Female Urology, Prolapse and Voiding Dysfunction

Pelvic organ prolapse is a very common condition – approximately 50% of women who have had even one childbirth will lose pelvic floor strength and about approximately 10 to 38% of these women, between 15 to 60 years of age will experience symptomatic prolapse. The incidence increases with advancing age. Every year close to 350,000 women undergo surgical interventions for the disorder. This places a severe social and economic burden on the society.  The lifetime risk for a woman to undergo surgery for a pelvic disorder is approximately 11%. Frequency of surgery will increase as women are living longer and the lifetime risk is projected to double for women between the ages of 30 and 89.

Pelvic organ prolapsed is defined as the abnormal decent or herniation of the female pelvic organs down into, or out of the vaginal opening.  The combination of weak pelvic muscles and ligaments and high abdominal pressure from exercise, coughing, sneezing, laughing, or having a bowel movement can force these organs into the vaginal canal giving the woman a sense of heaviness or pressure in the pelvis or vagina.

Which organs can prolapse and what are the common symptoms besides pressure that can occur?

Cystocele: Also known as Anterior Vaginal Prolapse, it is the abnormal descent of the bladder

Rectocele: Also known as Posterior Vaginal Prolapse, it is the abnormal descent of the rectum

Enterocele: Herniation of the small intestines into the vagina

Vaginal Vault Prolapse: The vaginal apex or cuff (after hysterectomy) descends into the vagina

Procidentia: The uterus and cervix descend into the vagina

In addition to pelvic or vaginal pressure which can also be experienced as pain, women can also experience lower back pain, difficulty with emptying the bladder, urgency, frequency of urination, incontinence of urine, constipation, pressure during bowel movement, and pain and leakage with intercourse. If mild or moderate, the prolapsed may still reside inside the vagina, yet if severe, can be seen at the vaginal opening or come out the opening altogether. Often, women will attempt to push the prolapsed back in order to aid in urination or bowel movements if they see or feel a lump.  Women may also experience as sense of looseness or lack of sensation with sex. Pain with penetration or on contact with the prolapse may occur. Vaginal bleeding can occur in neglected cases. Embarrassment from the condition leads to under-reporting – only 20% of the affected women actually seek medical assistance. Urinary leak and odor heightens the degree of embarrassment as well and is a reason for avoidance of social or sexual contact.

The most common causes of prolapse are those conditions that lead to weakness in the pelvic floor. They are: childbirth (even just one baby), prolonged labor, pregnancy itself, increasing number of vaginal births and large baby sizes, aging, post-menopausal status, malnutrition, hysterectomy, chronic cough, repetitive straining exercises, white race, obesity and family history. A full physical exam and medical and surgical history can determine which prolapsed is present. Women are examined both on the exam table and while standing, to determine the extent of the prolapse.

Many treatment options exist for prolapsed, and general are divided into three categories: No treatment, Conservative treatments, Surgical treatments. No treatment is certainly appropriate if the prolapse is mild and not causing symptoms, or in those too frail or unwilling to undergo surgery if severe. Conservative treatment is usually reserved for those who have mild but symptomatic prolapse, those who wish to have more children, and those who decline or are unable to have surgery. The aim of conservative treatment is to strengthen the pelvic floor muscles, prevent the prolapse from becoming worse, help to decrease the frequency and severity of symptoms, and to avert or delay surgery. Pelvic floor exercises, the use of a pessary, fluid and bowel manipulation to avoid incontinence and constipation, avoiding prolonged standing and straining are very commonly employed techniques.

Pessaries are vaginal inserts, usually shapes as a ring or cube that occupy space in the vagina and can support a prolapse. Pessary selection is based on the prolapse present, the severity of prolapse, and the pessary must be properly sized for the woman’s anatomy. Besides pelvic floor exercises, they are the most common non-surgical treatments. However, they must be routinely removed and cleaned, and require good follow up in order to prevent discharge, bleeding and vaginal skin irritation.

Estrogen supplementation does not improve pelvic floor prolapse or stress incontinence, but if applied topically, it can alleviate vaginal dryness, decrease vaginal irritation and lubrication for intercourse.

The objective of surgery is to permanently reduce the prolapse, restore normal vaginal anatomy, treatment the bladder and bowel symptoms from prolapse and improve discomfort and sexual intercourse. All prolapse and stress incontinence should be corrected at the same time. Many different techniques and types of surgery are available. The choice of which surgery to perform and which route is used is based on the patient’s prolapse, history of prior surgeries, the patient’s health, and surgeon experience.

Traditional restorative surgery using the patient’s own tissue is commonly used but subject to a relatively high failure rate, especially when correcting a cystocele. 30-40% of procedures fail within three years, and of the failures, 60% occur at the same site. The use of grafts, whether synthetic mesh or biological, has become popular in order to reinforce the repair to minimize recurrence. Lower recurrence rates are seen with grafts, but the grafts must be accepted by the patient’s tissue and are subject to erosion. Proper patient selection and surgeon experience is required for graft use.

If severe prolapse is present in frail, elderly women that are not sexually active, the vagina can be closed. Known as colpocleisis, it is safe, effective, does not require graft use, and relieves the symptoms of prolapse.

Women with concomitant stress incontinence can have it surgically treated at the same time as prolapse surgery. Highly effective in nearly 90% of women, minimally invasive slings are placed under the urethra to correct stress incontinence. Sling surgery can of course be done on its own if it is the only pelvic floor problem that exists. Careful pre-operative assessment of symptoms and testing with urodynamics helps to guide sling selection based on over bladder function and severity of leakage.

Matthew E. Karlovsky, M.D.
Center for Urological Services, P.C.
4545 E. Chandler Blvd, Suite 300
Phoenix (Ahwatukee), AZ 85048
480-961-2325 fax
Blog: www.femaleurologyaz.blogspot.com