Moving Well with Prolapse

"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 - rectocele and cystocele 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.

A Note on Working with a Pelvic Floor Physiotherapist

Before I go further, I want to say something that I think is important.

In writing this series, I shared this blog with my own pelvic floor physiotherapist and asked for her thoughts. She read it carefully and responded with real generosity, confirming that the content was factually correct, engaging with the TCM aspects with genuine curiosity, and offering some considered pushback in a couple of places. I'm grateful for that, and I want to reflect some of her perspective here, because I think it makes this a better and more honest piece.

Pelvic floor physiotherapy is an extraordinarily valuable discipline. A physiotherapist trained in internal examination can assess whether your floor is weak, hypertonic, or asymmetric and that information changes everything about how you should approach movement. I would always recommend working with one alongside anything I offer here. Find out what your floor is actually doing before you assume.

Exercise and Prolapse - A More Nuanced Picture

One of the things my physiotherapist gently pushed back on was the idea that impact exercise and heavy lifting are simply bad for prolapse. She's right to nuance this.

With the right instruction, careful monitoring, appropriate adaptations, and gradual progression, many women can and do return to running, lifting, and the activities they love. The goal of good pelvic health care, whether from a physiotherapist or a movement practitioner, is to help people get back to doing the things that matter to them. That is always the aim.

What I want to draw attention to is not that these activities are permanently off the table, but that doing them without understanding the breath, the pressure system, and the pelvic floor's role within it can exacerbate symptoms, particularly in the early stages of rehabilitation, or without proper guidance.

In TCM terms, we might understand poorly coordinated exercise 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. But this is not a permanent state. It is a starting point from which we work.

This does not mean women with prolapse should not exercise, far from it. It means we need to understand how we move, and build from there.

Hypopressive Breathing: Lifting Qi from the Inside Out

Hypopressive comes from the Latin hypo (below) and pressio (pressure), 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 tilted position depending on the protocol. This is not passive, it is an active 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. Not a forced blow but a long, relaxed release, allowing the thoracic volume to reduce naturally. This begins to lower intra-abdominal pressure. For beginners, it can help to take three normal breaths before this phase, settling the nervous system before the breath hold.

3. Apnea with costal expansion - the key phase: Exhale fully until the lungs are completely 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. For those with a Pilates background: 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.

Precaution: Hypopressive apnea should not be practised by anyone with uncontrolled hypertension. If dizziness or light-headedness occurs, return to normal breathing and rest.

Hypopressives and Kegels - Not Either/Or

My physiotherapist made an important point here: she does not recommend hypopressives as a standalone practice to the exclusion of pelvic floor muscle exercises (Kegels), as this may reduce the neurological connection between the brain and the pelvic floor musculature.

I think this is well made. Hypopressives are a powerful addition to pelvic floor rehabilitation and not a replacement for it. For most women, a programme that includes both voluntary pelvic floor muscle training and hypopressive breathing will be more complete than either alone. The two approaches work on different aspects of the same system: Kegels train the conscious motor pathway; hypopressives train the reflexive, pressure-mediated response. Both matter.

The exception, and it is an important one, is the woman with a hypertonic pelvic floor: one that is too tight, too held, and unable to fully relax. For her, adding more voluntary contraction can worsen rather than improve symptoms, and hypopressives alongside releasing work may be the better starting point. This is precisely why individual assessment matters so much.

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 profound 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 any movement practice, a word about the conditions that allow it to land well.

In Chinese medicine, movement should always follow the Qi. If Spleen and Kidney Qi are severely depleted ie if you are exhausted, cold, pale, and overwhelmed, 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 always comes before loading. Before any exercise, 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 persistent holding or bracing, that information is the starting point.

In Part 4, I'll take all of this into the body, a detailed bridge sequence that puts these principles to work in a practical, progressive way.

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 and in particular menopausal issues. 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: Moving Well with Prolapse

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