Pelvic Floor Disorder

A common urologic complaint is pelvic organ prolapse, a condition in which organs such as the bladder, rectum, uterus, and/or small intestines collapse into the vagina. This phenomenon occurs especially after vaginal childbirth, due to the acquired failed support of the vaginal walls. Other risk factors for vaginal prolapse include aging, menopause, and obesity.

Generalized symptoms of prolapse include a sense of vaginal fullness or bulging. Specific symptoms of a cystocele (bladder prolapse) include hesitancy of urination with a weakened urinary stream, urgency and frequency of urination, and sometimes even true difficulty emptying the bladder. Rectocele (rectum prolapsing into the vagina) symptoms often involve difficulty with emptying the rectum, to the point where a women will have to manually facilitate the evacuation of a bowel movement by pressing on the vaginal wall or the saddle area (perineum). Also, a rectocele may cause a woman to have difficulty with sensation during intercourse, due to the vagina being lax.

When a woman has pelvic organ prolapse, she often has associated stress incontinence, which is leakage urine with coughing, sneezing, laughing, and exercise. While prolapse itself does not cause stress incontinence, these disorders are often surgically fixed together.

The initial diagnosis vaginal prolapse is simple in that it involves a vaginal exam. When we perform a pelvic exam, we assess the severity of the prolapse using a scale from 0 to 4, with 0 being no prolapse and 4 being the most severe (the prolapse escapes the opening of the vagina). Many times, we perform certain tests, such as cystoscopy (looking into the bladder with a small telescope) to determine the internal anatomy of the bladder. We also study the function of the bladder with a test called a urodynamics or cystometrogram, so we can learn how the bladder empties, the force of the urine stream, and the internal pressure of the bladder. These tests help us tremendously in not only deciding which operations to offer a patient as well as which techniques to use during surgery.

A woman has several options for the treatment of vaginal prolapse. The initial treatment usually involves Kegel exercises to improve the strength of the pelvic floor that supports the vaginal walls. The muscles being exercised are the same type as a bicep. Just like a bicep, they can become stronger and firmer with repeated physical work. There even exist physical therapy locations to assist a woman in these sorts of exercises (pelvic floor physical therapy). As with any exercise, a woman may not realize improvement for approximately 2-3 months.

Alternatively, a woman may choose to have her gynecologist place a pessary, a ring or cubic structure inserted into the vagina to support the collapsing vaginal walls. These pessaries must be removed for cleaning and reinsertion at the gynecologist’s office every 6 weeks to 3 months. Advantages of a pessary include immediate relief of vaginal “bulging” and the possible ability to avoid or post pone surgery. However, pessaries might “fall out,” especially if a woman no longer has her uterus, or become bothersome for a woman still trying to remain sexually active. Other pessary disadvantages include irritation, pain, chafing, discharge, and even vaginal ulcers or infections.

For someone who has failed conservative therapy, we offer surgery. Our practice has performed thousands of operations for these particular problems. Typically, surgery entails entirely vaginal incisions to repair the vaginal walls. Through these incisions, we often reinforce the vaginal walls with either biological implants, which eventually dissolve and are replaced with a woman’s own scar tissue, or with simple suturing techniques. We then remove redundant, sagging vaginal tissues. We avoid the use of mesh for these vaginal repairs. However, very often we surgically treat stress incontinence in the same setting, and we typically use a very short, thin strap of polypropylene mesh through a small incision underneath the urethra to bolster the urethral support. This way, in addition to having her prolapse treated, a woman can avoid leaking urine with stressors.

These vaginal repair operations last approximately one hour, and the patient usually goes home the same day with a catheter to stay in place from 1-4 days. To avoid healing problems and prolapse recurrence, a woman must avoid strenuous activity, heavy lifting, and sexual activity for 6 weeks from the date of operation. Surgical complications are not common but include bleeding, infection, organ injury, chronic pain, and recurrence. However, in our experience, the long term success and satisfaction rates following vaginal surgery are quite high, on the order of 90%.