded movements may increase the risk of downward pressure on the pelvic floor, it’s important to keep in mind that a significant portion of women with POP have (heavy!) children that they are picking up and carrying around in addition to their athletic pursuits.
Women with POP are still living dynamic and physically active lives that do, to some extent, require them to lift heavy objects.
Instead of entirely shying away from any loaded exercise, teaching a client how to lift in a way that prioritizes their pelvic floor health (and overall bodily function) is a skill that will improve their athletic endeavors and their daily life activities for years to come.
Intense “Ab” Focused Movements
Movements like sit-ups, V-ups, or Pilates 100s-type movements can cause IAP and downward pressure on the pelvic floor to become unmanageable for women with POP. Additionally, many women with POP who are newly postpartum may have received poor information on how to regain function of their cores and may jump too soon into intense abdominal exercise in an effort to reshape their midsection after birth.
The pelvic floor forms the base of one’s core, and any exercise to promote healing and function needs to take this into consideration.
Taking an “abs-only” approach can potentially create a situation where the superficial abdominal musculature forcefully exerts pressure down onto the more-vulnerable pelvic floor. Exercise that emphasizes core function should stress the importance of a balanced use of the deep core musculature (pelvic floor, diaphragm, transversus abdominis, spinal stabilizers) that doesn’t lead to bearing down on the pelvic floor.
Also, consider the importance of training the “deep core” in a variety of positions. While many “POP Safe” programs emphasize only supine exercise, it’s important to train in a variety of positions, as most fitness endeavors and life tasks occur in positions other than lying down!
While women may find exercises like supine marching or heel slides to be a great way to initially understand the relationship of their deep core, there are several excellent options in side-lying, quadruped, kneeling, half-kneeling, seated, and standing positions that can emphasize optimal core function without introducing excessive amounts of downward pressure.
Movements Performed in a Wider Stance
The position of the body during movement may influence a client’s success in managing their POP while exercising. It is not uncommon for wider stance movements (deep squatting, lateral lunges) that place a greater stretch on the pelvic floor to feel uncomfortable for women with POP.
During the concentric phase of the movement, women with POP may bear down on a pelvic floor that is coming out of a lengthened position, potentially leading to a (perceived or real) lack of pelvic floor support. Some women will need to narrow the stance or lessen the depth of these movements, and deloading them to start is a smart move.
Not Using Gravity To One’s Advantage
When upright, the pelvic floor has to work harder to meet the demands of gravity. While trainers and coaches want clients to be confident in any position they may encounter in their sport or daily life, varying the body position during exercise sessions can ease some of the demand on the pelvic floor. This could be done, for instance, by alternating a supine exercise, such as a dumbbell floor press, with a standing one like lunges or squats.
One of the reasons women with POP might hire a trainer or coach is to help them navigate movements that have previously seemed inaccessible to them. Instead of writing off any movement that may initially seem problematic, see if there are appropriate regressions that you can use as building blocks to help your client get closer to their goals while managing their POP.
4. It’s Not Just What You Do, But How You Do It!
The bulk of information surrounding POP and exercise only discusses the “what” of exercise, but how movement is being performed is just as influential with respect to symptoms. Breathing, alignment, the degree of tension, and cueing are all variables that can be manipulated to optimize the ability of the pelvic floor to meet the demand of the exercise.
During a squat performed with a breath hold, for example, and excessive amounts of tension through the abdominal musculature might make a woman with POP feel pressure or heaviness. A more balanced breathing and tension strategy might make the same exercise symptom-free.
Recruiting pelvic floor musculature effectively may also depend on positioning. Research has suggested that changes in lumbopelvic positions influence both the contractility and the amount of vaginal pressure during static and dynamic tasks . One study found that a loss of lumbar lordosis was associated with an increased risk of developing POP . A relative “neutral” positioning of the pelvis can often result in decreased symptoms and improvements in pelvic floor muscle recruitment, and is likely to be a successful range for most clients with POP to work in, at least initially.
Trainers and coaches can also try various cues to elicit the preferred response of the pelvic floor and the rest of the body during movement. It is not uncommon to hear fitness professionals cue clients to aggressively squeeze their glutes and brace their abs as if ready to take a punch; while these cues may be appropriate for some people, in some contexts, the excessive engagement can lead to increased pressure on the pelvic floor, and increased symptoms for women with POP.
Assessing the alignment, breathing, and recruitment tendencies of your client may help you discover that there is an opportunity to change these variables, potentially improving symptoms and leading to a workout that is more appropriate for managing POP.
5. How Your Client Feels Goes Beyond the Physical (and May Impact Their Training)
Receiving a diagnosis of POP and managing it can be emotionally challenging, and our emotional state can impact our physical state (and vice versa). While trainers and coaches are not qualified mental health care providers, it helps to consider the impact that POP can have on a woman’s life.
Many women with POP are afraid to exercise, concerned that their training will exacerbate their condition. This means that trainers and coaches can benefit from spending more time building trust and prioritizing open communication (really, this should be a priority with any client!) so that the client with POP feels comfortable sharing if they’re having a symptomatic day, or if they’re uncomfortable with a movement suggested by their coach.
An unfortunate stigma surrounds pelvic organ prolapse and many women feel ashamed and embarrassed.
Trainers and coaches can help lessen the stigma by normalizing the discussion of symptoms, using correct anatomical terms, and treating clients with POP as they would any other client managing an injury or chronic condition.
Pelvic floor disorders are associated with anxiety and depression , so trainers and coaches should look out for symptoms of mental health concerns that would warrant a referral to a mental health care provider. Anxiety and depression may also make a woman with POP less likely to want to exercise, or more likely to engage in exercise despite experiencing an exacerbation of symptoms.
Many women with POP feel a loss of the physical aspect of their identity and will grieve that loss. Holding space for that process can be of great value to women with POP, especially because they may be unlikely to discuss POP with many of their friends and family.
A well-educated, empathetic, resourceful trainer or coach can make navigating exercise a lot less daunting for a woman with POP.
By collaborating with PHPTs, implementing smart programming, and keeping the channels of communication open, trainers and coaches can assist their clients in reaching their athletic goals while managing their POP, making a huge impact in the lives of so many women!
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