What causes pelvic organ prolapse?
Pelvic organ prolapse, also called pelvic floor dysfunction, is a situation in which the bladder, rectum, intestine, uterus, cervix or vaginal stump (part of the vagina that remains in the case of removal of the uterus) “protrudes” outward through the vagina due to a decrease in the support of muscles, fascia (a kind of muscle “covers”) and ligaments of the pelvic floor.
There are many causes for such problems, but the main one is an increased intra-abdominal pressure, for example, during childbirth, if the patient is overweight, has a chronic cough (bronchial asthma, smoking) or if the patient is involved in weightlifting. In all these cases, the muscles of the abdomen are excessively strained, which, in turn, puts pressure on all the organs of the small pelvis and stretches the muscles and ligaments that support these organs.
The decrease in the level of estrogen - a female hormone, for example, after menopause – also plays an important role. This affects the decrease in the synthesis of collagen and elastin - fibers that also help maintain the pelvic organs in an anatomically correct position.
Plus, heavy, long and / or numerous births predispose to prolapses, stretching the walls of the vagina and injuring the pelvic floor.
When we talk about urinary incontinence, it is important to emphasize that stress-induced urinary incontinence develops due to a weakened pelvic floor — when, with a little physical exertion — coughing, sneezing, bouncing, laughing — situations in which the patient’s intra-abdominal pressure increases, which means that the patient’s intravesical pressure rises, urine is released (leaked). This is the only of three types of incontinence (stress, imperative and mixed), that is associated exclusively with a disorder of the normal anatomy of the pelvis.
In case of the imperative or the so-called overactive bladder syndrome, the problem is an acute, strong, uncontrolled need to urinate (including at night), because of which the patient does not have enough time to run to the toilet. With this type of incontinence, the root of the problem is not in a weakened pelvic floor, but in a self-willed contraction of the bladder, in the problems of its innervation. In the case of mixed incontinence, the problem is complex: it is caused by both innervation and the problems of anatomical structures.
What are the symptoms?
The most common complaint in case of a prolapse is the sensation of a foreign body in the vagina. Often, there are also pulling pains in the lower abdomen, and in the vaginal area, which can become more pronounced after taking longer walks. More specific symptoms are characteristic for the prolapse of specific organs. So, if the wall of the bladder drops (such a problem is called “cystocele”), urinary incontinence or, on the contrary, the inability to urinate without taking the additional actions of “tucking” the prolapse back, are characteristic. The same thing happens in the case of rectal prolapse ("rectocele") - a feeling of constant urge to go to the toilet, gas and stool incontinence, constipation.
There also can be situations when there are no symptoms at all – the patient notices the prolapse visually and decides to consult with the doctor.
How to diagnose this problem?
There are no problems with the diagnosis of prolapse – it is done during a routine gynecological examination. It is important to determine the degree of prolapse by a special classification system so that each patient can be individually treated.
The first stage is a situation in which the lowest point of descent does not reach 1 cm to the vaginal vestibule, and it can be noticeable only if the patient is clenching. The second, when the prolapse has nearly reached the vagina or goes beyond it 1-1.5 cm - in this case, the patient herself can visually see it. Third, when the prolapse goes even lower and the fourth - when there is a complete prolapse in the entire length of the vagina.
If the patient has urinary incontinence, before planning treatment, she should undergo an urodynamic examination - this is done by a urologist, and by examining the way the bladder empties, the specialist can conduct a differential diagnosis between stress incontinence associated with decreased pelvic floor tonus, neurological, requiring exclusively drug treatment, and mixed when the problem must be approached from different angles.
Bladder ultrasonography and defecography are also done to assess the condition of the rectum and bladder.
How to treat this problem?
The main treatment for pelvic organ prolapse is surgical. Today, laparoscopic sacrocolpopexy is considered the “gold standard”: an operation in which an anesthetized patient has 3-4 small incisions in the abdomen (no more than a centimeter in diameter) through which the camera and instruments are inserted into the abdominal cavity. After such an operation, the patient remains in the hospital for 2-3 days.
During surgery, a special mesh-prosthesis is installed around the vagina, strengthening its walls and restoring the anatomical location of the vagina.
The second option is surgery through the vagina, when the mesh is installed separately on the front and rear walls. This method is often used for older women, who for various reasons may be contraindicated to laparoscopy. But in “vaginal” mesh, complications after surgery such as pain (especially during sexual contact) are observed more often, therefore, indications for this type of operation are narrower.
It should be noted that after installing the prosthetic mesh in one way or another, vaginal birth is impossible.
Speaking about the surgical treatment of stress urinary incontinence – based on the same principle as in the case of prolapse, synthetic material is used - a small tape that plays the role of a supporting hammock. This tape is placed under the urethra, restoring the correct anatomy. Usually, on the very day of the operation, the patient can go to the toilet, and the next day she can already go home.
Since this is a reconstructive operation, there are some peculiarities of the postoperative period, for example, the patient should refrain from physical activity (playing sports, sex life). But the effectiveness of the operation lasts for many years.
If the operation is contraindicated, as an alternative method of treatment for both incontinence and prolapse, vaginal pessaries - a sort of silicone ring individually selected for the shape and size of each patient – can be used. It is inserted into the vagina, mechanically providing the "correct" location of the pelvic organs.
Also, for stress urinary incontinence, vaginal injections of hyaluronic acid can help. The result after injections is achieved due to the effect of volume, filling the tissues near the urethra. True, the effect persists for about 12-18 months, after which the injection must be repeated.
How to prevent these problems?
Concerning pelvic floor dysfunction and stress urinary incontinence, a prerequisite is the prevention of problems in the risk group (women of a mature age and after childbirth). In both cases, such prevention is physiotherapy.
The most common pelvic physiotherapy method is Kegel exercises. By themselves, they are simple, but require a certain learning process, therefore, in order to learn how to "correctly" perform these exercises, the patient should definitely consult a physiotherapist.
There is also a biofeedback therapy, in which a special device, that is inserted into the vagina, captures muscle contractions by displaying them on the screen - in this way the patient learns to “correctly” isolate the necessary muscles, increasing the general tone of the pelvic floor muscles. This procedure is also conducted with a physiotherapist.
Classical physiotherapy can be combined with innovative methods: for example, there is a high-frequency magnetic therapy device - a special chair that strengthens the muscles of the pelvic floor. This is a painless procedure in which a clothed patient sits on the device for 28 minutes, during which, under the influence of a focused magnetic wave, the contraction and relaxation of the pelvic muscles are stimulated.
Physiotherapy, as well as a treatment procedure should be carried out after a consultation with a specialist and is preventive and additional to the main treatment method, which can help in the initial stages.
But, if the problem progresses and the complaints become more pronounced, then physiotherapy, alas, will not be able to help. In this case, it is imperative to contact a specialist for a more serious treatment method!
