Pelvic floor disorder (also known as pelvic floor prolapse) occurs when a pelvic organ drops (prolapses) from its usual place in the lower belly and pushes against the walls of the vagina. This happens when the muscles that hold the organs in place become weaker or are stretched from childbirth or surgery. Patients will contract these muscles rather than relax them, which has an impact on the ability to pass stools. Organs that can be affected are the uterus, vagina, bowel and bladder.
In many cases, there are no symptoms. However, the symptom that is most commonly reported, and gives patients considerable discomfort, is pressing of the uterus or other organs against the vaginal wall. Other symptoms may include:
- the feeling of needing to pass stools frequently;
- the feeling of being unable to pass stools efficiently;
- constipation or straining pain during bowel movements;
- frequent need to urinate and impaired ability to pass urine;
- pain when urinating;
- pain in the lower back;
- persistent pain in the pelvic and genital areas;
- and pain during intercourse.
Symptoms can be worse when the patient is standing, jumping, and lifting. The symptoms can be relieved when the patient is lying down.
Pelvic organ disorder is caused by damage to the tissues that support the pelvic organs, which allows the organs to move out of their normal positions. This causes them to press against or move the inside walls of the vagina.
Childbirth is a main cause of pelvic floor disorders. The risk is increased for women every time they go through childbirth. This is because it weakens and stretches the support structures in the pelvic area. Women who have a caesarean section, however, are at less risk of pelvic organ prolapse.
Significantly low levels of the hormone oestrogen is another cause of pelvic floor disorder. Women experience low oestrogen levels during and after the menopause. This leads to the body producing less collagen, a protein that helps the pelvic connective tissues stretch and revert to their usual positions.
Another cause is if the patient has had surgery to remove the uterus (hysterectomy) when treating other health problems. Such surgery can weaken support for other pelvic organs.
Other, less common causes, include: obesity, leading to long-term pressure within the abdomen; chronic coughing as a result of smoking or lung conditions; and conditions related to the spinal cord, that can lead to paralysis of the muscles of the pelvic floor.
The patient will meet with their doctor to discuss their symptoms and medical history. A physical examination will then by conducted, and close attention will be focused on the patient’s ability to control their muscles around the pelvic area. The doctor may also apply self-adhesive pads or use a small device called a perineometer to assess the patient’s muscle control.
The doctor may consider conducting a test called a defecating proctogram, during which the patient will be given an enema of a thick liquid that can be detected with an X-ray. The doctor will use a special video X-ray to record the movement of the muscles as the patient tries to push the liquid through the rectum. There is also a uroflow test which can be conducted to assess the patient’s ability to pass urine.
Pelvic floor disorders tends to run in families. It is a common condition, with around half of women who have had a child experiencing some form of prolapse, but the majority will not need medical attention. Women who have not undergone childbirth are still at risk of developing pelvic floor disorder, especially if they cough, strain on the toilet, or lift heavy loads. The risk also increases with age. Around half of women over 50 will have some symptoms of pelvic organ prolapse and by the age of 80 more than one in ten will have had surgery for prolapse.
There are a number of different treatment options available for a pelvic organ prolapse, depending on the severity of the symptoms, the patient’s age and overall health, and whether the patient is planning to have children. If the disorder is mild, patients are likely not to need any form of treatment.
For more mild forms of prolapse, the patient may be referred for a course of treatment with a physiotherapist who specialises in prolapse. Vaginal hormone treatment (oestrogen), in the form of tablets or cream, may also be prescribed by the doctor.
One of the widely used treatments is a pessary, which is a plastic device that is fitted into the vagina to help support the pelvic organs and hold up the uterus. This is a non-surgical option and is used by patients who are thinking about having children in the future or are not able to undergo surgery due to an underlying health condition. There are different types and sizes of pessaries, but the most common is a ring pessary.
The other option is surgery, primarily used for the more severe cases. A pelvic floor repair might be undertaken, which involves tightening the walls of the vagina to support the pelvic organs. This may be done through incisions in the vagina, and involves being under general anaesthetic. There are also new operations in which mesh is sewn into the vaginal walls.
For patients who experience complete prolapse of the uterus (womb), the doctor may suggest removing the uterus, an operation known as a hysterectomy. This can provide better support to the whole of the vagina and reduce any chance of a prolapse returning. However, this procedure will only be considered if the woman wishes does not wish to have any more children, as she will not be able to get pregnant afterwards.
The aim of surgery is to relieve the patient’s symptoms whilst also ensuring the bladder and bowels work normally following the operation. If the patient has a hysterectomy, they will see significant improvement in the support of the vagina and reduced chance of prolapse. The non-surgical treatments are safer and reduce complications that may arise as a result of surgery.
Pessaries do not tend to cause any problems but there is a possibility of some inflammation and unexpected bleeding. There are of course risks to surgery, albeit rare, and the patient will be advised against undergoing surgery if they are not healthy enough.
Whilst the majority of women treated with mesh respond well to the treatment, the risks and benefits of a mesh implant remain unclear. Patients have reported complications, including persistent pain, sexual issues, mesh exposure through vaginal tissues and occasionally injury to organs, such as the bladder or bowel.
Not all patients require treatment and may simply be encouraged to make a change of lifestyle in order to ease their symptoms or prevent further complications from occurring.
Lifestyle changes can include: losing weight and avoiding obesity; avoiding constipation; managing a chronic cough if the patient has one; quitting smoking; avoiding heavy lifting; and avoiding physical activity like trampolining or high-impact exercise.
Patients will also be encouraged to do regular pelvic floor exercises in order to strengthen the pelvic floor muscles.