POP and Exercise – Are We Too Cautious With Our Advice?

Traditionally, high impact exercise (including heavy weight lifting and running) has been discouraged in women with pelvic organ prolapse (POP). There is little research to support this, however, expert opinion hypothesised that high impact exercise results in significant increases in intra-abdominal pressure (IAP). This pressure may contribute to worsening POP symptoms by weakening the pelvic floor structures. This is a logical and reasonable assumption, however, is it correct?
Recent research into women with POP participating in heavy lifting and running challenges the notion that all women with POP need to avoid high levels of exercise. This is increasingly important as more women are keen to participate in running, boxing, CrossFit and weight lifting.1
There has been a large body of work in the last decade looking at IAP with certain types of exercise. Exercises that were once deemed ‘unsafe’ due to the high IAP, have been shown to generate less IAP than everyday activities such as sit to stand.2   Laughing generates a higher IAP than lifting!3   Have you ever told anyone with POP to avoid laughing?
Even the same exercise may generate different/ variable IAP between women suggesting that the threshold IAP that is clinically significant is unknown.2 Perhaps, we have been too cautious in our restrictions?

What Is The Effect Of Exercise On The Pelvic Floor Muscles (PFM) and POP?

We know there is Level 1 evidence that pelvic floor muscle training (PFMT) is effective in reducing pelvic floor symptoms in women with POP.4 But, what we want to know is, what is the effect of general exercise on the PFM and POP symptoms?
There have been two hypotheses raised:5
1. Exercise strengthens the PFM and decreases the levator hiatus and therefore decreases the risk of urinary incontinence, POP and anal incontinence.
2. Exercise overloads and stretches the PFM so therefore increases the risk of the urinary incontinence, POP and anal incontinence.
A recent Australian study1 looked at weight lifting and the prevalence of POP symptoms in a cross-sectional survey of women.  They had a heavy weight lifting group, light weight lifting group and an inactive group. This study found that the women who were lifting heavy weights (>50kg) did not have an increase in prevalence of POP symptoms.  This challenges the assumption that heavy weight lifting is detrimental for women with POP.  Interestingly, it found that the women in the inactive group had a higher proportion of women with POP symptoms. This supports the first hypothesis.
Despite this, we know women can present with an exacerbation of POP symptoms after exercise. It is most likely that the threshold for damage is not the same in every woman but is dependent on the woman’s individual characteristics. 

What About Running?

Recent guidelines have been developed to guide health professionals in assisting women in return to running post natally.6 While exercises such as lifting, squats, and Pilates require the PFM to counteract IAP, running may require the PFM to absorb ground reaction forces when the foot strikes the ground.
Once more, the guidelines recommend individual assessment to determine when it is appropriate for each woman to return to running, recognising that some women have signs present which will impact their ability to run without any symptoms of pelvic floor dysfunction. 
It is vital that we identify these ‘at risk’ women and provide them with a structured, gradual return to exercise without detrimental effects to their PFM and POP. This is best done through individual assessment of potential risk factors and re-assessment of POP and PFM.

What Do We Need To Assess?

Objective assessment signs for these ‘at risk’ women include:
Levator avulsion
Large levator hiatus
‘Ballooning’ – length of genital hiatus + perineal body
Weak PFM
Women with increased BMI
Stage 3-4 POP

A Pessary – The Magic Solution For Women With POP Wanting To Run?

The Australian Exercise Guidelines7 recommend for an adult per week:
2.5 to 5 hours of moderate intensity physical activity – such as a brisk walk, golf, mowing the lawn or swimming
1.25 to 2.5 hours of vigorous intensity physical activity – such as jogging, aerobics, fast cycling, soccer or netball
an equivalent combination of moderate and vigorous activities.
Muscle strengthening exercises at least twice
For post-menopausal women it is recommended to participate in high intensity and resistance training to stimulate bone tissue adaptation if they have osteopenia or osteoporosis. 
How do we balance these recommendations whilst trying to prevent POP? Bo and co-authors (2020) stated, “the pelvic floor in women may be the only area of the body where the positive effect of physical activity has been questioned.”
This is where a vaginal pessary can be of significant benefit. When inserted into the vagina, it provides support to the organs and may enhance the quality of PFMT, allowing women to engage in exercise they otherwise may not.8 It improves their quality of life while benefiting from the physical and mental health effects of exercise. 
1 Forner LB, Beckman EM, Smith MD. Symptoms of pelvic organ prolapse in women who lift heavy weights for exercise: a cross-sectional survey. Int Urogynecol J. 2020; 31: 1551-1558.
2 Coleman TJ, Nygaard IE, Holder DN, Egger MJ, Hitchcock R. Intra-abdominal pressure during Pilates: unlikely to cause pelvic floor harm. Int Urogynecol J. 2015 Aug; 26(8): 1123-1130.
3 O’Dell, K.K., Morse, A.N., Crawford, S.L. et al. Vaginal pressure during lifting, floor exercises, jogging, and use of hydraulic exercise machines. Int Urogynecol J 18, 1481–1489 (2007). https://doi.org/10.1007/s00192-007-0387-8
4 Hagen S, Stark D, Glazener C, Dickson S, Barry S, Elders A, et al. Individualised pelvic floor muscle training in women with pelvic organ prolapse (POPPY): a multicentre randomised controlled trial. Lancet. 2014 Mar; 383: 796-806
5 Bo K, Nygaard IE. Is physical activity good or bad for the female pelvic floor? A narrative review. Sports Medicine (Auckland). 2020 50:471–484. Available from:  https://doi.org/10.1007/s40279-019-01243-1 .
6 Donnelly G, Brockwell E, Goom T. Return to running postnatal – guidelines for medical, health and fitness professionals managing this population. Physiotherapy. 2020 May; 107(1): e188-e189
7 Australian Government Department of Health, Physical activity and exercise guidelines for adults. Available from: https://www.health.gov.au/health-topics/physical-activity-and-exercise/physical-activity-and-exercise-guidelines-for-all-australians/for-adults-18-to-64-years 
8 Bø, K, Majida, M & Engh, ME 2012, 'Does a ring pessary in situ influence the pelvic floor muscle function of women with pelvic organ prolapse when tested in supine?', Int Urogynecol J, vol. 23, no. 5, pp. 573-77.