Pelvic Support Disorders

Pelvic support disorders occur when weakened support allows the bladder, rectum, intestines, or uterus to drop down (prolapse) and, in some cases, protrude into the vaginal wall or even protrude through the opening of the vagina.

Causes

Pelvic support disorders occur because the muscles, connective tissue, and ligaments that keep the organs in place weaken over time. Lack of estrogen, damage to the pelvic muscles and nerves from childbearing and prolonged labor, chronic constipation, heavy lifting, and frequent coughing and sneezing can also cause pelvic support disorders. Obesity may be a factor as well.

Symptoms

Symptoms generally include a sense of pelvic or vaginal heaviness or pressure, a feeling of something bulging or protruding into or through the vagina, and discomfort when walking. Symptoms tend to subside when lying down and worsen when standing.

Other symptoms depend on which tissues are affected and which pelvic organ has lost its support. Weakened support that allows the bladder to drop and protrude into the wall of the vagina (cystocele) may cause pelvic pressure, difficulty starting urination, incomplete bladder emptying, uncontrollable loss of urine (urinary incontinence), and recurring urinary infections. Weakened support that allows the rectum to drop and sometimes protrude into the wall of the vagina (rectocele) may cause constipation and a sense of incomplete emptying during bowel movements. Relaxation of the small intestine that allows the small intestine to drop behind the wall of the vagina (enterocele) causes a feeling of fullness and low back pain. Uterine relaxation that allows the uterus to drop and protrude into the vagina (uterine prolapse) may cause low back pain. In general, multiple symptoms may occur when two or more organs (the bladder, rectum, small intestine, and uterus) drop down at the same time.

See the figure When the Bottom Falls Out: Prolapse of the Pelvic Organs.

The most severe of the pelvic support disorders occurs when the uterus and vagina both drop down and protrude completely through the vaginal opening (procidentia). Symptoms may include a combination of all of the above sensations along with bleeding due to breakdown and development of ulcers in the lining of the exposed vagina and cervix.

Diagnosis and Treatment

Pelvic support disorders are detected during a physical examination, which the doctor may perform with the woman lying or standing. Urine tests, including insertion of a catheter to measure how much urine is left in the bladder, may be useful when a woman has symptoms of bladder relaxation.

Treatment depends on the severity of the disorder. Pelvic relaxation that causes no or only minimal symptoms requires only avoidance of activities that could worsen the disorder—such as heavy lifting and straining during bowel movements—and exercises to strengthen the pelvic muscles (Kegel exercises).

Pelvic relaxation that causes more severe symptoms or that results in prolapse of the uterus and vagina outside the body can be treated in one of two ways: with a pessary or with surgery. A pessary is a latex or silicone support device—often in the shape of a ring, disk, or doughnut—that is inserted into the vagina to support the pelvic structures and relieve symptoms. It is safest when used with estrogen cream to protect the walls of the vagina. Ideally, a woman removes the pessary 1 or 2 nights per week and reinserts it in the morning. For those people who cannot themselves remove or insert the pessary, it should be removed and cleaned after being worn for 4 to 6 weeks. Pessaries are most appropriate when there are reasons to avoid surgery.

Surgery is extremely effective for all pelvic support disorders and in some cases can be performed without general anesthesia. In older women who no longer desire sexual activity, surgery that results in complete closure of the vagina is safe, causes few side effects, and is extremely effective for every form of pelvic support disorder. In sexually active women, reconstructive surgery involves replacement of the pelvic organs into their original positions. The goal of this surgery is to restore normal bladder, bowel, and sexual function. The surgery can be performed either through the vagina or through the abdomen, depending on the type and severity of the problem. Because repositioning the bladder can lead to urinary incontinence, bladder testing may be needed before surgery. This testing, called urodynamics, involves inserting a thin tube (catheter) into the bladder to evaluate the function of the bladder while it is filled and then emptied, during urination, during coughing, and with other maneuvers. In addition, a procedure to prevent incontinence may be needed during surgery.