Pelvic Support Problems
The Pelvic Organs
The parts of the body affected by pelvic support problems include the urethra and bladder, the small intestine, the rectum, the uterus, and the vagina. The urethra and bladder lie in front of the vagina. The bladder receives and stores urine from the kidneys and expels it through the urethra (a short, narrow tube).
The uterus is at the top of the vagina. Behind the uterus is a space within the pelvic cavity called the cul-de-sac. This space contains some of the small intestine. Along the back of this space is the rectum, which continues down the back of the vagina and ends at the anus. The perineum is the tissue between the opening of the vagina and the anus.
The pelvic organs information
The pelvic organs are held in place by three types of support:
- Layers of connecting tissue called endopelvic fascia
- Thickened parts of the fascia called ligaments
- A paired group of muscles that lies on either side and around the openings of the urethra, vagina, and rectum
Causes & Symptoms
The main causes of pelvic support problems are childbirth and aging. As the baby passes through the vagina during childbirth, the fascia and ligaments may be damaged. They may become weak. In later years, when a woman goes through menopause, the loss of the female hormone estrogen may make these problems worse.
Sometimes pelvic support problems occur in women who have never had children. In these women, the cause may be:
- Weakening of the vaginal tissues after menopause
- Increases in abdominal pressure because of a chronic cough (often linked to smoking or lung disorders), heavy lifting, obesity, or constipation
- An inherited weakness of the tissues
The symptoms of pelvic support problems depend on which organs are involved. They can cause minor discomfort or major problems in the way the organs work. Symptoms include:
- Feeling of pelvic heaviness or fullness, or as though something is falling out of the vagina
- Pulling or aching feeling in the lower abdomen, groin, or lower back
- Leakage of urine or problems having a bowel movement
You may notice the symptoms after you have been standing for a long time or at the end of the day. They may be worsened by repeated coughing, lifting, or straining. In severe cases, the pelvic organs may bulge into the vagina. This bulge may stick out of the vaginal opening, where it may be seen with a mirror or felt with the fingers. Sometimes a woman may need to push the organs back up into the vagina to empty the bladder or have a bowel movement. The uterus may stick out through the vaginal opening. If the uterus or a part of the vaginal wall stays outside of the vaginal opening, it may become irritated. It may develop small sores or ulcers that bleed or become infected.
Types of Pelvic Support Problems
The main types of pelvic support problems include:
- Cystocele (SIS-tow-seel) – bladder
- Enterocele (en-TARE-oh-seel) – small intesti
- Rectocele (REK-tow-seel) – rectum
- Uterine prolapse – uterus
- Vaginal prolapse – vagina
Although each problem occurs in different pelvic organs, they often occur at the same time.
A cystocele occurs when the bladder drops from its normal place into the vagina. Some cystoceles cause urine to leak when you cough, sneeze, lift objects, or walk. Large cystoceles may kink the urethra and cause problems with the passing of urine. If this occurs, you may have to strain or push the bladder up by reaching into the vagina to pass urine. If there is a very large cystocele and if the bladder loses some of its ability to contract, it may not completely empty.
Small cystoceles are common. In most cases, they do not cause problems with urination and do not need surgery. If a cystocele is causing symptoms, your doctor can suggest ways to relieve them. The place where the bladder joins the urethra is called the bladder outlet or bladder neck. When the tissues that support the bladder neck are damaged, it may drop and push against the vaginal wall. A dropped bladder neck is called a cystourethrocele. It may cause urine to leak. Urine is more likely to leak when there is a sudden increase in abdominal pressure caused by walking, jumping, coughing, sneezing, laughing,lifting, or making sudden movements. The amount of urine lost may be only a few drops. In other cases, it may be enough to require changing clothes or wearing pads. You should tell your doctor if you cannot control the leakage of urine. Sometimes leakage is not caused by a cystourethrocele. It may be caused by a urinary tract infection, bladder problems, or other medical conditions.
An enterocele forms when the intestine bulges into the upper vagina. To diagnose an enterocele, a doctor may place a finger in your vagina and a finger in your rectum while you are standing.
When the rectum bulges into or out of the vagina, it is called a rectocele. It is caused by a weakness of the back wall of the vagina. A large rectocele may make it hard to have a bowel movement, especially if you have constipation. Some women must push the bulge back into the vagina to have a bowel movement.
When the uterus drops down into the vagina, it is called uterine prolapse. The distance the uterus drops may vary. Mild degrees of prolapse are common. It often does not cause symptoms and does not need surgery. Women with more severe forms of this condition often will have a feeling of pelvic pressure or a pulling feeling in the groin or lower back. The cervix (the opening of the uterus) may stick out from the vagina. This may cause discomfort or problems with sex. Uterine prolapse most often occurs when other pelvic organs are also out of place.
Sometimes after hysterectomy (removal of the uterus), the top of the vagina loses its support and drops. This is called vaginal prolapse. The degree of prolapse varies. The top of the vagina may drop part of the way into the vagina and remain there, or it may extend part or all of the way through the vaginal opening. Most women who have vaginal prolapse also have an enterocele. Women who have complete vaginal prolapse also may have problems with bladder and bowel function.
Proper diagnosis is key to treating pelvic support problems. Diagnosis is not always simple, though. The symptoms of pelvic support problems often mimic those of other conditions. In most cases, a woman with these symptoms will know that she has a problem, but the cause may be unclear. The exact cause of the problem must be found before the best treatment can be given. To make an exact diagnosis, your doctor will take your medical history and do a thorough pelvic exam. You may be examined while you are lying down and again while you are standing. Your bladder function also may be tested.
If you have a problem with either passing or controlling urine, other tests may be needed:
- Cystoscopy and urethroscopy – the inside of the bladder and urethra is viewed through a small, lighted telescope
- Cystometry – the amount the bladder can hold and control is measured
- Uroflowmetry – urine flow is measured between the opening of the vagina and the anus.
Treatment of pelvic support problems may involve special exercises or insertion of a special device called a pessary. These treatments may improve support. Your doctor may suggest a high-fiber diet or medications to soften the stool and make bowel movements easier. Keeping your weight under control, eating right, not smoking, and not doing activities that stress pelvic support muscles also can help. Hormones may be given to improve the quality of the tissues. Many women with pelvic support problems do not need further treatment. Some bladder control problems respond best to changes in voiding habits, diet, and medications. Others may be treated by surgery. No form of treatment, even surgery, is certain to solve the problem. The chances for getting some degree of relief, though, are quite good.
Estrogen is a hormone often prescribed to preserve or improve the quality of the pelvic tissues. It can be given as a pill, skin patch, or vaginal cream. Sometimes a combination of these methods is used.
Hormone Replacement Therapy (HRT) may be used after a women has gone through menopause. It eases her symptomes of menopause and protects her from heart disease and bone problems. If a woman still has a uterus, the hormone progesterone is given as well.
Hormone Replacement Therapy may improve the results of surgery or pelvic exercises. Women who are note taking HRT may be prescribed an estrogen cream to help relieve symptoms.
Exercises called Kegel exercises, or pelvic muscle exercises, are used to strengthen the muscles that surround the openings of the urethra, vagina, and rectum (see box). Do these exercises three or more times a day. In time, you may be better able to hold urine.
The doctor may suggest that you drink fruit juices to help reduce the risk of bladder infection. You also may need to cut down on caffeine, which acts as a diuretic. It is found in coffee, tea, and soft drinks. A high-fiber diet may be prescribed to help with bowel control and to prevent constipation.
Sometimes a medication that softens stools is prescribed along with a special diet to help control intestinal symptoms. A medication that puts bulk in the stool also may be given with a high-fiber diet. There are special medicines that help to control urination. These drugs suppress bladder contractions. Other drugs will help prevent leakage by increasing the pressure inside the urethra. If there is a urinary tract infection, antibiotics may be need-ed. Some of these drugs have some side effects.
Pelvic support problems may be corrected by surgery. The type of support problem you have will decide whether surgery is done through the vagina or abdomen. It is best to put off surgery for pelvic support problems until you have completed your family. This is because if you have uterine prolapse, your doctor may suggest that your uterus be removed as a part of the procedure. If the uterus is left in place, a later vaginal delivery may increase the chances that a cystocele or rectocele will recur. If you have severe pelvic support problems and wish to keep your uterus so that you might still have children, discuss this with your doctor.
If you decide to have surgery, you should be aware of the risks:
- The operation may fail to correct your symptoms, and more surgery may be needed later.
- Chronic pain, discomfort, or pain during sex may persist if they were present before the surgery.
- Surgery may not correct your urinary or bowel problems.
Your vagina may be smaller after surgery. It may not be shorter, though. It is not likely to be so small that you will not be able to have sex. Surgery may relieve some, but not all, of the symptoms caused by pelvic support problems. In a few cases, symptoms may return. The doctor has to use the already weakened fascias, ligaments, and muscles that are within your pelvis to improve your pelvic support. In some cases, synthetic materials that the body accepts well may be used to help correct the problems. If you have had prior surgery or radiation, there is a much lower success rate.
The factors that caused you to have prolapse in the first place can cause it to occur again. After surgery, you should control your weight, avoid constipation, not smoke, and avoid activities, such as heavy lifting, that put pressure on these muscles.
Sometimes surgery is too risky because of a woman’s general health. In such cases, a pessary may be inserted into the vagina to support the pelvic organs. When a pessary is used, it must be removed, cleaned, and reinserted on a regular basis. If it is not cleaned, it might cause a bad-smelling discharge and ulcers in the vagina. If used correctly, a pessary can last for years. There are many types of pessaries. Your doctor can fit you with the right one for you. Like finding a comfortable shoe, it may take a few trials to get a good fit.
Many women suffer from pelvic support problems. If you have any symptoms, talk to your doctor about them. The right diagnosis and treatment can offer relief from pelvic support problems.