I’m honestly not sure why pelvic organ prolapse does not get talked about more, because it is very common and yet a lot of people have never even heard the term until they are the one sitting there wondering what on earth is going on with their body.

It can start with a feeling of heaviness in the pelvis that is barely noticeable in the morning but much more obvious by the end of the day. For others, the first clue is a new bulge inside the vagina, a feeling that something is sitting lower than it used to, or bowel movements that have suddenly become much harder to finish. You know something has changed, but unless somebody has explained prolapse to you before, it can be very difficult to accurately describe what you’re feeling.

I know this from both sides because I have a grade 2 rectocele, which is one type of pelvic organ prolapse. I have had it since I gave birth to my son almost 12 years ago, and I have done all of the appropriate pelvic floor physiotherapy for it. I have access to excellent practitioners, I understand the anatomy, and I have done the things I would recommend to somebody else dealing with the same problem.

Physiotherapy has been helpful, but in my case the rectocele simply has not improved to the point that I want it to. It has become more bothersome over the past few years, particularly as I get closer to menopause, and I have decided to have it surgically repaired.

Being on the patient side of this has been quite humbling, and it has changed the way I think about prolapse and the conversations we have around it. There is still an enormous amount of embarrassment attached to symptoms that are actually very common, and treatment can sometimes be presented as though there are only two outcomes: you do pelvic floor exercises and everything goes back to normal, or you need surgery.

It is much more nuanced than that. Pelvic floor physiotherapy can work very well and is often a very good place to start, but it cannot guarantee that every prolapse will fully heal. Surgery is certainly not inevitable either, although for some people, myself included, it can eventually become the option that makes the most sense.

Before we get into any of that, it helps to understand what is actually happening in the pelvis.

What is pelvic organ prolapse?

Pelvic organ prolapse, often shortened to POP, happens when the muscles and connective tissues supporting the pelvic organs are no longer providing quite the same support they used to, allowing one or more structures to sit lower in the vagina.

If you picture a cross-section of the pelvis, the bladder sits toward the front, the vagina runs through the middle, the uterus sits above it and the rectum is directly behind the vagina before continuing down to the anus. Muscles, fascia, ligaments and other connective tissues help support all of those structures.

Your pelvic floor is part of that support system, but it does much more than hold your organs up. It works with your diaphragm, abdominal wall, hips and the rest of your trunk every time you breathe, cough, laugh, lift something, exercise or have a bowel movement.

When that support changes, the bladder, rectum, uterus or vaginal walls can begin to move downward.

The word prolapse makes this sound much more dramatic than it often is. Most people tend to picture an organ falling right out of the body, but pelvic organ prolapse exists on a spectrum. A small change in support may be found during an internal examination even when a patient has absolutely no symptoms at all, while another person may be very aware of pressure, heaviness or a bulge.

Clinicians can grade prolapse according to how far the tissues have descended, but the grade does not tell us everything about how somebody feels. A relatively small prolapse can be extremely bothersome for one person, while somebody with more descent may barely notice it, which is why we need to look at both the anatomy and the person living with it.

Why does pelvic organ prolapse happen after childbirth?

Pregnancy and birth both place a significant amount of demand on the pelvic floor, although they do it differently.

During pregnancy, the pelvic floor is managing months of increasing load while your abdominal wall, rib cage, breathing mechanics and the way pressure moves through your trunk are all adapting around a growing baby, uterus, placenta and liters of fluid. Hormonal changes also affect the connective tissues that help support the pelvis.

For that reason, pelvic floor symptoms and prolapse can happen even after a cesarean birth. A C-section avoids some of the stretching and potential muscle injury associated with vaginal delivery, but pregnancy itself has still asked a great deal of the pelvic support system.

Vaginal birth adds another layer because the pelvic floor has to stretch considerably as the baby passes through the pelvis. Certain birth factors can increase the likelihood of pelvic floor injury or prolapse later, including assisted vaginal delivery, a longer second stage/pushing stage and significant perineal injury, although there is no formula that tells us exactly who will develop symptoms.

Pregnancy and birth are also not the whole story. Chronic constipation and repeated straining can put significant pressure through these tissues over time, as can a persistent cough and repeated heavy lifting. In fact, chronic constipation is more of a driver of some prolapses than other causes. Aging and the tissue changes that happen around menopause can affect pelvic support as well.

That last one has become particularly relevant in my own case. My rectocele has been there for almost 12 years, but it has become more bothersome as I have moved closer to menopause. If that stage of life is part of your picture too, you can read more about perimenopause and menopause care at Oona.

What does pelvic organ prolapse feel like?

Pelvic heaviness or pressure is probably the description people recognize most often, although the sensation can be surprisingly difficult to explain.

It may feel as though something is sitting lower inside the vagina, or like a tampon that has slipped down and is no longer sitting where it should. You might notice a soft bulge when you are washing or wiping, while another person may never actually feel a bulge and instead notice changes in their bladder, bowel or how their pelvis feels after activity. You may notice that when you wipe after a bowel movement, the paper just never seems to get clean.

The time of day can make a difference too. It is quite common for symptoms to be less noticeable in the morning and more obvious after you have spent hours standing, walking, carrying children, lifting things and generally moving through your day. Constipation or a more demanding workout may make the pressure more noticeable as well.

Depending on which area has lost support, you might have trouble emptying your bladder completely, feel as though you need to urinate again soon after you have just gone, have difficulty completely emptying your bowels or notice that sex feels different. If pain with sex is part of what brought you here, I have written separately about why sex can hurt after having a baby and what can help.

None of those symptoms automatically means you have pelvic organ prolapse, because there are certainly other things that can cause them. What they do tell you is that something has changed, and if it is bothering you, it is worth having somebody assess what is actually going on.

What are the different types of pelvic organ prolapse?

Pelvic organ prolapse is the umbrella term, and then we use different names depending on which part of the pelvic support system is involved.

You may hear words like rectocele, cystocele, anterior prolapse, posterior prolapse or uterine prolapse. The terminology can make an already unfamiliar problem sound unnecessarily complicated, so here is what those terms actually mean.

Rectocele or posterior vaginal wall prolapse

A rectocele is the type of prolapse I have.

Normally, the rectum sits directly behind the vagina with connective tissue helping to support and separate the two. When that tissue becomes less supportive, part of the rectum can push forward into the back wall of the vagina.

If that anatomy is difficult to picture, that is completely understandable. It can be remarkably hard to visualize what is going on down there even when you are the person who owns all of these organs.

The easiest way to think about it is that the rectum should continue down toward the anus, but with a rectocele, part of it pushes forward instead and creates a pocket or bulge against the vaginal wall. That change is what can create some of the very specific symptoms associated with a rectocele.

What does a rectocele feel like?

Pelvic pressure or an internal vaginal bulge can happen with a rectocele, but the bowel symptoms are often the thing that finally makes people realize something is different.

You may sit down to have a bowel movement, go as usual and still feel as though you have not completely emptied. In some cases, stool can collect in the pocket created by the rectocele, which makes it harder to pass without changing position or adding some support.

Discomfort during sex can be part of the picture as well, although symptoms vary quite a bit from person to person.

What causes a rectocele?

Vaginal childbirth is an important risk factor because of the stretch and load placed through the pelvic floor and connective tissues during birth, but it is certainly not the only contributor.

Chronic constipation is a big one. If you are regularly straining to have a bowel movement, that repeated pressure matters. A long-term cough can create a similar issue, and repeated heavy lifting may also contribute depending on the circumstances and how your body is managing that load.

The tissue changes associated with aging and menopause can become relevant later too, which is one reason somebody may have a rectocele for years and suddenly notice that the symptoms are changing.

What is a cystocele or anterior vaginal wall prolapse?

When the front wall of the vagina loses some of its support and the bladder moves downward with it, this is called an anterior vaginal wall prolapse and is also commonly referred to as a cystocele or bladder prolapse.

Vaginal heaviness or bulging can occur, although bladder symptoms may be more noticeable for some people. You might have difficulty emptying completely, for example, or notice changes in how urination feels.

Urgency, frequency and leaking can exist alongside prolapse as well, but those symptoms have a number of possible causes, so they do not automatically tell us that the bladder has prolapsed. This is one of the reasons I would much rather somebody come in for an assessment than spend three months trying to diagnose themselves based on symptom lists online.

What is uterine prolapse?

Uterine prolapse happens when the uterus and cervix descend lower into the vaginal canal because the tissues supporting them have changed.

The sensation can be similar to other types of prolapse, including pressure, heaviness or the feeling that something is sitting or moving lower in the vagina.

It is also possible to have more than one type of prolapse at the same time. Once you look at a cross-section of the pelvis and see how closely the bladder, vagina, uterus and rectum sit together, that becomes considerably easier to understand.

How common is pelvic organ prolapse after childbirth?

It is common, although giving percentage rates can be misleading because research studies do not all measure the same thing.

Some studies look for anatomical prolapse during a physical examination, including changes that the person themselves cannot feel. Others measure prolapse that reaches a particular point in relation to the vaginal opening, while some focus on symptoms that are actually affecting daily life.

Those are different questions and they produce different numbers.

The useful thing to know is that changes in pelvic organ support after pregnancy and childbirth are not unusual, and having some anatomical prolapse does not automatically mean you will have significant (or any) symptoms or require treatment.

On the other hand, you do not need to have a severe prolapse before your symptoms are worth addressing. If something is affecting your bowel movements, bladder, sex, exercise or simply how comfortable you feel moving through your day, that matters regardless of what stage ends up being written on your chart.

Can pelvic organ prolapse get better after birth?

Yes, pelvic support and symptoms can change as postpartum recovery continues, which is important to remember if you have been diagnosed very early after having a baby.

Your body does not finish recovering at six weeks postpartum. Tissues continue to heal, your strength changes, hormones change and the physical demands of life with a baby change considerably over the following months.

What your pelvic floor feels like at eight weeks postpartum is therefore not necessarily what it will feel like at eight months.

I also would not interpret that as a reason to spend a year waiting to see what happens if you are uncomfortable or worried about what you are feeling. Getting assessed does not interfere with recovery. It simply gives you a better idea of what is happening and what might make things easier while that recovery continues.

If you have recently had your postpartum medical appointment and were told everything looked fine, our guide to what the six-week postpartum check does and does not assess explains why that can still be completely compatible with having a pelvic floor concern.

What if I was cleared at my six-week postpartum check?

This is a really common source of confusion because being told that everything looks good at your postpartum medical appointment can sound as though the pelvic floor has been fully assessed.

A six-week medical check and a pelvic floor physiotherapy assessment are doing different jobs.

Your physician or midwife may be looking at healing, bleeding, infection, contraception and your general medical recovery. Pelvic floor physiotherapy goes much further into how your pelvic floor is functioning during the things you actually need it to do. In fact, most obstetricians, family doctors, and midwives recommend following up with a pelvic floor physio for a thorough assessment as a part of their discharge instructions at that six-week postpartum visit.

We want to know whether the muscles can contract and relax, how they coordinate with your breathing and abdominal wall, whether bowel or bladder habits are contributing to your symptoms, what happens when you lift or squat and how your symptoms change through the day.

Being medically cleared is good news. It just does not answer every pelvic floor question.

Does pelvic floor physiotherapy help pelvic organ prolapse?

For many people it does, and pelvic floor muscle training is an established conservative treatment for appropriate cases of symptomatic pelvic organ prolapse.

The important thing is to be clear about what successful treatment can look like.

Pelvic floor physiotherapy may improve strength, endurance and coordination, reduce prolapse symptoms and help your body manage everyday loads more comfortably. What I would not promise somebody is that physiotherapy will make every prolapse anatomically disappear.

That is not the only measure of whether treatment has worked.

If you can carry your child without spending the rest of the afternoon feeling pelvic pressure, have a bowel movement without straining, get back to running or strength training, have comfortable sex or simply stop thinking about your prolapse every time you move, those are meaningful changes.

My own experience is a good example of the distinction. Physiotherapy was useful and helped me manage my rectocele for many years, but I am still choosing surgery because my symptoms and my priorities have changed.

Both things can be true.

Why are Kegels not always enough for prolapse?

Kegels can absolutely be part of pelvic organ prolapse treatment, but simply telling everybody with prolapse to squeeze their pelvic floor more is not particularly useful.

First, we need to know what the muscles are doing. One person may need to build strength and endurance, while another has difficulty relaxing the pelvic floor properly. Someone else may think they are performing a contraction when they are actually bearing downward, which is exactly the opposite of what they intended to do.

The rest of the body matters too. Your pelvic floor has to coordinate with your breathing, abdominal wall and the pressure moving through your trunk when you stand up, lift, carry, exercise, cough or go to the bathroom.

Then there are the things happening throughout the rest of your day. If you are straining through every bowel movement because you are chronically constipated, that needs attention. When symptoms only appear after a certain amount of walking or lifting, we want to understand your current capacity and build from there.

Pelvic floor exercises may be part of that plan, but they are only one part.

What actually helps pelvic organ prolapse?

Treatment depends on your symptoms, the type and degree of prolapse, where you are in your postpartum recovery and what you want to be able to do.

Pelvic floor strength, relaxation and coordination

A pelvic floor physiotherapist may work on strength, endurance, relaxation or coordination depending on what they find during the assessment. The goal is not to give everyone the same exercise sheet, because two people with the same prolapse grade can have very different pelvic floor function and very different symptoms.

How your body manages pressure

Your breathing and the way pressure moves through your abdomen and pelvis can be part of treatment, along with gradually rebuilding strength through the hips, abdominal wall and the rest of the body. We are not trying to eliminate pressure from your life, because that would be impossible. We are looking at how your body handles it when you lift, carry, exercise, cough and move through an ordinary day.

Constipation and bowel mechanics

Bowel habits deserve particular attention with a rectocele. If constipation and repeated straining are contributing to the problem, improving how you empty your bowels and addressing the reason for the constipation can make a real difference to symptoms.

Returning to the things you actually want to do

Rehabilitation eventually needs to connect with your real life. If that means carrying children, lifting weights, running, having sex comfortably or simply getting through a full day without that heavy feeling in your pelvis taking over, those goals belong in the treatment plan.

Can a pessary help pelvic organ prolapse?

A pessary is a removable silicone device that sits inside the vagina and provides additional support to the pelvic organs.

These are professionally fitted for you by either a pelvic floor physiotherapist or by your gynecologist. There are different shapes and sizes (cubes, discs, and the like), and finding the right one for you can sometimes take more than one fitting. Depending on the person, a pessary might be used regularly or only for certain activities that tend to bring on symptoms.

Some people find one particularly helpful for exercise, running, lifting or longer days on their feet, while others prefer to wear it more consistently.

A pessary does not permanently change the prolapse while it is out of the body. Pessaries provide support while they are being worn, which can make it a very practical non-surgical option for the right person.

If you are wondering whether one might make sense for you, you can read more about the Oona Pessary Clinic and how pessary assessment and fitting works.

When is surgery considered for pelvic organ prolapse?

Surgery becomes part of the conversation when prolapse symptoms remain bothersome and conservative treatment has not given someone the improvement they want, or when surgery is simply the option that best fits their circumstances and goals after discussing the benefits and risks with the appropriate specialist.

I think it is important not to frame surgery as either the inevitable ending of a prolapse diagnosis or something that represents a failure of conservative treatment.

I have done the conservative treatment, and I am glad I did it. It helped me understand and manage my rectocele extremely well for years. I am now at a different point, my symptoms have become more bothersome, and I have decided that surgical repair is the right decision for me.

Somebody else with the same grade of rectocele may make a completely different decision because their symptoms, age, goals and experience of living with it are different.

That is exactly how it should be.

Can I lift my baby if I have pelvic organ prolapse?

Yes, and realistically, most parents do not have the option of simply never lifting their baby.

Rather than trying to avoid pressure altogether, pelvic floor physiotherapy can help you look at how your body manages it. Changing the way you breathe during a lift, adjusting the position of a load, building strength and varying how much you ask of your body at once can all be useful depending on your symptoms.

The goal is not to teach you that normal movement is dangerous. We are trying to help your body meet the demands of the life you actually have.

Can I run or lift weights with prolapse?

A pelvic organ prolapse diagnosis does not automatically mean you have to stop running, strength training or doing other forms of exercise.

Whether an activity is appropriate right now depends on your symptoms, your strength, your stage of recovery and how your body responds to the load.

If heaviness or pressure becomes increasingly noticeable during a workout or consistently remains worse afterwards, that is useful information for your physiotherapist. The programme may need to be adjusted, or you may need more time and strength before progressing.

That is very different from assuming the activity itself has permanently damaged you or that you can never do it again.

What happens during a pelvic floor physiotherapy assessment?

A first appointment usually starts with a lot more talking than people expect because there is quite a bit we need to understand before deciding what treatment makes sense.

Your physiotherapist may ask about your pregnancy and birth, bladder and bowel habits, constipation, pain, sex, exercise, and what you would like to get back to doing. They may also assess breathing, abdominal function, hip and trunk strength and how you manage movements such as squatting or lifting.

An internal vaginal assessment can provide useful information about pelvic floor muscle strength, endurance, coordination, relaxation and pelvic organ support, but it should always be explained and offered rather than assumed. You can decline it, postpone it or change your mind at any point.

If you want a more detailed explanation before you book, read what a pelvic floor physiotherapist actually does and what to expect at an appointment.

When should pelvic pressure or a vaginal bulge be checked?

You do not need to wait until you have a large visible bulge before asking somebody what is going on.

Pelvic heaviness, vaginal pressure, a change in bowel emptying, difficulty emptying your bladder, discomfort during sex or simply a feeling that something is different are all reasonable things to bring to a pelvic floor physiotherapist.

Most prolapse symptoms are not an emergency, but there are postpartum symptoms that require medical assessment rather than waiting for a physiotherapy appointment. Heavy or renewed vaginal bleeding, fever, foul-smelling discharge, severe or rapidly worsening pain, an inability to pass urine or a significant new loss of bowel control should be assessed promptly by your physician, midwife or another appropriate medical provider.

For a broader look at recovery after having a baby, our postpartum care guide brings together the different kinds of support available in Toronto and Newmarket.

Frequently asked questions about pelvic organ prolapse after birth

Is a rectocele a type of pelvic organ prolapse?

Yes. A rectocele, also called a posterior vaginal wall prolapse, is one type of pelvic organ prolapse. It happens when the rectum bulges forward into the back wall of the vagina.

Can childbirth cause a rectocele?

Vaginal childbirth is an important risk factor because of the amount of stretching and load placed through the pelvic floor and supporting tissues. Chronic constipation and straining, persistent coughing, repeated heavy lifting, aging and menopausal tissue changes can also contribute. For me, it was all of the above.

Can a rectocele make it difficult to have a bowel movement?

It can. The bulge created by a rectocele may make it more difficult to empty the bowel completely, and some people feel as though stool is getting caught rather than passing normally.

What is splinting?

Splinting means using a finger to press against or support the vaginal wall to help empty the bowel. It is a recognized symptom associated with rectocele, and if you have found yourself doing this without knowing why, it is worth mentioning during an assessment.

Can pelvic floor physiotherapy fix a rectocele?

Pelvic floor physiotherapy can improve symptoms, pelvic floor function and the way your body manages load, and for many people those improvements are significant. It cannot guarantee that every rectocele will anatomically disappear.

That has been my own experience. Physiotherapy helped me manage my rectocele, but after living with it for almost 12 years and finding it increasingly bothersome in the past 2 years, I ultimately decided to have it surgically repaired.

Does pelvic organ prolapse always require surgery?

No. Conservative treatment is often the first approach and can include pelvic floor physiotherapy, addressing constipation and other contributing factors, and pessary support. Surgery becomes an option when symptoms remain bothersome or when, after discussing the available treatments, someone decides it is the option that makes the most sense for them.

Can you have pelvic organ prolapse after a C-section?

Yes. Pregnancy itself places load on the pelvic support system and changes the abdominal wall and connective tissues, so cesarean birth does not completely eliminate the possibility of pelvic organ prolapse or other pelvic floor symptoms.

Can prolapse become more noticeable around menopause?

It can. Hormonal and tissue changes around menopause can affect vaginal and pelvic support, and some people notice that existing prolapse symptoms become more bothersome during this stage of life. That has been part of my own experience with my rectocele.

Do Kegels help pelvic organ prolapse?

Pelvic floor muscle training can be helpful for prolapse, but the programme needs to match what your pelvic floor is actually doing. Strengthening is not the only consideration because relaxation, coordination, breathing, bowel habits and the way you manage load can all be part of the picture. Because of my history with pelvic floor physiotherapy (I’m lucky to have access to the best of the best in our clinics!), my pelvic floor is very strong. But my rectocele remains.

Do I need a referral for pelvic floor physiotherapy in Ontario?

No. You can book directly with a registered physiotherapist, although very rarely some extended health plans require a physician’s referral before they will reimburse physiotherapy, so it is worth checking your individual policy.

If any of this sounds familiar

The main thing I would encourage you not to do is decide, without an assessment, that you simply have to live with this or that surgery is automatically where you are headed.

I have had a rectocele for almost 12 years. Pelvic floor physiotherapy was the mainstay of my care for a long time, and now surgery is the choice I have made because it is the right one for me at this point in my life.

Your path may be completely different.

A pelvic floor physiotherapist is often a very good place to start because they can help you understand which type of prolapse you have, what may be contributing to your symptoms, what can be addressed conservatively and what your other options are if you need them.

There should be nothing unusual about talking about a rectocele, a vaginal bulge, splinting or any of the other symptoms that come with prolapse. They are health concerns with names, explanations and treatment options, and the more plainly we talk about them, the less likely somebody is to spend years assuming they are the only person dealing with it.