Pelvic Floor Disorders
Pelvic floor (pelvic support) disorders involve a dropping down (prolapse) of the bladder, rectum, or uterus caused by weakness of or injury to the ligaments, connective tissue, and muscles of the pelvis.
Pelvic floor disorders occur only in women and become more common with 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, bladder, and rectum. If the muscles become weak or the ligaments or tissues are stretched or damaged, the pelvic organs may drop down and protrude into the wall of the vagina. If the disorder is severe, tissues may protrude all the way through 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 may increase with each delivery. The delivery itself may damage nerves, leading to muscle weakness. Delivery by cesarean section may reduce the risk of developing a pelvic floor disorder.
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 a hysterectomy, nerve disorders, injuries, and tumors. Some women 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 tissue protrudes abnormally because another 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.
 See the figure When the Bottom Falls Out: Prolapse in the Pelvis.
Symptoms tend to occur when the woman is upright and to disappear when she is lying down. For some women, sexual intercourse is painful. Mild cases may not cause symptoms until a woman is older.
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 to have a bowel movement.
An enterocele develops when the small intestine and the lining of the abdominal cavity (peritoneum) bulge downward between the uterus and the rectum or, if the uterus has been removed, between the bladder and the rectum. It results from weakening of the connective tissue and ligaments supporting the uterus. An enterocele often causes no symptoms. But some women have a sense of fullness or feel pressure or pain in the pelvis. Pain may also be felt in the lower back.
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. Either of these disorders may cause 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 passage of urine).
In prolapse of the uterus (procidentia), 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, causing total uterine prolapse. Prolapse of the uterus may cause pain in the lower back or over the tailbone, although many women have no symptoms. Total uterine prolapse, which is obvious, 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.
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 performing a pelvic examination, using 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 to determine how severe a rectocele is.
A woman may be asked to bear down (as when having a bowel movement) or to cough while standing. She may be examined while standing. The resulting pressure in the pelvis may make a pelvic floor disorder more obvious.
Procedures to determine how well the bladder and rectum are functioning, such as urine tests, may be performed. These procedures help doctors determine whether drugs or surgery is the best treatment. 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). Also, the amount of urine that the bladder can hold without leakage and the rate of urine flow may be measured. Doctors may determine whether prolapse of the uterus may be preventing urinary incontinence.
Treatment
If prolapse is mild, performing 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 10 seconds, then relaxed for about 10 seconds. The exercise is repeated 10 to 20 times in a row. Performing the exercises several times a day is recommended. Women can do Kegel exercises when sitting, standing, or lying down.
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. Women who have this problem can use a vaginal deodorizer to mask the odor. As long as no other problems occur, these women may continue to use the pessary, removing it for cleaning each month. These women should also see their doctor every 6 to 12 months.
Estrogen vaginal suppositories or cream may be used. These preparations can help keep vaginal tissues healthy and can prevent sores from forming.
Surgery is often needed but is usually performed only after a woman has decided not to have any more children. 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 to drain the urine for 1 to 2 days. If urinary incontinence is a problem or would occur after prolapse of the uterus is repaired, surgery to correct incontinence can usually be performed at the same time. In such cases, the catheter may be left in place longer. Heavy lifting, straining, and standing for a long time should be avoided for at least 3 months after surgery.
If prolapse of the rectum makes having a bowel movement difficult, surgery may be necessary.
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