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Jan 2008
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Obstetrics and Gynecology
Pelvic Support Problems of Women
Symptoms of pelvic support problems include feelings of pelvic heaviness or fullness, pulling, or an aching feeling in the lower abdomen. Leakage of urine or problems having a bowel movement can be a sign of pelvic support problems.
The main cause of pelvic support problems are associated with age, pregnancy and childbirth, genetics and prior surgery. A woman may have a genetic predisposition to weak endopelvic fascia, the connective tissue underlying the vagina. A woman who has had a hysterectomy may have increased pelvic support problems.
The pelvic organs are held in place by 3 types of support: fascia, ligaments, and a paired group of muscles that lie on either side and around the openings of the urethra, vagina, and rectum. The parts of the body affected by pelvic support problems include the urethra and bladder, small intestine, the rectum, the uterus and the vagina. When the tissues that support the pelvic organs are stretched and damaged, the organs that they support may drop down or press against the wall of the vagina. This causes a bulge and occasionally the organ will drop down or out through the vaginal opening.
Types of pelvic support problems include cystocele, enterocele, vaginal vault prolapse, rectocele, and uterine prolapse.
A cystocele is a downward displacement of the bladder. Some cystoceles cause urine to leak when a woman coughs, laughs, sneezes, or lifts objects. Large cystoceles can create a kink in the urethra and may cause problems with the passing of urine. Small cystoceles are common. Large cystoceles may need surgical repair if they contribute to urinary incontinence.
An enterocele occurs at the apex of the vagina, and is a true hernia of the small intestine into the vaginal lumen. Sometimes after hysterectomy (removal of the uterus) the top of the vagina loses its support and drops. This is called a vaginal vault prolapse. The top of the vagina may drop part of the way into the vagina or may extend all the way through the vaginal opening. Women who have complete vaginal prolapse may have problems with bladder and bowel function. Most of the women who have vaginal vault prolapse also have an enterocele. An enterocele forms when the small intestine drops through the supporting tissue and bulges into the vagina.
A rectocele is a protrusion of the rectum into the posterior vaginal lumen. It is sometimes called a posterior wall prolapse. It is caused by weakness of the fascia and the posterior wall of the vagina. A large rectocele may make it difficult to have a bowel movement, especially if one is constipated. Often a women will have a feeling of pelvic pressure or a pulling feeling in the vagina or lower back.
When the uterus drops into the vagina it is called uterine prolapse. The cervix or uterus extending out from the vagina may cause discomfort or problems with sexual intercourse. Uterine prolapse most often occurs when other pelvic organs are out of place.
The diagnosis of pelvic support problems is not always simple. A thorough medical history and physical exam is performed. A pelvic exam is often performed with the patient lying down, sitting, and standing. A rectal exam is performed. Often patients are asked to cough or strain during the exam.
Treatment includes Kegel exercises, changes in diet, and weight control. Kegel exercises are pelvic muscle exercises used to strengthen the muscles that surround the openings of the urethra, vagina, and rectum.
Tobacco cessation, and the avoidance of heavy lifting and straining are helpful.
There are medications to help treat urinary and bowel systems. Often a stool softener is prescribed, and dietary changes are made to help control constipation. A high fiber diet may be helpful. Estrogen vaginal cream applied to the vagina can strengthen the vaginal tissues.
Pelvic support problems may be corrected by surgery. Surgery can be performed through the vagina or the abdomen based on the type of support problems. If the woman has uterine prolapse her physician may suggest that the uterus be removed as part of the procedure. Surgery may relieve some but not all of the patient's symptoms. Recently, synthetic materials have been used in surgery to help correct pelvic support problems, strengthen weakened fascia, ligaments, and muscles within the pelvis. It is important to control weight, avoid constipation, discontinue smoking and avoid such activities such as heavy lifting or straining after surgery.
New procedures and technology have increased the success rate for repair of pelvic support problems, although failures do occur due to weakened support structures, medical conditions, and surgical technique. Should you have symptoms of pelvic support problems, speak with your physician since the right diagnosis and treatment is needed for relief.
(Dr. Richard Rafael, M.D., is a Diplomate of the American Board of Obstetrics and Gynecology. His office is located at 770 Mill Street, Reno, NV, 89502. He can be reached at (775) 323-4545, fax: (775) 323- 4869.)