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Pelvic Floor Disorders

by S. Gene McNeeley, MD

Pelvic floor (pelvic support) disorders involve a dropping down (prolapse) of the bladder, urethra, small intestine, rectum, uterus, or vagina caused by weakness of or injury to the ligaments, connective tissue, and muscles of the pelvis.

  • Women may feel pressure or a sense of fullness in the pelvis or have problems with urination or bowel movements.

  • A pelvic examination is done while a woman bears down to make abnormalities more obvious.

  • Pelvic muscle exercises and pessaries may help, but surgery may be needed.

Pelvic floor disorders occur only in women and become more common as women age. During their lifetime, about 1 of 11 women needs surgery for a pelvic floor disorder.

The pelvic floor is a network of muscles, ligaments, and tissues that act like a hammock to support the organs of the pelvis: the uterus, vagina, bladder, urethra, and rectum. If the muscles become weak or the ligaments or tissues are stretched or damaged, the pelvic organs or small intestine may drop down and protrude into the vagina. If the disorder is severe, the organs may protrude all the way through the opening of the vagina and outside the body.

Did You Know...

  • During their lifetime, about 1 of 11 women needs surgery to repair a pelvic floor disorder.

Pelvic floor disorders usually result from a combination of factors. The following factors commonly contribute to development of these disorders:

  • Having a baby, particularly if the baby is delivered vaginally

  • Being obese

  • Having a hysterectomy (removal of the uterus)

  • Aging

  • Frequently doing things that increase pressure in the abdomen, such as straining during bowel movements or lifting heavy objects

Being pregnant and having a vaginal delivery may weaken or stretch some of the supporting structures in the pelvis. Pelvic floor disorders are more common among women who have had several vaginal deliveries, and the risk increases with each delivery. The delivery itself may damage nerves, leading to muscle weakness. The risk of developing a pelvic floor disorder may be less with a cesarean delivery than with a vaginal delivery.

As women age, the supporting structures in the pelvis may weaken, making pelvic floor disorders more likely to develop. Having a hysterectomy also weakens the structures in the pelvis, making these disorders more likely.

Other factors that may contribute include accumulation of fluid within the abdomen (ascites, which puts pressure on pelvic organs), disorders of nerves to the pelvic floor, tumors, and connective tissue disorders. Some women have birth defects that affect this area or are born with weak pelvic tissues.

Types and Symptoms

All pelvic floor disorders are essentially hernias, in which organs protrude abnormally because supporting tissue is weakened. The different types of pelvic floor disorders are named according to the organ affected. Often, a woman has more than one type. In all types, the most common symptom is a feeling of heaviness or pressure in the area of the vagina—a feeling that the uterus, bladder, or rectum is dropping out.

When the Bottom Falls Out: Prolapse in the Pelvis

Symptoms tend to occur when women are upright, straining, or coughing and to disappear when they are lying down and relaxing. For some women, sexual intercourse is painful. Mild cases may not cause symptoms until the woman becomes older.

Prolapse of the rectum (rectocele), small intestine (enterocele), bladder (cystocele), and urethra (urethrocele) are particularly likely to occur together. A urethrocele and cystocele almost always occur together.

Damage to the pelvic floor often affects the urinary tract. As a result, women who have a pelvic floor disorder often have problems controlling urination, resulting in urine leaking out involuntarily (urinary incontinence) or problems completely emptying the bladder (urinary retention).

Rectocele

A rectocele develops when the rectum drops down and protrudes into the back wall of the vagina. It results from weakening of the muscular wall of the rectum and the connective tissue around the rectum.

A rectocele can make having a bowel movement difficult and may cause constipation. Women may be unable to empty their bowels completely. Some women need to place a finger in the vagina and press against the rectum to have a bowel movement.

Enterocele

An enterocele develops when the small intestine and the lining of the abdominal cavity (peritoneum) bulge downward between the vagina and the rectum. It occurs most often after the uterus has been surgically removed (hysterectomy). An enterocele results from weakening of the connective tissue and ligaments supporting the uterus or vagina.

An enterocele often causes no symptoms. But some women feel a sense of fullness or pressure or pain in the pelvis. Pain may also be felt in the lower back.

Cystocele and cystourethrocele

A cystocele develops when the bladder drops down and protrudes into the front wall of the vagina. It results from weakening of the connective tissue and supporting structures around the bladder. When a urethrocele and cystocele occur together, they are called a cystourethrocele.

Women with either of these disorders may have stress incontinence (passage of urine during coughing, laughing, or any other maneuver that suddenly increases pressure within the abdomen), overflow incontinence (passage of urine when the bladder becomes too full), or urinary retention. After urination, the bladder may not empty completely. Sometimes a urinary tract infection develops. Because the nerves to the bladder or urethra can be damaged, women who have these disorders may develop urge incontinence (an intense, irrepressible urge to urinate, resulting in the passage of urine).

Prolapse of the uterus

In prolapse of the uterus, the uterus drops down into the vagina. It usually results from weakening of the connective tissue and ligaments supporting the uterus. The uterus may bulge

  • Only into the upper part of the vagina

  • Down to the opening of the vagina

  • Partly through the opening

  • All the way through the opening, resulting in total uterine prolapse (procidentia)

Prolapse of the uterus may cause pain in the lower back or over the tailbone, although many women have no symptoms. Total uterine prolapse can cause pain during walking. Sores may develop on the protruding cervix and cause bleeding, a discharge, and infection. Prolapse of the uterus may cause a kink in the urethra. A kink may hide urinary incontinence if present or make urinating difficult. Women with total uterine prolapse may also have difficulty having a bowel movement.

Prolapse of the vagina

In prolapse of the vagina, the upper part of the vagina drops down into the lower part, so that the vagina turns inside out. The upper part may drop part way through the vagina or all the way through, protruding outside the body and causing total vaginal prolapse. Usually, a cystocele or rectocele is also present.

Total vaginal prolapse may cause pain while sitting or walking. Sores may develop on the protruding vagina and cause bleeding and a discharge. Prolapse of the vagina may cause a compelling or frequent need to urinate. Or it may cause a kink in the urethra. A kink may hide urinary incontinence if present or make urinating difficult. Having a bowel movement may also be difficult.

Diagnosis

Doctors can usually diagnose pelvic floor disorders by doing a pelvic examination with a speculum (an instrument that spreads the walls of the vagina apart). A doctor may insert one finger in the vagina and one finger in the rectum at the same time to determine how severe a rectocele or enterocele is.

A woman may be asked to bear down (as when having a bowel movement) or to cough. She may be examined while standing with one foot on a stool. The resulting pressure in the pelvis from bearing down, coughing, and/or standing may make a pelvic floor disorder more obvious.

Procedures to determine how well the bladder and rectum are functioning may be done. For example, doctors often measure the amount of urine that the bladder can hold without leaking, the amount of urine left in the bladder after urination, and the rate of urine flow. If a woman has a problem with the passage of urine or urinary incontinence, doctors may use a flexible viewing tube to view the inside of the bladder (a procedure called cystoscopy) or the urethra (a procedure called urethroscopy). These procedures help doctors determine whether drugs or surgery is the best treatment. If the bladder is not functioning well, women are more likely to need surgery.

If sores are present inside the vagina or on the cervix, doctors may take a sample for examination under a microscope (biopsy) to check for cancer.

Treatment

Exercises

Pelvic floor exercises, such as Kegel exercises, can lessen bothersome symptoms, including stress incontinence, but do not affect prolapse itself. They tend to be most helpful if prolapse is mild. These exercises help by strengthening the pelvic floor muscles. Kegel exercises target the muscles around the vagina, urethra, and rectum—the muscles used to stop a stream of urine. These muscles are tightly squeezed, held tight for about 1 or 2 seconds, then relaxed for about 10 seconds. Gradually, contractions are lengthened to about 10 seconds each. The exercise is repeated about 10 times in a row. Doing the exercises several times a day is recommended. Women can do Kegel exercises when sitting, standing, or lying down.

Some women have difficulty contracting the correct muscles. Learning the exercises can be made easier by using the following:

  • Cone-shaped inserts placed in the vagina, which help women focus on contracting the correct muscle

  • Biofeedback devices

  • Electrical stimulation (a health care practitioner inserts a probe, which transmits an electrical current to make the correct muscle contract)

Pessaries

If prolapse is causing symptoms, a device called a pessary may be inserted into the vagina to support the pelvic organs. Pessaries are especially useful for women who are waiting for surgery or who do not want or cannot have surgery.

A pessary may be shaped like a diaphragm, cube, or doughnut. Some can be inflated. A doctor fits the pessary to the woman by inserting and removing different sizes until the right size is found. Some women choose to wear the pessary constantly. Other women choose to remove the pessary sometimes (for example, overnight).

A pessary must be periodically removed and cleaned with soap and water. Women are taught how to insert and remove the pessary for cleaning. If they prefer, they may go to the doctor's office periodically to have the pessary cleaned. The pessary should be cleaned or changed at least once every 2 to 3 weeks. It should be removed during intercourse.

Pessaries sometimes irritate the vaginal tissues and cause a foul-smelling discharge. The discharge can be reduced by regular cleaning, nightly if possible. Using a vaginal jelly that restores and maintains the normal acidity (pH) of the vagina can also help. Restoring the pH to normal keeps odor-producing bacteria from growing. This jelly is inserted into the vagina with an applicator, as instructed by a doctor. One such jelly contains hydroxyquinoline sulfate plus sodium lauryl sulfate.

Women who use a pessary should see their doctor periodically (for example, a week or two after the pessary is first inserted, then a month or two later, then every 6 to 12 months).

Surgery

Surgery is done if symptoms persist after women have tried pelvic floor exercises and a pessary. Surgery is usually done only after a woman has decided not to have any more children.

One of the following types of surgery is used:

  • Vaginal surgery: Surgery is done through the vagina rather than the abdomen. In such cases, no external incision is needed.

  • Abdominal surgery: One or more incisions are made in the abdomen.

Abdominal surgery includes laparotomy and laparoscopic surgery. For laparotomy, an incision that is several inches long is made in the abdomen. For laparoscopic surgery, a viewing tube (laparoscope) and surgical instruments are inserted through several tiny incisions in the lower part of the abdomen.

The weakened area is located, and the tissues around it are built up to prevent the organ from dropping through the weakened area. For example, for rectoceles, enteroceles, cystoceles, and cystourethroceles, doctors may reconnect tissues that normally support the vagina but have separated over time (called colporrhaphy). Sometimes doctors also repair the tissues between the opening of the vagina and the anus (called perineorrhaphy). For these two procedures, surgery is done through the vagina. These procedures do not require an incision in the abdomen.

For severe prolapse of the uterus or vagina, the uterus, if still present, is usually removed. The upper part of the vagina may be attached with stitches to a nearby stable structure, such as a bone or strong ligament in the pelvis. These procedures are done using a laparoscope or by making an incision in the abdomen or vagina. Colporrhaphy or perineorrhaphy may also be necessary.

Using a synthetic mesh to repair the prolapse makes the support stronger. Mesh is used mainly when surgery is done using a laparoscope or an abdominal incision. Mesh is not typically used when surgery is done vaginally because when placed during vaginal surgery, it often causes complications. Complications include infections, damage to structures in the pelvis, pelvic pain, and/or pain during intercourse. The mesh used to repair the vagina is different from that used to treat urinary incontinence.

If vaginal prolapse is severe and women do not plan to be sexually active, another option is vaginal obliteration. For this procedure, most of the vagina's lining is removed, and the vagina is stitched shut. Because this procedure can be done quickly and causes few complications, it may be a good choice for women who have conditions that make surgery risky (such as a heart disorder). Also, after obliteration, prolapse is unlikely to recur.

After surgery to correct a pelvic floor disorder, a catheter is often inserted in the bladder to drain the urine for up to 24 hours. If urinary incontinence is present or would occur after this surgery, surgery to correct incontinence can usually be done at the same time. Then the catheter to drain urine may need to remain in place longer. Lifting, straining, and standing for a long time should be avoided for at least 3 months after surgery.

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