by Sue Croft Physiotherapist
Adapted from author’s blog first published May 23, 2019 at SueCroftPhysiotherapy.com.au
Overview
Pelvic organ prolapse (POP) is a common and often misunderstood condition. For many women, even hearing the word prolapse can trigger anxiety. With so much information now available online, it’s easy to feel overwhelmed or fearful.
This article explains how prolapse is measured, what those measurements mean, and why knowledge—balanced with reassurance and professional guidance—can help women feel more confident and informed about their pelvic health.
Clinical Assessment of Pelvic Organ Prolapse
The POP-Q System
The Pelvic Organ Prolapse Quantification (POP-Q) system is the standardised method of assessing site-specific pelvic floor defects through nine measurements of the vagina and perineum obtained during a routine pelvic exam.(1)
Additional Diagnostic Tools
Other clinical tools may be used to assess pelvic floor health:
- POP-STIX: a measuring stick that records genital hiatus and perineal body length.
- Peritron: a device that measures pelvic floor muscle strength over time, helping monitor progress between appointments.
- 3D/4D ultrasound: allows detailed visualisation of pelvic floor anatomy, identifying issues such as levator avulsion (muscle detachment) or hiatal ballooning that may contribute to symptoms.
These technologies support accurate diagnosis and provide women with clearer information about their pelvic floor function.
The Information Age: Knowledge and Anxiety
One of the positives and also one of the challenges, of prolapse diagnosis today is how much more informed women have become. Because of the internet, information is readily available, which can be empowering. Yet, as many pelvic health clinicians observe, self-research can sometimes heighten anxiety. Women may read about prolapse symptoms and panic that they have the condition when they do not, or when their prolapse is very mild and not clinically significant.
In other cases, there may be no visible prolapse, but ultrasound reveals muscle trauma that could predispose someone to prolapse in the future. Reading about complex terms such as “levator avulsion” can understandably cause fear, anxiety, and even depression.
These feelings are valid. They reflect a growing awareness of pelvic health and a deep desire among women to understand their bodies. However, balanced, evidence-based information and a calm, compassionate discussion with a qualified health professional, can make all the difference in turning worry into empowerment.
Understanding Post-Birth Changes
It’s important to remember that some degree of pelvic change after vaginal birth is normal. The vagina and surrounding tissues are designed to stretch and recover. While some women experience mild prolapse or pelvic floor weakness, many recover well, particularly with guidance from a pelvic health physiotherapist.
Factors influencing post-birth pelvic floor outcomes
The extent of pelvic floor changes following vaginal birth varies widely between women. A number of factors can influence how the tissues and muscles recover after delivery, including:
- Collagen composition and connective tissue integrity:
The strength and elasticity of the body’s connective tissue play an important role in pelvic support. While no single genetic predisposition has been firmly identified, a systematic review of genetic studies found that collagen type III alpha 1 was associated with an increased likelihood of developing pelvic organ prolapse (odds ratio 4.79))(1). - Foetal size and delivery method:
Larger babies, particularly those with greater head circumference or overall birth weight, can place more strain on the pelvic floor during birth. - Maternal age and number of births:
Women who have their first baby after the age of 35 have a higher risk of pelvic floor dysfunction. Repeated pregnancies and deliveries may also contribute to gradual changes in pelvic support over time. - Instrumental assistance during birth:
The use of instruments such as forceps or vacuum extraction can increase the likelihood of pelvic floor trauma. In particular, forceps deliveries are associated with up to a 40% risk of levator avulsion injury—a separation of the pelvic floor muscles from their attachment to the pelvic bone.
Understanding these factors can help guide early assessment, preventive strategies, and postpartum rehabilitation to support optimal pelvic floor recovery.
Collaborators from a number of centres around the world, led by Eric Jelovsek, have developed UR-CHOICE, a scoring system to predict the risk of future pelvic floor dysfunction based on research looking at the many major risk factors, enabling early support and preventive strategies. This research has followed up women at 12 years and 20 years after delivery and this scoring system together with the mother’s own preference, may help with counselling women regarding pelvic floor dysfunction prevention.(4, 5)
UR-CHOICE stands for:
U – Urinary incontinence before pregnancy.
R – Race (ethnicity).
C – Child. Bearing first child started at what age?
H – Height. Mother’s height (if < 160cm).
O – Overweight. Weight of mother, Body Mass Index.
I – Inheritance. Family history of PFD (mother and sister).
C – Children. Number of children desired.*
E – Estimated foetal weight (baby weighing greater than 4kg).
*If caesarean deliveries are indicated this is important due to an increased risk of placenta praevia and accreta with increased number of caesarean deliveries.(5)
A Dynamic and Adaptable System
Researchers Hallock and Handa (2016) concluded “Recent studies have shown that the pelvic floor is a dynamic structure that adapts during pregnancy and delivery by expanding the levator hiatus, increasing elastase activity, and lengthening pelvic floor muscle fibers. Future studies with animal or imaging models will provide even more insight into these mechanics.” (3)
In short, research shows that the pelvic floor is not static—it adapts over time.
Statistics show that up to 50% of women over the age of 50 who have had a vaginal birth will have some degree of prolapse in their lifetime. However, many prolapses are asymptomatic for many years with only 15% of women being symptomatic at 20 years.(5) That is, 20 years after they had their babies.
Hillock and Handa (2016) also stated that mild prolapse (i.e. any degree of prolapse) is practically universal in older women, yet only a small percentage experience significant symptoms. Thus, estimates of the prevalence of POP will be impacted by the threshold used to define the condition.
For many, prolapse remains stable for decades or improves with targeted muscle training. This underscores the importance of individualised care, reassurance, and conservative management as the first step in treatment. Pelvic floor exercises, pessary support, and education can all make a significant difference.
Emotional and Psychological Wellbeing
A diagnosis of prolapse can stir a complex mix of emotions—fear, frustration, sadness, or even a sense of “falling apart”. These reactions are common and understandable.
Healthcare professionals now increasingly recognise the biopsychosocial model in pelvic health care, which considers not only the physical structures but also emotional and social wellbeing. A calm, caring, informed conversation can help ease fears, validate experiences, and encourage confidence in recovery.
A diagnosis of prolapse can stir a complex mix of emotions—fear, frustration, sadness, or even a sense of “falling apart”. These reactions are common and understandable. For many women, prolapse is not just a physical change but an experience that affects confidence, identity, and everyday life.
Recent research has explored this emotional impact in more detail. A qualitative study by Ghetti and colleagues (2015) analysed women’s experiences of living with prolapse and identified three main emotional themes:
- Emotions associated with the condition itself:
Women reported a spectrum of feelings from minimal emotional response to annoyance, irritation, frustration, anger, sadness, anxiety, and, in some cases, depression. These emotions were often linked to the uncertainty of what was happening in their bodies and how it might affect their lives. - Communicating emotions about prolapse:
Many women described difficulty talking about prolapse, even with close friends or family. Feelings of embarrassment and the taboo surrounding pelvic health often made it challenging to seek emotional support. Some found it hard to express these concerns to healthcare providers, while others felt relief when their emotions were acknowledged in a safe, understanding environment. - Emotions relating to treatment:
Treatment itself could evoke both positive and negative emotions. For some, receiving support and care brought hope and empowerment. For others, managing ongoing symptoms or considering treatment options could be stressful or discouraging.
The study concluded that prolapse can significantly impact a woman’s emotional wellbeing and quality of life. Understanding these emotional dimensions can help healthcare providers offer more compassionate, holistic care—acknowledging not just the physical symptoms, but also the psychological and social effects.
Healthcare professionals are now increasingly recognising the biopsychosocial model in pelvic health care, which considers the interplay between biological, psychological, and social factors. Supportive conversations, empathy, and reassurance can help women feel understood and confident in their ability to recover and manage their condition.
Reassurance and Recovery
Most importantly, prolapse does not have to be viewed as a devastating diagnosis. The degree of prolapse can change from day to day depending on activity, posture, and fatigue. Early, compassionate intervention, especially from a pelvic health physiotherapist, can provide women with the tools, education, and reassurance they need to move forward with confidence.
References
- Bump RC, Mattiasson A, Bo K, Brubaker LP, DeLancey JOL, Klarskov P, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol. 1996;175:10–17. [PubMed] [Google Scholar]
- Dietz 2007
- Hallock, J. L., & Handa, V. L. (2016). The Epidemiology of Pelvic Floor Disorders and Childbirth: An Update. Obstetrics and gynecology clinics of North America, 43(1), 1–13. doi:10.1016/j.ogc.2015.10.008
- Sue Croft Pelvic Floor Essentials, Edition 3
- Jelovsek E, Chagin K, Gyhagen M, Hagen S, Wilson D et al (2018) Predicting risk of pelvic floor disorders 12 and 20 years after delivery Am J of O & G Vol 218, Issue 2 Feb: 222.e1-222.e19.
- Hagen S, Stark D, Maher C, & Adams E (2006). Conservative management of pelvic organ prolapse in women. Cochrane Database of Systematic Reviews (Online), (4), CD003882. 10.1002/14651858.CD003882.pub3.
- Ghetti, C., Skoczylas, L. C., Oliphant, S. S., Nikolajski, C., & Lowder, J. L. (2015). The Emotional Burden of Pelvic Organ Prolapse in Women Seeking Treatment: A Qualitative Study. Female pelvic medicine & reconstructive surgery, 21(6), 332–338. doi:10.1097/SPV.0000000000000190
