Friday Q&A: Organ Prolapse and Intra-Abdominal Pressure

White Rose by Melina Meza

Today’s question was left as a comment on our post Organ Prolapse and Yoga, which was written by guest contributor Shelly Prosko. Rather than just leaving a short answer in the comments section, Shelly decided to write long, more thorough answer that we could share with all our readers. Thank you, Shelly!

Q: Thanks for the more nuanced understanding of this issue. Could you help me understand why uddiyana bandha increases IAP (intra-abdominal pressure)? My experience and theoretical understanding suggest that is would decrease pressure because a) the diaphragm is rising, thus relieving pressure on the abdomen, b) the pelvic floor will slightly life if it is relaxed during uddiyana, a sign of decreased pressure, c) the lungs are at less than atmospheric pressure, which should drop general fluid pressure in the torso. Am I missing something?

A: Thanks for your thoughtful and wonderful observation, insight, and question. It gives me an opportunity to more thoroughly explore this topic, and gives me a chance to better explain my perspective about re-evaluating the use of uddiyana bandha for prolapse.

You said, "the diaphragm is rising, thus relieving pressure on the abdomen". Well, yes, the diaphragm ascends on exhalation, but that doesn't automatically decrease intra-abdominal pressure (IAP). If abdominal muscles are engaging such that it increases pressure in the system (the abdominal cavity being the hydraulic part of the piston system), the intra-abdominal pressure may not necessarily be reduced at the end of exhalation, when the diaphragm is elevated.

You also said, "the pelvic floor will slightly life (lift) if it is relaxed during uddiyana, a sign of decreased pressure." I agree for the most part. If the pelvic floor and abdominals are truly relaxed and they draw upward/inwards during uddiyana bandha, one would assume the intra-abdominal pressure has reduced, resulting in a passive lifting effect of the abdominal and pelvic organs. However, it's a challenge to know if the pelvic floor is completely passively lifting or actually actively lifting without EMG, US, or internal manual palpation.

This is where I feel I need to clarify my perspective and explain my experience (personal and clinical) with uddiyana bandha. I am by no means a bandha expert. I understand there are different interpretations and teachings of uddiyana bandha, depending on lineage. Some of these may potentially increase intra-abdominal pressure, others may decrease intra-abdominal pressure, depending on how it is taught and understood.

Here is my translation and understanding of how uddiyana bandha is supposed to be performed (please feel free to add/clarify from your knowledge): After a full exhalation, breath is retained. The intercostals and perhaps even some accessory muscles of respiration are supposed to then be engaged to expand the rib cage, therefore increasing volume in the thoracic cavity which will create reduced intra-thoracic pressure. This, in turn, is supposed to pull up the respiratory diaphragm because of the vacuum created, which in turn is supposed to passively “suck” the abdominal organs up higher. One would assume the same for pelvic organs.

Although even though the “abdominal lock” is supposed to be a passive indrawing/lifting of the abdomen, I believe it is rarely taught or performed (in our western mainstream yoga culture) this way. Even the way we've translated it as the “abdominal lift” can be confusing. To me—and I know many others—this implies that the primary action is to “lift or pull in the abdomen” Instead, maybe we should call it “rib cage vacuum.”

But I've seen videos, books, and teachers give instructions to "pull the abdomen in." If that is the case, then potential is there to incorrectly use surrounding trunk/abdominal muscles to move the abdomen, increasing intra-abdominal pressure, which may be unfavorable for someone with prolapse. (I sure would love to do a study though!)

So, I do feel that people suffering from organ prolapse should re-evaluate their use of uddiyana bandha if they are performing it, particularly if they are performing this bandha regularly, thinking it should help, but they are getting worse (which I've witnessed). In retrospect, I would have re-worded my statement: "precaution with advanced yoga methods such as uddiyana bandha, as this could potentially increase intra-abdominal pressure if not performed correctly."

Finally, reader, I think you're onto something. There is actually a relatively new approach to treating reproductive organ prolapse that is gaining popularity in the pelvic health world called hypopressives. From photos/videos, it looks interestingly similar to uddiyana bandha. Research is still in its infancy, but perhaps there is actually some therapeutic value in uddiyana bandha for reproductive organ prolapse! 

Thanks for opening up this conversation and providing me with this opportunity to expand on this topic. Hope this helps clarify my article.

—Shelly

Disclaimer: This article is not meant to diagnose, treat or act as medical advice. Please consult your health care provider for clearance and guidance before following or participating in these activities. 

Shelly Prosko is a Physical Therapist, Yoga Therapist and a Certified Pilates Instructor. She received her Physical Therapy degree at the University of Saskatchewan, Canada in 1998, her Yoga Therapist training through Professional Yoga Therapy Studies in North Carolina and her Pilates certification through Professional Health and Fitness Institute in Maryland. 

Since 1998, Shelly has been integrating yoga principles and methods into her physical therapy treatments. She has treated a wide variety of musculoskeletal, neurological and cardiorespiratory  conditions while working in private orthopaedic clinics and long term care facilities across Canada and the United States.


Currently, Shelly resides in Sylvan Lake, AB and travels across Canada and the United States offering specialty Physio-Yoga Therapy workshops, classes, private sessions, lecturing at University and College programs as adjunct faculty of Professional Yoga Therapy Studies, teaching at YTT’s and actively promoting the integration of medical therapeutic yoga into our current healthcare system. She believes that bridging the gap between Western and Eastern healthcare philosophies is essential in order to achieve optimal health. Her treatments are individually based and are a unique blend of both approaches. Please visit www.physioyoga.ca for more information about Shelly’s mission and services, and to read a variety of testimonials of how PYT has profoundly influenced many people’s lives.

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Organ Prolapse and Yoga

by Shelly Prosko

Iris in the Rain by Melina Meza

Recently the blog received a question from a yoga teacher asking about the role of yoga to both reduce the likelihood of prolapse in her students (most of whom are middle aged mothers of at least one child), and to serve as a therapy to those who have had the surgery and are looking to improve the situation. She also wanted to know if there any poses or actions that could potentially damage this area.

There is certainly a role that yoga can play in the management of reproductive organ prolapse, but there are also some poses, movements and breathing methods that could potentially exacerbate the condition. For our readers who may not be familiar with what a reproductive “organ prolapse” means, Wikipedia defines the term prolapse as “to fall out of place.” There can be different kinds of prolapses. The bladder, intestines, bowel, uterus or vaginal walls can “fall” or collapse downwards. A prolapse of one of these organs results when there is too much intra-abdominal pressure in the abdominal and pelvic cavities, causing a downward force that the pelvic floor muscles (PFM’s) and surrounding connective tissue are unable to support. The organs can even fall down through the vaginal opening.

It is beyond the scope of this post to outline the causes of a prolapse. But it is important to clarify the common misconception that prolapses are caused by weak PFM’s. Yes, if the PFM’s are weak, they won’t be able to hold or support the downward force of these organs, leading to an increase risk of a prolapse when the intra-abdominal pressure rises. However, there are other connective tissue structures like fascia and ligaments that help hold all of our pelvic organs in their respective space and place. You can imagine if these structures are damaged during childbirth, or if one of these organs is removed, as in a hysterectomy, that it will change the support system in the entire cavity. This is important to understand because it will dictate how you address the prolapse with yoga or other exercises.

To answer our reader's questions, we need to look at some yoga poses that might help improve support within and surrounding the pelvic and abdominal cavities without increasing an unfavourable amount of pressure, and then look at ones that might cause an unwanted increase in the intra-abdominal pressure, potentially worsening the prolapse.

Let’s first take a look at what poses or activities to avoid (or consider re-evaluating) in your practice:

1. Poses that tend to unfavourably increase the intra-abdominal pressure (IAP) are some of the intense core poses such as Boat (navasana), Four-Limbed Staff pose (Chaturanga Dandasana), Plank pose (on elbows or hands) or variations of these poses.
2. Uddiyana Bandha forcibly and considerably increases the IAP and can exacerbate prolapse.
3. Depending on the severity of the prolapse, forward bending poses with the legs abducted (wide apart), may induce an increased downward pressure in the pelvic cavity that the PFM’s cannot support, such as Garland pose (Malasana), Wide-Legged Forward bend (Prasarita Padottanasana), Extended Child’s Pose (big toes are touching, heels and knees are wide apart, and arms extending forward).
4. Power or flow yoga transitions where there is jumping. Repeated jumping consistently increases the downward force. 
5. Breath Holding. If ANY yoga pose is too challenging for you or causes you to strain and hold your breath, then this can cause an increase in the intra-abdominal pressure, worsening your prolapse. Proper breathing during any yoga practice or other activity is always important for pelvic health and overall health of many systems of your body!
6. Avoid Kapal Bhati Pranayama (vigorous abdominal contractions during breath method).
7. Avoid activities such as heavy lifting or “pushing” (as in constipation). Lifestyle choices (forcing yourself to take several trips to unload groceries) and nutritional changes (increase bowel motility and softening) may be helpful.

Here are some poses or activities that may help manage or reduce symptoms in your practice:

1. Slightly elevate hips during Legs up the Wall pose (Viparita Karani), Supported Bridge pose (Setu Bandha Sarvangasana), Reclined Cobbler’s pose (Supta Baddha Konasana), Supported Shoulderstand (Salamba Sarvangasana).
2. Focus on awareness of the pelvic diaphragmatic breath or Reverse Kegel. Many people experiencing a prolapse assume that their PFM’s are loose and need to be tightened.  However, Jocelyn Unger, a PT pelvic health specialist at the University of Arizona Health Network agrees that the majority of women she treats that have weak and ineffective PFM’s, but also that they demonstrate tight PFM’s.  For this reason, she, along with many of the leading pelvic health specialists, recommend focusing first and foremost on the RELAXATION and release of the PFM’s before learning to engage and activate. See Urinary Incontinence for info on the pelvic diaphragmatic breath method or Reverse Kegel.
3. Breathe. It is important to ensure you are breathing effectively and not holding your breath in all your yoga poses, and in all your activities of daily living. Breath holding can increase strain and pressure against the pelvic floor. However, you must be even more mindful of effective breathing strategies in standing poses; because the force of gravity pulls downwards, the position of standing may be a somewhat precarious position if the prolapse is moderate to severe.
4. Mountain pose (Tadasana) and modified Powerful pose pose (Utkatasana) with a block between the thighs, ensuring proper postural alignment.  Alignment of the spine and pelvis can influence the position of the abdominal and pelvic organs and also influence the effectiveness of the PFM’s ability to contract. Ensuring you have a natural low back curve with a neutral pelvic alignment in your standing poses is important. An assessment from your physical therapist can help you determine where your optimal lumbo-pelvic position should be. Modify the Powerful pose simply by not squatting down as far so that there is no extra unwanted downward pressure.
5. Pranayama (breathing methods) that are meant to calm the nervous system would be beneficial for addressing anxiety that sometimes causes you to hold tension in the pelvic area. Nadi Shodana (alternate nostril breathing), Abdominal-Diaphragmatic breathing (Belly Breath) and Bee’s breath (Bhramari) may be useful.

Once you have practiced pelvic diaphragmatic breath awareness and learned to release the PFM’s, then you may be ready to start a gentle engagement of the pelvic floor muscles AS YOU EXHALE. Lie on your back with your knees bent and feet flat on the mat, or sit upright in a comfortable position. As you inhale, allow your belly to naturally move out. As you exhale, very gently draw your lower belly inwards, keeping your spine and pelvis neutral.  Inhale and relax, allowing your belly to soften. During the next exhalation, you can try to add a gentle lifting sensation of the pelvic floor. This is an extremely subtle movement, but is the beginning of learning how to incorporate gentle core activation movements, which may be part of your overall prolapse yoga program. I recommend seeking a health care professional who can help you accurately activate these muscles before you start engaging them in your yoga practice, as research shows they often are not engaged properly in group settings.

It is important to understand that these poses do not treat a prolapse. There are a variety of causes, severities and treatment options for different prolapses, so it is wise to follow advice from your health care practitioner as to which treatment approach is best suited for you and your specific case.

Finally, our reader asked about using yoga to prevent organ prolapse for her students. It is inaccurate for me to say these exercises will help prevent a prolapse, because there are truly so many different factors that contribute to prolapse, some of which we can’t control. Therefore, it would be almost impossible to pinpoint the cause that may be unique to each of your students. However, if you take into consideration some of the above tips and recommendations, this may help reduce some of the risk factors. I would strongly encourage ALL women to visit a Physical Therapist who specializes in pelvic health PT at any stage in life, so their alignment and pelvic floor health can be individually assessed, and a home program unique to their needs can be implemented.

A visit to your pelvic health specialist does not need to be only when a dysfunction arises! As a yoga teacher, it would be helpful if you could find a pelvic health PT in your area that you can team up with to discuss individual home yoga programs for your students with these prolapse concerns. The PT could assess each woman and then communicate with you what areas need to be addressed for optimal pelvic health. This would be a great preventative and health creation approach. Pelvic health PT’s are found in these online directories across Canada and the USA. 

Disclaimer: This article is not meant to diagnose, treat or act as medical advice. Please consult your health care provider for clearance and guidance before following or participating in these activities. 

Shelly Prosko is a Physical Therapist, Yoga Therapist and a Certified Pilates Instructor. She received her Physical Therapy degree at the University of Saskatchewan, Canada in 1998, her Yoga Therapist training through Professional Yoga Therapy Studies in North Carolina and her Pilates certification through Professional Health and Fitness Institute in Maryland. 

Since 1998, Shelly has been integrating yoga principles and methods into her physical therapy treatments. She has treated a wide variety of musculoskeletal, neurological and cardiorespiratory conditions while working in private orthopaedic clinics and long term care facilities across Canada and the United States.


Currently, Shelly resides in Sylvan Lake, AB and travels across Canada and the United States offering specialty Physio-Yoga Therapy workshops, classes, private sessions, lecturing at University and College programs as adjunct faculty of Professional Yoga Therapy Studies, teaching at YTT’s and actively promoting the integration of medical therapeutic yoga into our current healthcare system. She believes that bridging the gap between Western and Eastern healthcare philosophies is essential in order to achieve optimal health. Her treatments are individually based and are a unique blend of both approaches.

Please visit www.physioyoga.ca for more information about Shelly’s mission and services, and to read a variety of testimonials of how PYT has profoundly influenced many people’s lives.

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