Understanding Prolapse | Physio Pelvic Floor

What is prolapse?

Prolapse occurs when pelvic organs, the bladder, uterus, or rectum, descend because the muscles, fascia, and ligaments that normally hold them in place have been stretched or weakened. The descent is usually described in relation to the vaginal opening (the vaginal opening).

Common types include a bulge of the bladder into the vaginal wall (bladder prolapse into the front vaginal wall), a bulge of the back wall of the vagina (rectum into the rear wall), uterine prolapse, and prolapse that can occur after a hysterectomy.

Common causes and risk factors

Childbirth, particularly multiple or difficult vaginal deliveries
Aging and menopause, reduced oestrogen affects tissue integrity
Chronic straining from constipation or chronic cough
Obesity and heavy lifting occupations
Genetic predisposition to connective tissue laxity
Prior pelvic surgery

Symptoms

Symptoms vary with position and activity. Common experiences include a feeling of heaviness or pressure in the pelvis, a sensation that something is falling out, urinary leakage or difficulty emptying, constipation or incomplete bowel emptying, and discomfort during sexual activity or long periods of standing.

Many people with anatomically significant prolapse have mild or no symptoms. Equally, symptoms often feel worse at the end of the day or after prolonged activity and better after lying down.

Staging systems

Two main systems are used:

POP-Q (Pelvic Organ Prolapse Quantification), the most precise system, using measured points on the vaginal walls in relation to the the vaginal opening. Used in research and specialist settings.

Baden-Walker, grades 0–4, based on the lowest point of descent relative to the vaginal opening during straining.

Stage 2a vs 2b

Stage 2a, prolapse stays above the vaginal opening, even with straining. Usually mild symptoms, rarely visible externally.

Stage 2b, prolapse reaches the level of the vaginal opening. More noticeable symptoms, may be visible or palpable with straining, and often flares with standing, lifting, and end-of-day activity.

Pelvic organ prolapse, physiotherapy and pessary support

Treatment

Conservative management: what the evidence says

Pelvic floor muscle training (pelvic floor exercises)

pelvic floor exercises, properly prescribed and progressed, is the first-line conservative treatment for prolapse. The goal is not simply to make the pelvic floor squeeze harder, but to improve timing, graded control, endurance, and coordination with breathing and movement. Symptoms are often managed best when training is done in position-specific progressions (lying first, then sitting, then standing and functional load).

Pessary use alongside pelvic floor exercises, especially for Stage 2b

At Stage 2b, the prolapse reaches the vaginal opening and symptoms often flare during everyday activities, standing, coughing, lifting, bowel movements. In this context, a pessary can be a meaningful adjunct to physiotherapy for several reasons:

Immediate symptom relief, reducing the "something is falling out" sensation often makes it easier to persist with pelvic floor exercises long enough to see meaningful change.
Better training mechanics, with 2b prolapse, the bulge can interfere with feeling a clean upward pelvic floor lift. A pessary supports the vaginal walls so pelvic floor contractions feel clearer and more effective.
Allows functional training, pelvic floor exercises is ultimately about timing before a cough or lift. A pessary provides structural support so this "anticipatory" skill can be practised in upright, functional positions with less discomfort.
Rests overstretched passive tissues, the ligaments and fascia that hold organs in position cannot be strengthened by exercise; they need support while muscles are trained. The pessary provides that support from below.

Evidence summaries report that when someone's bladder has lowered to a certain threshold, combining a pessary with pelvic floor exercises improves prolapse symptoms and quality of life compared with pelvic floor exercises alone. Side effects of pessaries including vaginal irritation can occur and need monitoring with the prescribing clinician.

Lifestyle modifications

Addressing constipation, managing chronic cough, avoiding heavy lifting or modifying how loads / abdominal pressure are managed, maintaining a healthy weight, and using topical oestrogen (where appropriate after menopause) all reduce ongoing strain on pelvic support structures.

When surgery may be considered

Surgery is typically considered when symptoms significantly impair quality of life and conservative measures, including well-supervised pelvic floor exercises with or without a pessary, have not provided adequate relief. Surgical options include native tissue repair and mesh procedures; decisions should be made with full information and shared decision-making between patient and specialist.

This article is part of our patient education library. For a personal assessment and a treatment plan specific to your situation, book an appointment at our clinic, no referral required.

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