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Pelvic Floor Disorders

December 21, 2010
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. About 1 of 11 women needs surgery for a pelvic floor disorder during her lifetime.

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.

Pelvic floor disorders usually result from a combination of factors. 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 may be less with a cesarean delivery than with a vaginal delivery.

Obesity, chronic coughing (for example, due to a lung disorder or smoking), frequent straining during bowel movements, and heavy lifting can also contribute to pelvic floor disorders. Other causes include disorders of nerves to the pelvic floor, injuries (including those due to surgery), and tumors. Some women have birth defects that affect this area or are born with weak pelvic tissues. As women age, the supporting structures in the pelvis may weaken, making pelvic floor disorders more likely to develop.

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.

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 a sensation of constipation. 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. An enterocele results from weakening of the connective tissue and ligaments supporting the uterus. 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. A cystourethrocele is similar but develops when the upper part of the urethra (bladder neck) also drops down. 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) or overflow incontinence (passage of urine when the bladder becomes too full). After urination, the bladder may not feel completely empty. 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, into the middle part, or all the way through the opening of the vagina, 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. Prolapse of the vagina occurs only in women who have had a hysterectomy. 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. The resulting pressure in the pelvis from coughing, standing, or both 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.

Treatment

Exercises: If prolapse is mild, Kegel exercises can 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 severe, a pessary may be used to support the pelvic organs. A pessary may be shaped like a diaphragm, cube, or doughnut. Pessaries are especially useful for women who are waiting for surgery or who cannot have surgery. A doctor fits the pessary to the woman by inserting and removing different sizes until the right one is found.

A pessary can be worn for many weeks before it needs to be removed and cleaned with soap and water. Women are taught how to insert and remove the pessary for monthly cleaning. If they prefer, they may go to the doctor’s office periodically to have the pessary cleaned. Pessaries can irritate the vaginal tissues and cause a foul-smelling discharge. The discharge can be reduced by regular cleaning, nightly if possible. Some women choose to wear the pessary constantly, in which case the pessary should be changed every 2 to 3 weeks. They should also see their doctor every 6 to 12 months.

Surgery: Surgery is done if symptoms persist after women have tried Kegel exercises and a pessary. Surgery is usually done only after a woman has decided not to have any more children. The surgery usually involves inserting instruments into the vagina. The weakened area is located, and the tissues around it are built up to prevent the organ from dropping through the weakened area.

For severe prolapse of the uterus or vagina, the surgery may require an incision in the abdomen. The upper part of the vagina is attached with stitches to a nearby bone in the pelvis. Often, a catheter is inserted in the bladder to drain the urine for up to 24 hours. If urinary incontinence is present or would occur after prolapse of the uterus is repaired, 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. Heavy lifting, straining, and standing for a long time should be avoided for at least 3 months after surgery.

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