Pelvic organ prolapse (POP) refers to the descent of one or more pelvic organs, such as the bladder, uterus, or rectum, into or through the vaginal canal, resulting from weakened pelvic floor support.1 It is a common condition with prevalence estimates between 1% to 31% based on symptomatic assessments, 10% to 50% during pelvic examination, and 20% to 65% when both methods are employed.1,2 POP significantly reduces a woman's quality of life (QoL) and patients often report experiencing a vaginal bulge within the previous four weeks.3 Research suggests that women have a 12.6% lifetime risk of requiring surgical correction for POP by the age of 80.4 The primary objective of these surgeries is to restore anatomy and thus, improve QoL by effectively alleviating symptoms.5 It is estimated that aging population in the United States will result in 47% increase in pelvic floor restorative surgeries between 2010 and 2050 leading to more women exposed to these procedures and so it is important to evaluate their outcomes on these women.6

The etiology of POP is multifactorial. Factors such as obstetrical trauma, hysterectomy, age, physical exercise involving chronic or repetitive straining have been associated with its development.1,7 Many of these factors may contribute to POP due to changes in muscles, ligaments, and connective tissues.1 There are two opposing hypotheses regarding the effect of physical activity on the pelvic floor in elite athletes.8 One hypothesis suggests that regular physical activity could strengthen the pelvic floor muscles (PFM), leading to coordinated muscle contractions and morphological changes such as hypertrophy and shortening of surrounding muscles, potentially reducing the risk of pelvic floor dysfunction, including stress urinary incontinence (SUI), anal incontinence (AI), and POP.8 The opposing hypotheses postulates that increased intra-abdominal pressure (IAP) during physical activities, if not counteracted by strong or quick co-contraction of PFM, might stretch and weaken these muscles during exercise.8

Contradictory evidence exists in the literature on the effects of physical exercise on POP.9–13 Some authors indicate that physical activities such as household chores are not associated with POP,4,14–16 while others suggest the onset or worsening of POP symptoms is related to the intensity of the physical exercise.11,17 Given this discrepancy, it is important to understand whether level of physical activity may be associated with prolapse severity at baseline and how these levels relate to symptoms and quality of life before and after surgery. Therefore, the objective of this study was to describe patterns of physical activity and examine their association with prolapse severity, symptoms, and quality of life before and after reconstructive prolapse surgery.

In line with our aim to describe patterns of physical activity and evaluate their associations with symptoms and QoL before and after reconstructive prolapse surgery, our study showed that comparison between patients who underwent corrective surgery for stage II versus stage III-IV had similar levels of physical activity at baseline and throughout the year after surgery. Prolapse-related symptoms and QoL improved over time at 3 months and 12 months postoperatively. Additionally, we found a significant increase in MET for patients in the stage III-IV between the 3rd and 12th months, as well as between baseline and the 12th month.

Although women with stage III–IV prolapse demonstrated more advanced anatomical findings, symptom severity at baseline did not significantly differ from those in stage II. This is consistent with evidence showing that patient-reported symptoms do not necessarily progress in a linear fashion with anatomical stage.23 Symptom burden may vary across compartments and is not always proportional to POP-Q measurements.23 Furthermore, it has been reported that severe prolapse may mask symptoms of stress urinary incontinence due to urethral kinking,24 illustrating the complex and non-linear relationship between anatomical stage and symptom perception.

Few studies have examined the relationship between physical exercise and POP, indicating no significant association,12,14–16 as well as no correlation with the severity of POP.25 Similarly, our data confirm these findings of no difference in exercise intensity between stage II and stage III-IV up to one-year post-surgery. However, some studies suggest there might be an association between POP and exercise.11,17 Nygaard et al. (2016) described methodological challenges in research linking physical exercise with POP, including confounding factors, unclear occupational and activity histories, the use of non-standardized measures for POP outcomes, and the exclusion of domestic activities, which constitute a significant portion of daily activities for many women.11

One-year post-surgery, the majority of study participants reported a frequency of major effort in physical activity of less than once a week, which is different from current recommendations. Additionally, most patients indicated that they did not engage in strenuous exercise on any day of the week. In one study, physically active women who engage in heavy weightlifting as part of their exercise routine do not show a higher prevalence of POP symptoms.26 A case-control study involving 1610 women found no evidence that lifetime physical activities, including strenuous activities performed throughout their lives, increase the likelihood of POP in middle-aged women, except for possibly very high levels of strenuous activity during adolescence.27

Despite significant improvements in prolapse-related symptoms and QoL, there was no difference between the groups one year postoperatively. These results likely reflect the beneficial effects of surgical correction of prolapse, independent of prolapse stage, while also suggesting improvements that are independent of the level of physical activity. It is known that regular physical exercise offers numerous health benefits including improved QoL.28 Although some strenuous activities may damage the pelvic floor, it has been shown that regular low-impact activity, like walking, is associated with a lower prevalence of pelvic floor disorders.13

The data from this study showed that most patients were inactive at baseline, regardless of the level of POP. Nygaard et al. (2008) suggested that many women may be sedentary due to the physical, mental, and psychological burden of POP.29 The fear of worsening POP by engaging in physical activities is one of the self-imposed restrictions by women.30 Discomfort during physical exercise is a common reason for seeking health services.31

In our study, three months postoperatively, most patients remained inactive regardless of the group. A clinical trial aimed to compare patient satisfaction and pelvic floor symptoms after prescribing two forms of postoperative activity recommendations – one liberal and the other more restrictive – following reconstructive prolapse surgery showed that satisfaction was higher three months after surgery for women who were instructed to resume activities liberally.32 It was also observed that women in this group reported fewer prolapse and urinary symptoms and had similar short-term anatomical outcomes. The authors suggested that allowing women to resume normal activities postoperatively may lead to improvements in pelvic floor health.32

Interestingly, >40% of patients with POP remained inactive one year after surgery, despite improvements in QoL and pelvic symptoms. A study with 301 patients undergoing abdominal sacrocolpopexy indicated that only one-third of the women increased their exercise intensity and were less likely to report perceived interference with physical activity due to POP or its treatment.29 The same authors emphasized that there is insufficient scientific evidence to suggest an adverse effect of physical activity one year after prolapse surgery.29

Although most women resume physical exercise within a year after surgery, it is essential to provide guidance for those who remain inactive. There is a prevailing belief that engaging in physical exercise may increase the risk of POP recurrence, even after corrective surgery. Patients are advised to avoid specific activities during the recovery period to ensure the repair is not compromised before it has adequately healed. However, many of these activity restrictions have traditionally been based on limited or no solid evidence.33 Research indicates that physical exercise does not hinder the healing process.33,34 Typically, collagen deposition in the healing process begins on the second day, reaching its peak synthesis around the fifth day.35

Many restricted activities after pelvic floor surgery do not necessarily increase intra-abdominal pressure more than the act of standing up from a chair.31 Recently, three randomized clinical trials compared expedited activity with standard activity restrictions after POP surgery concerning anatomical outcomes, symptoms, and patient satisfaction.32,36,37 The findings indicate that expedited postoperative activity does not lead to inferior outcomes compared to those with more restricted activities.36,37 These studies support the resumption of physical activities ad libitum after minimally invasive prolapse surgery.32,36

The American College of Sports Medicine encourages most adults to engage in moderate-intensity cardiorespiratory exercise of ≥150 min/week or vigorous-intensity of ≥75 min/week. A combination of moderate and vigorous-intensity exercise is also an option with the goal of achieving a total energy of >500–1000 MET min/week.28 Nygaard et al. (2008) reported that 47% of patients who underwent abdominal sacrocolpopexy maintained unchanged exercise intensity, 36% increased their preoperative exercise intensity, and 18% decreased it. A minority (16%) participated in strenuous activities both before and after surgery.29

Our findings have several practical implications. Postoperative counselling should reassure patients about resuming normal activities once initial healing is achieved. Current evidence, including randomized trials, suggests that expedited resumption of activity after minimally invasive prolapse surgery does not compromise anatomical or functional outcomes.32,36,37 Enhanced Recovery After Surgery (ERAS) programs may provide a framework for standardized advice regarding postoperative activity and gradual return to exercise, emphasizing individualized approaches based on patient tolerance and comorbidities.38 Additionally, structured pelvic floor muscle training may be considered for patients who remain inactive or experience persistent symptoms, in line with recommendations from clinical guidelines. Overall, clinicians should provide evidence-based guidance to encourage safe physical activity, addressing patient fears regarding POP recurrence and promoting long-term health benefits.

The strengths of this study include its comprehensive analysis of a large randomized clinical trial with well-characterized data collected at baseline, 3 months, and 12 months. The use of MET allowed for a detailed characterization of physical activity levels, including functional and occupational activities, as well as specific questions regarding strenuous activities. Physical activity was assessed using self-reported data and expressed in MET values. This approach, although widely used in epidemiological and clinical research, is subject to recall bias and social desirability bias associated with self-reported questionnaire data and MET calculations. However, self-reported questionnaires are considered feasible and appropriate for large clinical trials and have been previously applied in studies with women undergoing pelvic surgery. Future research should consider incorporating objective measures, such as accelerometry or wearable activity trackers, to improve the accuracy of physical activity assessment.

As this study represents a secondary analysis, the potential influence of unmeasured confounders should also be considered, including prior physical activity history, variations in surgical techniques, and comorbidities that may influence postoperative physical activity levels. Moreover, a limitation of the study is the lack of information on participants' compliance with the postoperative instructions, and no data were collected on the participants' history of strenuous activities prior to surgery or other clinical conditions (disabilities, comorbidities, among others) that may interfere with physical exercise practice. There is no information available to justify the number of inactive individuals after one year. Data on general health over the course of one year and information on contraindications for physical exercise were not recorded in the primary study. In this exploratory study, using large, longitudinal data we were able to observe trends in certain subgroups, that could potentially be observed in daily clinical practice as patients with more advanced stages of POP tend to refrain from any exercise in fear of progressing it further as well as social shame that is linked to this condition refraining from e.g. group exercises. Thus, we believe correction of POP may lead to increased physical activity in real life scenario.

Our findings indicated that patients with stage II and stage III-IV had similar levels of physical activity at baseline, 3 months, and 12 months following corrective POP surgery. Additionally, there was no significant difference when comparing symptoms and QoL between the two groups over the course of one year. These results describe patterns of physical activity and postoperative outcomes that did not differ by prolapse severity; however, these findings should be interpreted within the limitations of our dataset. Future studies should investigate optimal strategies for the gradual and safe implementation of exercise programs, as well as monitor physiological responses to exercise in active populations. Finally, new studies are required to answer the question of possible recurrence of prolapse after 12 months.

MM: Data analysis, Manuscript writing/editing.

RMG: Manuscript writing/editing.

IG: Manuscript writing/editing.

VAM: Manuscript writing/editing.

None.

Institutional Review Board (IRB) of Mass General Brigham in Boston, Massachusetts, United States (protocol number 2023P001511).