Pelvic organs prolapse (POP) may not be a pleasant topic, but if you train women then it’s a very important one to be aware of.
Fifty per cent of mothers and 30 per cent of all women experience pelvic organs prolapse (POP). Since exercise can initiate or aggravate this condition, it is your responsibility as a fitness professional to provide exercise programs that protect the positioning of the female pelvic organs for high risk groups.
POP is not an ‘old ladies’ disease. Even women in their twenties, who have never given birth, can experience it. Though it is not a life threatening condition, prolapse can have a seriously negative impact on a woman’s quality of life and self esteem. Advanced prolapse is a devastating condition both physically and emotionally.
The female pelvic organs (bladder, urethra, uterus, vagina, and rectum) are kept in their anatomically correct positions by a network of elements working in synergy. One of these dominant elements is the pelvic floor muscle group. These muscles seal the pelvic outlet and provide a shelf for the pelvic organs to sit upon. Their constant automated contractions, provoked by increases of intra-abdominal pressure, eliminates any opening in the pelvic floor though which POP could occur and stabilises the organs in their right place.
If the supportive network for the pelvic organs becomes compromised, an organ can dislodge from its correct positioning, push into the vagina and descend. POP is not a single cause condition; however the pelvic organs become vulnerable in their positioning if the pelvic floor musculature:
- is too weak to effectively lift during rises of intra-abdominal pressure or fail to lift altogether
- is overwhelmed by excessive intra-abdominal forces (even if they are in good condition), therefore becomes unable to contract effectively
- loses automated function
- is injured as a result of childbirth or other trauma or
- is hypertonic or too tight to function properly.
So how severe can it become? Once an organ is dislodged from its correct positioning, it is possible that the descent continues until eventually it creates a protruding bulge outside the vagina. This can happen slowly and progressively, or suddenly due to physical strain. The pelvic organs are closely linked with endopelvic fascia, so once one slides down, others can be dragged behind.
It is important to recognise the sagging of the organs early, since natural reversal at this stage is possible with the help of pelvic floor muscle training (unless the pelvic floor is hypertonic, then the first line of action is to release the tightness) and lifestyle changes. Once an organ protrudes from the vagina, pelvic floor exercises cannot lift the organ back up. At this stage the goal is to prevent POP from progressing further. To help with the management of this condition, there are devices available from gynaecologists or some pelvic floor physiotherapists, to support the descending pelvic organs in position (pessaries). These can provide a permanent solution for approximately 70 per cent of women who seek to avoid surgery. Hormone replacement therapy can also be helpful if appropriate. Great nutrition and good physical condition are also essential parts of healing. Despite best efforts, surgery fails in up to 53 per cent of cases, so it is worth trying to fix this problem naturally.
There is no doubt that women are more physically vulnerable when it comes to the pelvis. POP is virtually unheard of in men. This is because women’s pelvises need to accommodate pregnancies and childbirth. For this reason the pelvic outlet in women is more open than in men, so the pelvic floor muscles need to bridge a bigger gap. Women also have an extra opening (vagina) in the middle of the pelvic floor. These prominent anatomical differences between the male and female pelvises warrant alterations in exercise prescription.
Higher risk clients
If you have a client that fits into one of the following women’s demographics she automatically belongs to a higher risk category for experiencing POP, so her exercise prescription should be altered accordingly:
- Mothers and pregnant women (the more pregnancies and complications during child birth the higher the risk is)
- Menopausal or beyond menopause
- Family history of POP (from the mother’s side)
- Being overweight (BMI >25)
- History of heavy lifting or ballistic activities (work or sport).
The following are also aggravating factors for POP: living with chronic chest disease or constipation, recurrent urinary tract infections, persistent pelvic or lower back pain, hysterectomy (high risk of small bowel or vaginal wall prolapse) or other pelvic surgery, hyper mobility, scoliosis, Multiple Sclerosis, fibroids or other pelvic tumours.
Exercises to avoid
Exercises can upset the positioning of the pelvic organs if they:
- internally bounce the pelvic organs up and down (high impact activities, plyometrics, step downs).
- squash them down and significantly increase intra-abdominal pressure (all kinds of abdominal crunches, trunk curls or rotations, knee raises, full plank, leg press, double leg lifts, heavy weights, any exercise that elevates both shoulders or both legs off the floor when lying supine).
These exercises are best avoided for high risk group. For their protection adapt the guidelines of Pelvic Floor First, via researching their website or attending their online course via Fitness network. These guidelines can still provide adequate intensity and variety of exercise selection to satisfy the expectations of clients.
When the natural lumbar curve of the spine and forward tilt of the pelvis is compromised, the vulnerability of pelvic organ positioning is increased. For this reason, maintenance of correct postural alignment is important for high risk groups during all exercise executions and levels of intensity. Furthermore, correct postural alignment will optimise core engagement, which in turn improves pelvic organs support. For this to occur, the pelvic floor and other members of the core muscles group need to be strong enough to handle the demands of the chosen exercise. This can be encouraged by effective daily pelvic floor muscles training and simple, functional core exercises. If correct postural alignment cannot be maintained during any particular exercise, you should divert your client to a less challenging one, or provide recovery, so the increased postural demands for stabilisation can be met.
Regular and correct pelvic floor muscle training can not only result in optimised core function, but also in better resistance against organ displacement by providing a:
- higher ‘pelvic floor shelf’
- increased vaginal tone
- more closed levator hiatus.
My experience of teaching hundreds of women how to properly exercise their pelvic floor muscles has shown me that over 60 per cent of them are not engaging correctly, or are unsure of their muscle contraction. For this reason encourage your clients to learn these exercises correctly and effectively and to perform them on most days.
Breath holding during activity significantly increases the downward force on the pelvic floor, so instructing clients to exhale on exertion can be an easy protective measure. If this is not possible an alternative exercise option should be offered.
Despite the high incidence of POP among women, it remains a rarely talked about subject. It doesn’t make a pleasant topic for an article in popular women’s magazines and friends don’t usually discuss it over a cup of tea. As a fitness professional you are well placed to be the instigator of this conversation. You can help to educate your clients by providing them with POP and pelvic floor safe exercise-related information. Excellent free hand outs on both of these topics are available from the websites of the Continence Foundation of Australia and from Pelvic Floor First.
There is no question that POP is a prominent health issue for women, one that can alter a woman’s life forever. Some women with POP are asymptomatic and do not need treatment. However this benign state can be easily provoked by inappropriate exercise choices. Fitness professionals are, therefore, in a powerful position to help protect clients from this disorder.
Presently this is not a position we take best advantage of. A 2009 survey conducted by Australian Fitness Network found that 89 per cent of 320 fitness professionals asked were not aware of the prevalence of incontinence among their female clientele. It is reasonable to assume that they would also not be aware if any of their clients had POP.
These findings may lead us to conclude that many trainers do not adjust exercise prescription and training sessions according to the pelvic floor status of their clients. Yet, making such alterations is an essential part of living up to our duty of care. It not only protects the long term wellbeing of your clients, but since many would feel too uncomfortable to train with POP, it also has the potential to prevent women with the condition from quitting exercise altogether.
Learn how to deliver optimal pelvic floor training to your clients with CEC-accredited online courses from Australian Fitness Network and the Continence Foundation of Australia. Click HERE to find out more about ‘CFA Part 1: Positive Practice for the Pelvic Floor’ and ‘CFA Part 2: Proactive Programming for the Pelvic Floor’
Kathi Janssens is a women’s health educator and exercise therapist. Developer of the Discreetly Fit pelvic floor education and training program, she is passionate about empowering women in pelvic floor health. Kathi has over 20 years’ fitness industry experience, as a fitness club manager, international presenter, coach and personal trainer.