Why Most Exercise Makes Prolapse Worse

"The pelvis is not a problem to be managed. It is a place to come home to."

In Part 1 of this series, I wrote about my own diagnosis of prolapse - of both the rectocele (rectum into the vagina) and cystocele (bladder into the vagina) and what Chinese medicine understands to be happening in the body when the pelvic organs begin to descend.

In Part 2, I explored the acupuncture, herbal, and dietary strategies we can draw on to lift Qi, nourish Kidney Jing, and rebuild the structural integrity of the pelvic bowl.

This third piece turns to movement and in particular, to a practice that I believe is among the most underknown and underused tools available to women with prolapse: hypopressive breathing.

I'm writing this from a particular vantage point. I'm a Chinese medicine practitioner, acupuncturist, and registered medical herbalist but I'm also a qualified Pilates instructor and personal trainer with a background in functional anatomy and movement rehabilitation spanning over twenty years. The exercise content here is not borrowed from other sources. It is what I use clinically, what I practise myself, and what I believe makes a genuine difference to most pelvic floor dysfunction.

That said, pelvic floor physiotherapy is an extraordinarily valuable discipline and one I'd always recommend working with in parallel. Not because I'm deferring to it but because specialist hands-on assessment of the pelvic floor is something that a physiotherapist trained in internal examination can offer, and that information changes the picture.

Whether your floor is weak, hypertonic, or asymmetric matters enormously for how you exercise. Find out before you assume!

Why Conventional Exercise Often Makes Things Worse

This surprises people. Surely exercise is good for the pelvic floor?

The answer is: it depends profoundly on which exercise, and how you do it.

Many common forms of movement such as running, jumping, heavy lifting with poor breath mechanics, even poorly-cued Pilates can generate high intra-abdominal pressure. Every time you hold your breath and bear down, every time you cough, lift, or land without coordinating your breath and your deep canister, a downward force is transmitted through the abdominal cavity directly onto the pelvic floor. Over time, and particularly when the supporting structures are already compromised, this exacerbates the very problem we are trying to resolve.

In TCM terms, we might understand this as repeatedly driving Qi downward, the opposite of the Spleen's lifting function. The Middle Qi, already deficient and sinking, is pushed further. The Kidney's ability to grasp and anchor is overwhelmed.

This does not mean women with prolapse should not exercise - FAR FROM IT!! It simply means we need to choose movement that raises rather than descends, that cultivates the upward vector of Spleen Qi and supports the Kidney's deep, rooted holding.

Hypopressive Breathing: Lifting Qi from the Inside Out

Hypopressive comes from the Latin hypo (below) and pressio (pressure). This is literally, below-pressure. Hypopressive techniques are a system of breathing and postural exercises developed in the 1980s by Belgian physiotherapist Marcel Caufriez, originally for postnatal rehabilitation. They have since been widely used in Spain and Portugal for prolapse, incontinence, and core rehabilitation, though they remain less well known in the UK.

The mechanism is elegant and, to those of us who think in terms of Qi dynamics, intuitively resonant.

What Happens in the Body

A standard hypopressive sequence involves three phases:

1. Postural alignment: 

The spine is lengthened, the ribcage slightly expanded, and the pelvis in a specific neutral or gently posteriorly (hips tucked slightly under) tilted position depending on the protocol. This is not passive, rather it is an active energetic and structural organisation of the body. For those familiar with Pilates: think of the deep axial elongation we cue before any movement but taken a step further into deliberate costal opening. In TCM terms, we are arranging the body so that Qi can circulate freely along the Du Mai and Ren Mai, the governing and conception vessels that run along the spine and midline.

2. Full exhalation: 

A complete, slow exhalation through the mouth, emptying the lungs thoroughly. This is not a forced blow, it is a long, relaxed release, allowing the thoracic volume to reduce naturally. This begins to lower intra-abdominal pressure.

3. Apnea with costal expansion (the key phase): 

Exhale fully until the lungs are empty, then hold. With the breath held out, expand the ribcage laterally — wide, like opening a bellows — without inhaling. The resulting drop in pressure draws the diaphragm upward and the pelvic floor lifts reflexively in response. You are not contracting it. You are creating the conditions for it to rise on its own.

This reflex lift of the pelvic floor is not a voluntary contraction. It is a passive, neurologically mediated response to the drop in intra-abdominal pressure created by the apnea and the expanding thoracic cavity. The pelvic floor is drawn upward, like a sail filling with wind from above. For Pilates practitioners: this is not a Kegel, and it should not be confused with one. It is the pelvic floor responding to a pressure differential rather than a conscious motor command and this distinction matters both functionally and in terms of which neural pathways we are training.

The apnea is typically held for 8–12 seconds, repeated three times per breath cycle, and practised for 20 minutes several times per week.

The TCM Resonance

In Chinese medicine, the breath is intimately connected to the Lung, which governs Qi and its descending and dispersing movements. But the Lung also has a relationship with the Kidney: the Lung sends Qi downward, and the Kidney receives it and anchors it, what we call the Kidney's function of grasping the Qi.

Hypopressive breathing creates a moment of held emptiness, a vacuum in which the Lung's capacity to lift and the Kidney's capacity to hold are called upon simultaneously. The thoracic expansion is a movement of the chest, the residence of the ancestral Qi (Zong Qi). The reflex lift of the pelvic floor is an expression of the Kidney's root, rising to meet the demand placed on it.

The Spleen, too, is engaged: the whole posture of a hypopressive practice is one of lifting and raising - the yang ascent that the Spleen governs. We are, in a very literal sense, training the body's capacity to hold things up.

This is not a metaphor stretched over anatomy. It is a coherent map of the same physiological event, described in two languages.

Preparing the Ground: Before You Move

Before introducing specific exercises, a word about the conditions that allow them to land well.

In Chinese medicine, movement should always follow the Qi. If Spleen and Kidney Qi are severely depleted i.e if you are feeling exhausted, cold, pale, and overwhelmed, then vigorous exercise will scatter rather than consolidate.

We begin gently. We eat warm, nourishing food. We sleep before midnight. We rest in ways that are genuinely restorative, not just passive.

Moxa on Ren 4 (Guanyuan), Ren 6 (Qihai), and St 36 (Zusanli), either self-applied or as part of a treatment programme can support the constitutional ground from which exercise becomes productive rather than depleting. This is the soil preparation before the planting.

As a movement practitioner, I'd add: body awareness comes before loading. Before any of the exercises below, spend a few minutes in constructive rest, lying supine, knees bent, hands on the lower abdomen simply noticing the breath and the movement of the pelvic floor with each cycle. The pelvic floor should descend gently on inhalation and rise gently on exhalation. If you feel nothing, or feel holding and bracing, that information is the starting point.

As a movement practitioner, I'd add: body awareness comes before loading. Before any of the exercises in Part 4, spend a few minutes in constructive rest - lying on your back, knees bent, hands resting on the lower abdomen - simply noticing the breath and the movement of the pelvic floor with each cycle. The pelvic floor should descend gently on inhalation and rise gently on exhalation. If you feel nothing, or feel persistent holding and bracing, that information is the starting point.

In Part 4, I'll take all of this into the movement practice itself - a detailed bridge sequence and progression that puts these principles to work in the body.

Jenny Swan is a Chinese medicine practitioner, registered medical herbalist, acupuncturist, Tui Na bodyworker, qualified Pilates instructor, and personal trainer with over 20 years of clinical experience. She practises at West Aish Farm, Crediton, mid-Devon, and works with women online across the UK. She is registered with the Register of Chinese Herbal Medicine (RCHM) and specialises in women's health, menopause, and reproductive medicine. To discuss what's possible for you, contact Jenny here.

This series: 

Part 1: When the Ground Gives Way - Understanding Pelvic Organ Prolapse Through TCM 

Part 2: Lifting the Qi - TCM Treatment Approaches for Pelvic Floor Prolapse and Menopause 

Part 3: Why most exercise makes prolapse worse

Part 4: Moving from the Ground Up - The Bridge Sequence for Pelvic Floor Rehabilitation