Pelvic Organ Prolapse (POP) is a common condition where the support structures of the pelvic floor weaken, allowing one or more organs—such as the bladder, uterus, or rectum—to descend into the vaginal canal. This often creates a sensation of pressure or a bulge in the vagina. Pelvic Floor Muscle Training (PFMT), commonly known as Kegel exercises, is generally recommended to strengthen the muscles that form the pelvic floor hammock. However, whether these exercises can make a prolapse worse depends entirely on the underlying state of the muscles. For some individuals, performing standard Kegels without proper assessment or technique can increase tension and pressure, potentially worsening POP symptoms.
Understanding Pelvic Organ Prolapse and Muscle Function
The pelvic floor is a group of muscles, ligaments, and connective tissues that stretch like a supportive hammock across the bottom of the pelvis. This structure is responsible for holding the pelvic organs in their correct positions and ensuring the proper function of the bladder and bowels. It runs from the pubic bone in the front to the tailbone in the back, acting as a dynamic base for the entire torso.
Pelvic organ prolapse occurs when this supportive system becomes weakened or damaged, often due to factors like childbirth, chronic straining from constipation or coughing, or age-related tissue changes. When the muscles and fascia lose their integrity, the organs they support can sag or herniate into the vaginal space. The function of a Kegel exercise is to contract and lift these muscles, increasing their strength and endurance to provide better support for the descended organs.
For many people with POP, Kegels are a first-line, non-surgical treatment that can improve symptoms, especially in mild to moderate cases. The exercises work by increasing the muscle mass and tone of the levator ani group. This increased tone helps counteract the downward pressure placed on the pelvic organs. However, this strategy relies on the assumption that the muscles are simply weak and need strengthening.
The Key Factor: Hypertonic vs. Hypotonic Muscles
The core issue determining whether Kegels help or harm is the difference between a hypotonic and a hypertonic pelvic floor. A hypotonic pelvic floor is characterized by muscles that are too weak or have a low resting tone, which is the state most people associate with POP. These muscles lack the strength to contract effectively and support the organs. This often leads to symptoms like urinary leakage with coughing or a feeling of heaviness or “dropping.”
Conversely, a hypertonic pelvic floor is one where the muscles are too tight, overactive, or unable to fully relax. In this scenario, the muscles are already in a shortened, tense state. Attempting to strengthen them further with Kegels can exacerbate the problem. Performing a standard Kegel on an already tense muscle group increases the muscle’s overall tone and rigidity, leading to increased pain and functional issues.
The tightening effect of repetitive Kegels on a hypertonic floor can increase intra-abdominal pressure without sufficient counter-relaxation. This increased pressure is transmitted downward onto the pelvic organs, potentially worsening the sensation of a bulge or pressure associated with POP. Symptoms of a hypertonic floor often include pelvic pain, discomfort during intercourse, and difficulty fully emptying the bladder or bowels. In such cases, the discomfort is often caused by the muscle tension rather than the prolapse itself.
Safe Pelvic Floor Training and Contraindications
The correct approach to pelvic floor training must be tailored to the muscle’s specific condition to ensure it is safe and effective. If a person has a hypotonic pelvic floor, the focus should be on proper strengthening techniques. A correct Kegel involves a distinct “squeeze and lift” sensation, drawing the muscles upward and inward without tightening the glutes, thighs, or abdominal muscles.
It is important to integrate the “Knack” maneuver, which involves consciously contracting the pelvic floor immediately before and during activities that increase intra-abdominal pressure, such as coughing, sneezing, or lifting. This preemptive contraction helps brace the pelvic floor against the sudden downward force, protecting the supporting tissues. Breath-holding must also be avoided during any contraction, as it drastically increases pressure in the abdominal cavity and can push down on the prolapse.
For individuals with suspected hypertonicity, training must shift entirely from strengthening to relaxation, or “down training.” This involves techniques designed to lengthen the overly tense muscles and restore their ability to fully relax. Diaphragmatic breathing is a primary tool, focusing on deep, slow breaths that allow the pelvic floor to naturally descend and release tension on the inhale. Another technique is the “reverse Kegel,” which is the conscious effort to push the pelvic floor muscles gently downward and outward, similar to a slow release during urination, to encourage relaxation.
When to Consult a Pelvic Floor Specialist
Self-diagnosing the state of the pelvic floor muscles as either hypertonic or hypotonic is often unreliable and can lead to counterproductive exercise choices. The most important step for anyone concerned about POP or pelvic floor symptoms is to seek an assessment from a certified Pelvic Floor Physical Therapist (PFPT). These specialists use internal and external evaluations to accurately determine muscle tone, strength, and coordination, creating an individualized treatment plan.
Starting any pelvic floor exercise regimen without professional guidance carries the risk of incorrect technique, which can increase pressure and potentially aggravate symptoms. Immediate consultation with a healthcare provider is necessary if a person experiences warning signs. These include a sudden worsening of the vaginal bulge sensation, new or increased pelvic pain, or unexplained vaginal bleeding or discharge. A specialist can ensure that the exercises are therapeutic and not harmful to the supportive structures.