Specialised Care For:

Pelvic Floor Dysfunction and Prolapse

What is the pelvic floor?

The pelvic floor is the hammock of muscles which spans the pelvis from front to back and is responsible for supporting all the pelvic organs and controlling the openings.

How does it work and what causes it to weaken?

The muscles are usually firm and slightly tense to prevent leakage from the bladder and bowel and to maintain the normal position of the organs and thus prevent a prolapse.

When you empty your bladder or bowels the muscles relax and then tighten again to restore control. The muscles can get weaker gradually, possibly over several years.

Childbirth, chronic constipation, being overweight are all factors which can weaken muscles, and once this happens they cannot perform their functions of support and control as efficiently as before and this is when the problems usually become obvious.

Other factors affecting the pelvic floor muscles include aging, the menopause and reduction of oestrogen, being a smoker or having a chronic cough. An occupation that involves repeated lifting can also lead to a greater risk of pelvic floor dysfunction.

What is prolapse?

When the pelvic floor weakens, it causes the supports of the various parts of the vagina and sometimes the uterus to loosen. This results in these structures 'dropping' so that they can be felt outside the body, or cause problems with passing urine or stools without being replaced. This is commonly called prolapse.

Sometimes, the vaginal opening can be larger especially when a lady has had many vaginal deliveries.

How is a prolapse diagnosed?

Prolapse is diagnosed by a trained consultant or nurse when doing a pelvic examination.

What problems can it cause?

• Feeling of something coming out of the vagina
• Difficulty with passing urine or stools
• Soreness and vaginal discharge with or without an infection
• Backache and pelvic pain
• Kidney pains in severe conditions with repeated urinary and kidney infections
• Urinary leakage and recurrent cystitis
• Difficulty with sexual intercourse

When do I need to see a doctor about prolapse?

• If the prolapse is getting worse, or if there is any difficulty with passing urine or stools, you need to seek treatment as soon as possible
• If you get repeated urinary tract infections and you know you have a prolapse you should seek treatment
• If you feel your relationship with your partner is suffering as a result of your prolapse or urinary incontinence

Conservative treatment

Physiotherapy - pelvic floor exercises can be very useful in those women with mild degrees of prolapse and/or stress incontinence. Perseverance and professional help with these exercises is important.

Surgery

If conservative measures fail to improve the situation, the options of surgery may be discussed with a gynaecologist. The following operations are available:

Anterior Repair (colporrhaphy) - tightens up the front walls of the vagina - this procedure is used to treat prolapse of the bladder (cystocele), urethra (urethrocele) or both the bladder and urethra (cystourethrocele).

Repair with mesh - If you've had recurrent prolapse and this is not your first repair operation, mesh (synthetic or animal-based) may be used to help support the vaginal wall and keep the prolapsed organ(s) in place. This may provide better long-term support, but may also cause additional complications such as inflammation or erosion of surrounding tissues and an increased risk of painful sex.

Posterior repair or posterior colporrhaphy - tightens up the back wall of the vagina - posterior repair is used to treat prolapse of the rectum (rectocele) and small bowel (enterocele). Mesh may be used.

Treating Uterine Prolapse - there are two surgical approaches to treating a uterine prolapse: removing the uterus altogether (hysterectomy) or lifting it and holding it in place (suspension).

Suspending the Uterus - treatments that suspend rather than remove the uterus are recommended for women who want to keep their uterus or have children in the future. Procedures can be done either vaginally or abdominally, and there is some evidence to suggest that abdominal repairs tend to have better long-term results. The options are between sacrocolpopexy (using special mesh) and sacrospinous fixation. Key hole surgery (laparoscopy) is usually used.

Seeking help

Many women delay seeking help for this condition due to embarrassment. For further advice please speak to your family doctor.

For more information please contact Mr Arunkalaivanan, our consultant gynaecologist, at Birmingham & Solihull Bladder Clinic.