What do we know about strength training, prolapse, and prolapse symptoms?

When I was diagnosed with pelvic organ prolapse after the delivery of my first child, I became frozen with fear. I was afraid of lifting, walking, coughing, and standing. I was afraid of movement. Many people who experience prolapse also have this fear of movement because they worry it might worsen their prolapse or the symptoms that come with it. Nearly half of women surveyed by Marques, et al noted that they had stopped exercise they had been doing previously due to pelvic floor symptoms. Of that group, 37% were because of prolapse symptoms. This statistic makes me incredibly sad that so many people have made drastic life changes because of prolapse. What I would like to share is what I learned from my journey towards healing. You cannot let this fear keep you from experiencing the fullness of life, and you must strengthen your whole body.

What do we know about strength training, prolapse, and prolapse symptoms?

Strength training is well-researched and has many benefits including reducing the risk of mortality from cardiovascular disease, cancer, and diabetes (Momma, et al). It has also been shown to improve the symptoms of urinary incontinence when combined with pelvic floor muscle training as compared to pelvic floor muscle training alone. In a twelve-week study by Virtuoso et al, the researchers demonstrated that the reductive rate of incontinence symptoms were significantly higher in the weight training group after only four weeks.

Exercise training has three basic principles that relate to pelvic floor function: overload, specificity, and reversibility. Overload is the principle that a muscle group needs to perform more work to experience an increase in strength and endurance. This applies to the pelvic floor muscles as well (Dakic et al). Overload is important for those with prolapse because the daily, cumulative demands on the pelvic floor are numerous. Consider how many times you squat during the day: sitting down in a chair and standing up, using the toilet, picking something up, reaching into a low cupboard, picking up your child, etc. For the postpartum population, overload is important when considering the weight of your child. Mothers routinely pick up and carry children over 25 pounds yet are afraid to lift a similar weight during their workout.

The principle of specificity demands that a muscle group must be trained in the same manner that muscle is used functionally and at a same intensity (Dakic, et al). Consider this, a weightlifter prepares to perform heavy squatting exercises by lying on her back and engaging the muscles of her thighs repeatedly. I hope you realize how non-functional this would be. So why do we believe that training our pelvic floor by lying on our backs and engaging our pelvic floor muscles is enough? It is not! For example, to train your pelvic floor for carrying a baby on your hip all day, you should perform weightlifting exercises with a weight held in one hand. This task is specifically addressing a daily demand on your pelvic floor and is very functional.

Lastly, reversibility is the principle that the benefits gained by training a muscle group can be lost if not regularly working those muscles (Dakic, et al). To maintain the strength and endurance improvements of the pelvic floor, exercise must be continued.

I would be doing people with prolapse a disservice if I did not address the psychological aspect of experiencing symptoms. Prolapse symptoms do not correlate with the severity of the grade/stage. What does correlate with symptoms is the amount of psychological distress a person experiences regarding their diagnosis (Drage, et al). When we are more bothered by our diagnosis, we tend to catastrophize the future and what it might hold. I know I am guilty of this. This pattern of thinking can create an inescapable feedback loop. We might experience symptoms and begin to worry. This increases our awareness of the pelvic floor and the prolapse thus heightening the symptoms. Then the cycle repeats.

When we think about our pelvic floors constantly, our brains begin to allot more of its real estate for the pelvic floor. This means that more neurons are dedicated to the sensation experienced in the pelvic floor. Thus, every time you feel any sensation near the vulva or vagina, the sensation is heightened because more and more neurons are firing.

What exercise allows us to do is to change this narrative. By experiencing something different with our bodies, we are providing an opportunity for our brain to create a new pathway. Instead of feeling prolapse symptoms you might feel muscle soreness or fatigue, both of which are safe and not bad signs. Weightlifting is unique in that you need to hyperfocus on each movement in order to perform it correctly and safely. We (pelvic floor physios) teach patients to inhale with the easy part of the motion, and exhale with the challenging part. This type of breathing helps your pelvic floor lengthen and shorten at the right times. You are strengthening your pelvic floor as you are strengthening the rest of your body.

Resistance training exercise is safe to perform when you have a prolapse and lifting heavy weights does not increase the prevalence of prolapse symptoms. In a study by Forner et al, prolapse symptoms were studied in groups of women who regularly lifted weights. Those who lifted heavy weights, compared to those who lifted a moderate amount of weight, had not increased their prevalence of symptoms. This is excellent news for those who share my initial fears of strengthening. We can rest assured that when done properly we can effectively and safely lift weights without worrying about increasing our symptoms.

So how do you start? You start slowly and with guidance of a pelvic physio or postpartum trainer. You also find others who are on this same journey towards healing so you can have accountability. This is the reason I created a community for people with prolapse. My hope is that people can connect, share stories, encouragement, and learn about treatment strategies.

You can find Margo’s community at P4Moms.com and on Instagram at @postpartum_prolapse. 

Citations: 

Dakic J, Cook J, Hay-Smith J, Lin K, Frawley H. Pelvic floor disorders stop women exercising: A survey of 4556 symptomatic women. Journal of Science and Medicine in Sport. Volume 24. Issue 12. 2021. Pages 1211-1217.

Drage K, Aghera M, MacKellar P, et al. The relationship between symptom severity, bother and psychological factors in women with pelvic organ prolapse: A cross-sectional observational study. Neurourol Urodyn. 2022 Jan;41(1):423-431.

Forner L , Beckman E, Smith M. Symptoms of pelvic organ prolapse in women who lift heavy weights for exercise: a cross-sectional survey. Int Urogynecol J. 2020 Aug;31(8):1551-1558.

Marques A, Stothers L, Macnab A. The status of pelvic floor muscle training for women. Can Urol Assoc J. 2010 Dec;4(6):419-24.

Momma H, Kawakami R, Honda T, et al. Muscle-strengthening activities are associated with lower risk and mortality in major non-communicable diseases: a systematic review and meta-analysis of cohort studies. Br J Sports Med. 2022;56:755–763.

Virtuoso J, Menezes E, Mazo G. Effect of Weight Training with Pelvic Floor Muscle Training in Elderly Women with Urinary Incontinence. Research quarterly for exercise and sport. 2019, Apr:141-150.