For years we have been working with the theory that increasing pelvic floor muscle strength will improve prolapse symptoms. It makes sense, and this is why pelvic floor exercises (PFEs) have been the gold standard treatment within pelvic health for prolapse and urinary incontinence for 80 years.
But surprisingly, the evidence for pelvic floor muscles training (PFMT) as an effective treatment for pelvic organ prolapse (POP) is scarce, according to leading researchers in women's health (Hagen, et al 2014).
Some women with POP do benefit from individualised PFMT - but we don't actually have strong evidence that increasing the strength of the pelvic floor improves prolapse symptoms.
The evidence from the research into PFMT for prolapse ONLY indicates:
'a small, but probably important reduction in prolapse symptoms' (Hagen et al 2017).
In this big multicentre study published in the Lancet, the researchers discuss the following in the conclusion to their research:
"45% of women in the control group in our study reported that their prolapse was better at 12 months. This finding is partly because about half of these women had received further treatment for prolapse by this timepoint. Although significantly more women in the intervention group than the control group reported that their prolapse was better, the remaining participants reported no change or worse prolapse. Thus, a substantial group of women did not benefit [from PFMT]. One potential reason for this finding is that a more intensive intervention might be needed for some women. Another reason is that some types or stages of prolapse do not respond to pelvic floor muscle training as well as do others, and hence, improved selection of women for training might be needed."
Although some women experience improvements with PFMT, they conclude that a substantial number of women didn't benefit.
So why don't PFEs help more with prolapse symptoms?
So far the theory has been that because the pelvic floor muscles provide a hammock of support, below the pelvic organs - improving their strength would logically improve POP, because you're increasing the support from below.
That makes sense right?
But if that was the case, and this was the correct approach, there would surely be many more women getting positive outcome from PFMT and much fewer women living with prolapse?
So let's break it down - what do we know from the research into PFMT?
We know that:
PFMT are widely regarded as the gold standard treatment for increasing pelvic floor muscle strength, but we know a substantial number of women don't find PFMT improves their prolapse symptoms.
the severity of prolapse symptoms doesn't seem to correlate to what grade of prolapse a woman has (Ellerkmann at al 2001 and Mouritson and Larsen 2003). So for example, you might have a grade 1 prolapse but your symptoms are really impacting your everyday life - or have a grade 2-3 prolapse and you hardly notice it. The experience of prolapse is highly individualised to the women.
for women experiencing urinary incontinence and pelvic floor discomfort, a recent study found that there was no correlation between pelvic floor muscle function (so muscle strength and power) and symptoms experienced (Fontenele et al, 2021). In this study they found that improving pelvic floor muscle strength didn't mean symptoms would improve. However they did find that there was a correlation between women's quality of life and symptoms experienced - the more symptoms a woman experienced, the more it impacted her quality of life.
We know there are other things that can help improve prolapse symptoms such as improving posture and whole body strength, reducing constipation and learning how to lift properly. We know that surgery can help in the short-term, but that many women will need repeat surgery - about 30%. We also know that pessaries can be really helpful.
So could we missing something big?
After decades of focusing on PFMT / Kegels, are there other approaches which could be more effective at treating prolapse - I really hope so.
It was what led me to hypopressives when I had a prolapse - I couldn't believe that my only options were PFMT, a pessary or surgery.
So what if we turn the science we know on its head and instead of assuming prolapse happens because the pelvic floor is weak, we assumed that prolapse could happen as a result of tension. This is a relatively new science, but one that makes sense, and the research to support it is (thankfully) looking good - because we need new innovative treatments for women experiencing prolapse.
Here are 2 approaches to treating POP which make sense with the tension theory: (no surprises here, one of them is hypopressives)
Biotensegrity focused therapy - releasing tension and scar tissue in the pelvic floor has been shown to have a beneficial impact on pelvic organ position and prolapse symptoms (Crowle A. and Harley C. 2021). This is relatively new research, but is related to the biotensegrity model and science where things can't fall out of place - but rather they get pulled out of place because of tension. With pelvic organ prolapse, this would be tension or scar tissue in the pelvic floor pulling the pelvic organs out of place. The research shows positive changes in pelvic organ positions and symptoms, when tension is released in the pelvic floor.
Hypopressives works within the biotensegrity model science. One of the primary ways it works is by releasing tension in the pelvic floor. Hypopressives also restores functional movement through the pelvic floor, helps realign the bladder in particular, decongests the pelvic area and increases the resting tone of the pelvic floor. Hypopressives has already been shown to improve symptoms and the quality of life of women experiencing POP and urinary incontinence (Soriano et al 2020; Juez at al 2019; Parle et al 2021). Some women we work with report a reduction in prolapse grade too.
So is it time for a different approach? Or a combination of different approaches? As with lots of areas of women's health we need more research, but a lot of women don't want to wait - they just want to feel better - now.
It feels like an exciting time and I can't wait to see how things develop in this really important area of women's health.
Crowle, A. and Harley, C. (2021). Biotensegrity Focused Therapy for Pelvic Organ Prolapse: A nonrandomised Prospective Clinical Case Series. Journal of Women's Health Physical Therapy. Vol 45 (3): 135-142.
Fontenele M.Q.S., Moreira M.A., de Moura A.C.R., de Figueiredo V.B., Driusso P., Nascimento S.L. (2021). Pelvic floor dysfunction distress is correlated with quality of life, but not with muscle function. Arch Gynecol Obstet. 303(1):143-149.
Hagen S., Stark D., Glazener C., Dickson S., Barry S., Elders A, et al (2014).Individualised pelvic floor muscle training in women with pelvic organ prolapse (POPPY): a multicentre randomised controlled trial. The Lancet, vol 383 (9919): 796-806
Hagen S, Glazener C, McClurg D, Macarthur C, Elders A, Herbison P, Wilson D, Toozs-Hobson P, Hemming C, Hay-Smith J, Collins M, Dickson S, Logan J. Pelvic floor muscle training for secondary prevention of pelvic organ prolapse (PREVPROL): a multicentre randomised controlled trial. Lancet. 2017 Jan 28;389(10067):393-402.
Juez L, Núñez-Córdoba JM, Couso N, Aubá M, Alcázar JL, Mínguez JÁ. Hypopressive technique versus pelvic floor muscle training for postpartum pelvic floor rehabilitation: A prospective cohort study. Neurourol Urodyn. 2019 Sep;38(7):1924-1931. doi: 10.1002/nau.24094. Epub 2019 Jul 11. PMID: 31297874.
Soriano et al, 2020, 'Effect of an abdominal hypopressive technique programme on pelvic floor muscle tone and urinary incontinence in women: a randomised crossover trial', Physiotherapy, vol. 108, pp37-44.