Pelvic Relaxation and Prolapse
What is it and how common is it ?
When people think of the pelvis, they think of the bony cradle which attaches the spine to the legs. However, the pelvis is also a set of muscles which make a hammock like sling to hold the organs in place so they can work properly. These pelvic floor muscles can become stretched out or damaged leading to problems such as incontinence and discomfort.
The diagram at right is by Henry Gray, author of Gray's Anatomy. I refer not to the TV show, but to a real book that I used and that still sits in my bookshelf.
This diagram show a sagittal cross section of the female pelvis. You will note that the vagina is a "potential" space and has little diameter unless distended. If you are unsure about where the vagina is, look between the bladder and the rectum. The bladder is said to be anterior to the vagina and so that wall of the vagina is called the anterior wall. Conversely, the rectum is posterior to the vagina, and the vaginal wall between them is called the posterior wall of the vagina. The muscles in the cross section are in red.
Defects in the pelvic floor musculature can be isolated or multiple. For example., in an isolated anterior vagina wall defect, only the bladder would protrude down. Everything else, such as the uterus and rectum would still be in its place. Unfortunately, these defects often come in groups, and some make others worse.
For an excellent set of videos showing you exactly what happens in all the various forms of pelvic relaxation, click HERE. I wish I had these in medical school !
Causes of and risks factors for pelvic relaxation
vaginal deliveries, especially traumatic ones
aging
obesity
chronic cough, such as from smoking
chronic constipation
weak tissue from connective tissue disorder, lack of estrogen, or smoking
genetic factors
Symptoms of Pelvic Relaxation
Feeling of pelvic pressure, pulling or "something falling out", especially when active
Irritation of the surface of the prolapsed part
Urinary symptoms such as frequent urinary tract infections, frequency, urgency, or problems getting urine out even though you feel you have to go.
Bowel symptoms like having trouble getting stool out, or incontinence of gas or stool
Workup, or evaluation
History - to understand general health and risk factors for the condition, to understand what is going wrong
Physical - to see exactly which part of the pelvis is relaxed and how it behaves
Possibly urodynamics - to study the behavior of the bladder and urethra under different conditions
Possibly imaging such as Ultrasound to evaluate the pelvic organs
Treatments
Many women who have pelvic relaxation noted on exam do not have symptoms and do not need treatment. However among those that do need treatment, nonsurgical methods are explored before surgical ones.
Nonsurgical Treatment of Pelvic Relaxation
Pelvic floor physical therapy - such as Kegels, ideally with a specialist physical therapist who makes measurements
Pessary - a device to insert in the vagina in order to support the pelvic organs and correct the symptoms (See videos linked above on this page.)
Surgical Treatment of Pelvic Relaxation
The specific surgical therapy depends on the exact anatomic defect present and the symptoms that it produces. All of them require anesthesia, and some require an overnight stay. For more on general information on surgery, see our page Surgery FAQs.
1. Anterior repair, aka cystocoele repair - The anterior vagina is separated from the lower part of the bladder. Stitches or mesh are placed to lift the bladder back into its proper place. The now redundant stretched out vagina is trimmed and stitched back up. If the patient does have or seems likely to develop stress urinary incontinence, special stitches or meshes placed under the urethra (neck of the bladder) in such a way as to give more control.
2. Posterior repair, a.k.a. rectocoele repair - The posterior vagina is separated from the rectum. Stitches or mesh are placed to push the rectum back into its proper place. The now redundant stretched out vagina is trimmed and stitched back up. If the patient has a gaping vaginal opening (introitus), special stitches are placed to narrow and build it up for more support of everything else upstream.
3. Hysterectomy - This is done if the uterus itself is prolapsed, or is worsening prolapse of the bladder or rectum. Please see our page Hysterectomy for more information on hysterectomy.
4. Vaginal cuff suspension - This is done if the patient's vaginal cuff, meaning the top of the vagina itself, is coming down. This can happen if the patient has had a hysterectomy in the past, or it can be diagnosed at hysterectomy for uterine prolapse. Either way, the vaginal cuff needs to be supported. This can be done abdominally, through an open or laparoscopic procedure, or vaginally. A variety of techniques may be used, and they may or may not involve mesh. You should discuss the details of all this with your doctor.
Mesh has been in the news lately and as usual, the media and the lawyers are having a heyday. Get your facts from the source: the FDA, the Food and Drug Administration.
Diagnosis and treatment of pelvic floor disorders
can greatly contribute to women's quality of life. Please do not be afraid
to discuss your symptoms with your doctor.