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Blader and Prolapse Concerns

On this page we will answer the following questions you might have about bladder issues and pelvic relaxation:

Why do I always have to run to the bathroom?

Is it normal to get up at night to go to the bathroom?

Why do I lose urine when I cough or sneeze?

Why do I keep getting bladder infections?

What are those tests the doctor wants me to do?

How can I tell if I have interstitial cystitis?

What is that bulge down there?

How did this happen?

What symptoms will I have from pelvic relaxation?

I lose my urine. Is that because of my dropped bladder?

Is this condition dangerous?

What can I do to keep this from getting worse?

How are prolapse disorders corrected?

I hear that surgery doesn't always work. Why?

Why do I always have to run to the bathroom?

It seems as if you’re always running to the bathroom. You know where all the bathrooms are located, even the disgusting one behind the butcher counter in the supermarket. Your children have started to kid you about it. If this sounds familiar, you may have an unstable bladder. This condition is also referred to as an irritable bladder, spastic bladder, and, if you want to sound fancy, detrusor instability. An unstable bladder wants to contract before you are ready to void. It causes an increase in the frequency of voiding as well as a sense of urgency (get to the bathroom quickly). When severe, it is associated with urgency incontinence. You start to lose urine before you can make it to the bathroom. The unwanted bladder contractions may occur spontaneously or be triggered by a specific event (ex. the sound of running water). The uninhibited contractions may be secondary to conditions that cause inflammation or irritation to the bladder (infection, stones, estrogen deficiency). They can also result from diseases that affect the nervous system (stroke, dementia, Parkinson’s disease, multiple sclerosis, spinal cord injury). Most often there is no identifiable source for the unstable bladder.

If you have urgency incontinence, you should see a gynecologist, urologist, or gynecologic urologist (How fancy can you get?). Some conditions that cause incontinence can only be diagnosed with specific testing. The doctor will probably perform a cystoscopy and cystometrogram. These are described below. He will also obtain urine for analysis. These studies can rule out underlying conditions that may be inducing the unwanted bladder contractions.

OK, you’ve been evaluated and there is no obvious cause for the unstable bladder. Now what do you do? Start by eliminating caffeine (coffee, tea, chocolate, colas), alcohol, hot spices, acidic foods (citrus and tomato products, or use Prelief with them), and artificial sweeteners from your diet. Alternatively, keep a food diary and see which items increase your bladder urgency. Your doctor may also have a more extensive list of possible culprits. If you take a prescribed diuretic, ask your doctor if it can be stopped (and replaced by a different type of medication), or reduced. If you must take a diuretic, time it so that you will be home. The first approach to treating an unstable bladder is “bladder retraining”. We have to get you back to the point where you are controlling your bladder, not vice versa. Pick a time interval that you can successfully wait between voidings. This may be as low as 1/2 hour. For purposes of discussion, let’s say you choose 1 hour. For one week, you must go to the bathroom every hour on the hour and empty your bladder. If you are successful (without any accidents), add 15 minutes to the next week. Every week that you are successful, add 15 more minutes until you get to a reasonable interval (at least 3-4 hours). This method of training using “timed voiding” really does work, but (and this is a big BUT) you have to be very motivated to follow through with the schedule. You do not have to wake yourself at night to comply with the schedule (Let’s not get too crazy!).

 Another goal is for you to learn how to control the sense of urgency until it subsides. What’s happening now is that you run to the nearest bathroom as soon as you feel the urge. That seems like the right thing to do. After all, you don’t want to have an accident. Wrong! You’ve just let your bladder win. Your running to the bathroom only heightens the sensation of a full bladder. Running to the bathroom also stimulates the bladder muscles thereby inducing contractions. Burgio, Pearce, and Lucco recommend the following six steps in their book Staying Dry: A Practical Guide to Bladder Control (highly recommended):

1. Stop what you are doing and stay put. Sit down when possible, or stand quietly. Remain very still. When you are still, it is easier to control your urge.

 2. Squeeze your pelvic floor muscles quickly several times (described below). Do not relax fully in between.

 3. Relax the rest of your body. Take a few deep breaths to help you relax and let go of your tension.

4. Concentrate on suppressing the urge feeling.

5. Wait until the urge subsides.

6. Walk to the bathroom at a normal pace. Do not rush. Continue squeezing your pelvic floor muscles quickly while you walk.

 If you are menopausal, estrogen replacement may reduce your urgency and frequency. Estrogen sustains the inside lining of the bladder and urethra, referred to as the mucosa. Without estrogen, the mucosa atrophies (similar to the vaginal mucosa). This produces increased frequency, urgency, and burning with urination. Estrogen replacement therapy will reverse these changes. Even small amounts of estrogen applied vaginally, which doesn’t have the same risks as systemic estrogen, can help correct the mucosal atrophy.

When all else fails, there are medications that help reduce bladder irritability. These medications reduce bladder contractility. You’re thinking, “Hey, this sounds great. Just give me those magic pills and my problem will be solved.” Unfortunately, there’s a catch (isn’t there always). Most of these have annoying side effects. The most common side effect is dry mouth. Sucking hard candy or chewing gum may help with the dryness. Other side effects include palpitations, constipation, blurry vision, and decreased sweating. They cannot be used in women with glaucoma, unstable heart disease, or conditions associated with blockage of the bowel or bladder. There is also a newer medicaion, Myrbetriq, that has fewer side effects but must be used with caution in women with hypertension (high blood pressure)

Is it normal to get up at night to go to the bathroom?

Getting up once during the night is not unusual. More than that isn’t typical and is referred to as nocturia. There are many reasons for nocturia, some of which are obvious. Of course I’ll mention them anyway (It’s never stopped me before).

Many people consume beverages in the late evening. It may be the first time all day they have had the opportunity to sit down and relax. Reading a good book with a cup of tea sounds just perfect. Others don’t drink adequate amounts of liquids throughout the day. They make up the difference in the evening hours. Unfortunately, those liquids will come back to haunt you in the middle of the night requiring several trips to the bathroom. Try to drink more throughout the day and restrict the amount of fluids consumed in the late evening. This is particularly true of caffeinated and alcoholic beverages which have diuretic properties (help your kidneys get rid of fluid). Do not take a prescribed diuretic (“water pill”) within 2-3 hours of bedtime.

Some women retain fluid throughout the day when they are on their feet. You can recognize this as swelling in your legs (particularly ankles and feet; tight shoes). When recumbent at night, the fluid finally makes its way out of the legs and up to the kidneys where it is eliminated. This results in extra trips to the bathroom. In this situation, a prescribed diuretic taken earlier (around dinner) may be able to help the kidneys excrete the retained fluid prior to bedtime. You should consult your doctor to exclude more serious conditions that cause fluid retention. Your doctor can also rule out other diseases, such as diabetes, that cause frequent urination.

Women with an unstable bladder will also note increased nighttime frequency and urgency. Refer to our discussion above on the unstable bladder.

Why do I lose urine when I cough or sneeze?

Have you ever heard a woman exclaim,“ Don’t make me laugh or I’ll have an accident!” How about, “I laughed so hard that I wet myself.” They probably weren’t kidding. Losing urine with a cough, sneeze, or laugh is common and referred to as urinary stress incontinence (USI). It is usually caused by inadequate support under the bladder neck, where the urethra enters the bladder. Childbirth, age, menopause, and a lifetime of lifting and pushing have conspired to destroy the support in this region. Even your genes may have betrayed you. Fair skinned women (northern European) and Asian women have a particularly high likelihood of developing stress incontinence, as well as prolapse disorders (see below) . Stresses that may produce incontinence include coughing, sneezing, laughing, running, jumping, and dancing. All of these cause the bladder neck to descend and urine can escape.

Urinary stress incontinence is cured by restoring the support at the bladder neck. Some of this support is provide by the muscles of your pelvic floor. One of these muscles, the pubococcygeus (throw that one at your gynecologist if you really want to show off), can be strengthened to help with bladder neck support. You can strengthen it through Kegel exercises. First you must identify the proper muscle. Place one or two fingers in the vagina. Now squeeze the pelvic muscles until you feel them tighten around your finger. Those are the muscles used in Kegel exercises. It is the same muscle group that enables you to voluntarily shut off your stream of urine or prevent the passing of gas. Try to contract these muscles without contracting your abdominal muscles. Place your other hand on your abdomen to make sure that it remains soft while you contract the pelvic muscles. Squeeze the pelvic muscles for a count of three, then relax for a count of three. Repeat this fifteen times during one session and try to do three sessions daily. Every week increase the length of time that you hold your squeeze until you reach a count of 10. However many counts you are contracting the muscle, is the same amount of time that you will wait between squeezes. When you can reliably identify the correct muscles, you don’t have to do these exercises with your fingers in the vagina. You can do them while waiting in line for the train, or while sitting at a traffic light. You can do them almost anytime. As long as you’re not grimacing, who’s going to know?

There are also fancy gadgets to help train the muscles involved in pelvic support. A manometer (a device that measures pressure) can be used to provide feedback. It registers the amount of pressure generated by squeezing the pelvic support muscles. The exercises are more effective if you have this feedback. Weighted vaginal cones (tampon-like devices) are also useful. You are provided with a set of cones that are of the same shape and size but gradually increasing in weight. You place a cone in the vagina and retain it for 15 minutes twice daily. The cone can only be held in place if you correctly tighten the pelvic support muscles. The weight of the cone is increased until you can successfully retain the heaviest cone. Another approach involves placement of an electrical cylinder in the vagina. It delivers an electrical impulse that contracts the pelvic support muscles. Additionally, electrical stimulation inhibits involuntary bladder contractions. Therefore, these devices are also of benefit in the treatment of an unstable bladder (see above). Your doctor may utilize the services of a gynecologic physical therapist or nurse practitioner for instituting these therapeutic devices.

Unfortunately, most of the support for the bladder neck is provided by fibrous tissue. You can’t exercise fibrous tissue back into shape. Once it is torn or stretched, it cannot be restored without surgery. There is not a lot you can do to make this tissue stronger. A healthy diet helps. Estrogen replacement (after menopause)also may strengthen the tissue. However, most of its strength is predetermined by genetics. In other words, you’re born with either strong or weak fibrous tissue.

 Mechanical devices may be used to elevate the bladder neck. In one form or another, these are designed to either increase support at the bladder neck (Impressa Poise device) or block leakage( Femsoft insert). They have only had a fair amount of success and tend to come on and off the market fairly quickly. For mild situational incontinence, use of the tampon may also be of some help, by elevating the bladder neck. With the advent of less invasive surgical approaches, most mechanical devices have fallen by the wayside.

If conservative measures don’t correct the incontinence, surgery is recommended. Traditionally, urinary stress incontinence surgery required reasonably major surgery with significant sized incisions. However, there has been a gradual evolution away from these larger procedures to those which are now classified as minimally invasive. The most commonly used procedures currently, use a small strip of mesh is threaded through very tiny incisions. This type of surgery is still 80 to 90% successful and can be performed either as an outpatient, or at most with an overnight stay.

The single most important factor in determining the success of surgery is proper patient selection. Although it is not universally recommended, I strongly encourage urologic evaluation prior to surgery. If you have genuine stress incontinence, your chances of success with surgery are great. If your incontinence is related to other causes, such as an unstable bladder, the surgery will not be successful. In fact, you may be worse after surgery.

Stress incontinence may also be related to an intrinsic defect in the urethral sphincter mechanism. The urethral sphincter is comprised of the muscles in the wall of the urethra as it passes into the bladder. If these don’t keep the urethra closed, you will lose urine with any activity that increases the pressure in your abdomen (laugh, cough, sneeze). This type of defect can be more resistant to standard treatment. Some medications can strengthen urethral tone. They usually contain either phenylpropanolamine (ex. Ornade) or pseudoephedrine (ex. Sudafed). Many over-the-counter decongestants and appetite suppressants contain one of these two medications. They must be used cautiously in individuals with high blood pressure, cardiac disease, or hyperthyroidism. Side effects include palpitations, nervousness, headaches, and insomnia. Doctors also inject collagen (the stuff that makes up fibrous tissue) or synthetic beads directly into the wall of the urethra to correct intrinsic urethral defects. These injections help the urethral close more effectively. They can be performed as an outpatient under the guidance of a cystoscope. Often repeat injections are necessary for optimal benefit. If collagen injections are not successful, your doctor may recommend a “sling” procedure. This may be similar in technique to the minimally invasive procedures mentioned above that are performed for genuine stress incontinence, but it may also be more involved, including more significant abdominal or vaginal incisions.

 Why do I keep getting bladder infections?

Bladder infection, or cystitis, is a fairly common infection. The urethral meatus (opening) is located just above the opening of the vagina. Since the vagina has many bacteria, it is not surprising that these organisms gain access into the bladder. This is particularly true with intercourse. It is not uncommon for women to get a bladder infection during their honeymoon (“honeymoon cystitis”) from the increased sexual activity. Isn’t that a heck of way to celebrate your new marriage!

The occasional cystitis can be treated with antibiotics and forcing fluids. Ideally, you should have a urine culture performed if you present with symptoms of infection (frequency, urgency, and burning). Not all infections respond to the same antibiotic. Your doctor can choose the correct antibiotic if a culture is done. Recurrent bladder infections should prompt your doctor to order additional studies. First you should get urine cultures every time there is an infection. A repeat culture should be obtained 2 weeks after finishing the antibiotics. If the same bacteria is still present on culture after treatment, then it probably did not respond to the original antibiotic. This may be resolved by taking a different antibiotic. If the infection appears to clear each time (negative post-treatment cultures), then you are dealing with reinfection.

 Frequent reinfection (3-4 times per year) may be a sign of a more serious underlying condition. You should see a urologist for additional studies. You may have a congenital defect in your urinary tract (born with a faulty design in your plumbing). You might have bladder (or kidney) stones or diverticuli (sac or pouch opening out from the bladder wall). The doctor will probably perform cystoscopy and order an IVP (see below). He may also want to perform a cystometrogram (see below) to evaluate your bladder function. Often no source for the recurrent infections is found. In that situation, you may be given prophylactic antibiotics. A low dose of an antibiotic is given daily (sometimes less frequently) to prevent future infections.

 What else can I do to avoid recurrent infections? If the infections are induced by sexual activity, it is recommended that you empty your bladder after intercourse. You may also be instructed to take an antibiotic after intercourse. Prevent urethral injury by using a sterile lubricant (such as KY Jelly) if there is inadequate natural lubrication. With recurrent infections, make sure you drink plenty of liquids throughout the day and empty your bladder on a regular basis. After voiding, wipe only from front to back. Good hygiene is essential in preventing recurrent infections. You and your partner need to keep the genital and anal areas clean. Showers are better than baths. Avoid tight clothing and wear cotton rather than synthetics. Synthetics trap heat and moisture (a lovely environment for bacteria), whereas cotton breathes. Everyone has heard of cranberry juice, but does it really work? Scientists have found a compound in cranberry juice (and blueberry juice) that inhibits bacterial growth, so it’s probably worth a try. In postmenopausal women, estrogen replacement (even just vaginal estrogen) may help prevent recurrent infections.

What are those tests the doctor wants me to do?

Your doctor has forewarned you that additional tests will be required to diagnose the cause of your bladder problem. Now what exactly does he have in mind? Some of those words he was throwing around sounded rather ominous. Let’s spend some time examining these tests. What is involved? What can they accomplish?

Cystoscopy (also cystourethroscopy) -- Cystoscopy is a procedure in which a doctor inserts a thin telescope through the urethra into the bladder. This enables him to look directly into the bladder for evidence of tumors, stones, diverticuli (see above), or inflammatory conditions. He also can visualize how well the urethral sphincter closes. Insertion of the cystoscope may cause discomfort. The doctor may use a numbing ointment or sedation to lessen the pain. Occasionally, the procedure is done under anesthesia as outpatient surgery. You may have some burning and frequency with urination after the procedure. A small amount of blood in the urine afterwards is not unusual. If these persist more than 24 hours, notify your doctor (you may have an infection).

Cystometrogram -- A cystometrogram measures the pressure in your bladder as it is filled. It also evaluates your bladder capacity and looks for unwanted bladder contractions (bladder spasms). A catheter is placed in the bladder through the urethra. Sometimes more than one catheter is placed, and the doctor may also insert a catheter into the rectum to measure abdominal pressure (gee, this just keeps getting better and better). Your bladder is then filled with water or carbon dioxide (a gas). The doctor asks you to indicate your first sense of bladder filling (first sensation). You then tell him when it feels as if you must void (bladder capacity). As the bladder is filling, he looks for involuntary contractions (bladder spasms). Women with urgency incontinence (unstable bladder) will demonstrate first sensation at lower bladder volumes and exhibit involuntary contractions. This test can also detect problems with your nervous system that cause abnormal bladder function (inadequate sensation or poor contraction of the bladder muscles).

IVP (intravenous pyelogram) -- An IVP is a radiologic test that lets your doctor visualize the collecting system from the kidneys down to (and including) the bladder. He can evaluate the position and integrity of the ureters (the tubes connecting your kidneys to the bladder -- not to be confused with the urethra). Certain disorders (kidney stones, congenital defects) are visualized best with an IVP. The test is performed in the radiology department. A radiologic dye is injected intravenously and X-rays are taken as your kidneys excrete the dye. Most people tolerate this test well, but you can have a severe reaction if you are allergic to iodine (also shellfish allergy). If you know of such an allergy, inform your physician.

Voiding Cystourethrogram -- A radiologic test to evaluate the structure and function of your urethra and bladder. The bladder is filled with dye through a catheter. X-rays are taken of you standing, bearing down, and voiding. A voiding cystourethrogram may help diagnose structural support problems or intrinsic urethral defects (see above section on stress incontinence).

Urethral pressure profile -- This test compares the pressure in your bladder to that in the urethra. A pressure catheter is placed into the bladder. A small amount of water is placed into the bladder and the pressure measured. The catheter is then withdrawn into the urethra and the pressure measured at several points along the urethra. The pressure in the urethra must be greater than that in the bladder if you are to remain continent. Low urethral pressures may be associated with stress incontinence.

Q-tip test -- A Q-tip is placed into the urethra. You are then asked to strain (bear down). If there is inadequate support of the bladder neck and urethra, the angle of the Q-tip will change. This is seen in women with stress incontinence.

Marshall test -- You are asked to bear down or cough with a full bladder. Your doctor looks (through the vagina) for descent of the bladder neck and loss of urine. He then elevates the bladder neck (using his fingers in the vagina) and has you cough or strain again. If there is no more leakage, you probably have genuine stress incontinence. Surgery that elevates the bladder neck (see above) should solve your problem.

 “You’ve got to be kidding! You don’t really expect me to go through all of these. I’d rather live with my incontinence.” Let’s not panic. It isn’t very likely that you will have to undergo most of these tests. Your doctor will only submit you to those that are necessary for your particular situation. Most of these tests sound worse than they are in reality. Of course, that’s easy for us to say.

If you would like more information on incontinence, consider the following resources:

National Association for Continence

Continence Restored, Inc. at 407 Strawberry Hill Ave., Stanford, Ct. 06902 203-348-0601         

How can I tell if I have interstitial cystitis?

Interstitial cystitis is an inflammatory bladder disorder that causes frequency, urgency, and suprapubic (just above your pubic bone) or pelvic pain. If you have these symptoms and no obvious cause has been identified (infection, stones, tumor, unstable bladder, gynecologic diseases), interstitial cystitis must be considered. Nobody knows for sure what causes interstitial cystitis and women often have symptoms for years before an accurate diagnosis is made.

 The diagnosis of interstitial cystitis is usually made by cystoscopy. Under anesthesia, a telescope is introduced into the bladder through the urethra. The bladder may initially look normal, or there may be ulcerations of the inside lining (mucosa). The urologist will then distend the bladder with water, a process called hydrodistention. Small hemorrhagic areas may then be seen, called glomerulations. A bladder biopsy may be taken and sent for analysis. The biopsy may show inflammation or fibrosis (scarring) if you have interstitial cystitis. Another test performed for diagnosis of this condition is called the potassium sensitivity test (PST). In this test, your doctor places two solutions — water and potassium chloride — into your bladder, one at a time. You're asked to rate on a scale of 0 to 5 the pain and urgency you feel after each solution is instilled. If you feel noticeably more pain or urgency with the potassium solution than with the water, your doctor may diagnose interstitial cystitis. People with normal bladders can't tell the difference between the two solutions. Because both of these diagnostic techniques are either invasive or painful, some doctors are now willing to proceed with treatment on the basis of severe bladder symptoms, presuming no other cause for the symptoms can be discovered.

No one specific treatment for interstitial cystitis has been found to work for everybody. Hydrodistention provides temporary relief of symptoms in 30% of women. Some foods and beverages appear to aggravate the symptoms of interstitial cystitis. Alcohol, caffeine-containing beverages, chocolate, citrus fruits, tomatoes, and spicy foods seem to be the prime offenders. Avoid these and any other foods that consistently worsen your symptoms. Bladder training (as outlined above in our discussion of the unstable bladder) will also help some women. Other conservative support measures include stress management, hypnotherapy, biofeedback, and electrical stimulation therapy. Medical regimens are used with varying degrees of success. Elmiron (pentosan polysulfate sodium for those of you with a chemistry degree), is approved by the U.S. Food and Drug Administration for the treatment of interstitial cystitis. It has been found to relieve symptoms in nearly 40% of patients. Elmiron is generally well tolerated although side effects may include nausea, diarrhea, headaches, and reversible hair loss. Anti-inflammatory, antidepressants, antihistamines, and anti-spasmodic drugs are also used by physicians with varying degrees of success. Some forms of treatment include the installation of medication or chemicals directly into the bladder. Approximately 90% of women will respond to medical treatment although several different agents may be necessary before success is achieved.

Transcutaneous electrical nerve stimulation (TENS) uses mild electrical pulses to relieve pelvic pain and, in some cases, reduce urinary frequency. Electrical wires are placed on your lower back or just above your pubic area, and pulses are administered for minutes or hours, two or more times a day, depending on the length and frequency of therapy that works best for you. In some cases a TENS device may be inserted into a woman's vagina. Another option is percutaneous tibial nerve stimulation (PTNS) where the nerve stimulator is placed near your ankle.

Another possible nerve stimulation treatment is sacral nerve stimulation. Modulation of your sacral nerves — a primary link between the spinal cord and nerves in your bladder — may reduce feelings of urinary urgency that accompany interstitial cystitis. With sacral nerve stimulation, a thin wire placed near the sacral nerves delivers electrical impulses to your bladder, similar to what a pacemaker does for the heart. If the procedure successfully lessens your symptoms, a permanent device may be surgically implanted.

When all else fails, surgery may be recommended. Cystoscopy with either fulgeration(burning) or excision of the ulcerations which are sometimes present in interstitial cystitis can be done as outpatient surgery. Enlarging the bladder (augmentation cystoplasty) may help reduce urinary frequency and urgency in those individuals that have a small bladder capacity. Although this may increase bladder capacity, patients may have difficulty in emptying it (usually requiring intermittent catheterization) and still have bladder pain. When symptoms are severe and intractable, urinary diversion can be performed. In this procedure the bladder is no longer functional. Instead, the urine is diverted to a pouch constructed from intestinal tissue. Strong consideration should be given to removing the bladder (cystectomy) if diversion is elected. Urinary diversion without cystectomy increases the chance of persistent pelvic pain after surgery. Urinary diversion with cystectomy is only considered when there is “end-stage” bladder disease that is refractory to medical management.

Interstitial cystitis is a frustrating condition for you and your doctor. You may have symptoms for years before an accurate diagnosis is rendered. Various treatment regimens may be tried without significant or lasting improvement. You have to be persistent in exploring a variety of treatment modalities. Using the available treatments, most women will ultimately find relief.

For further information on interstitial cystitis, we suggest you consult the Interstitial Cystitis Association (    

What is that bulge down there?

You were feeling perfectly fine. Then one day you notice something at the opening of your vagina. You feel a mass bulging when you wipe yourself and you’re scared out of your wits! Your first thought is that you must have a tumor, but it is much more likely that you have pelvic prolapse. Pelvic prolapse (also called pelvic descensus or pelvic relaxation) is descent of the pelvic organs from inadequate support. Failure of the support between the vagina and the bladder leads to a cystocele (“dropped bladder”). A rectocele occurs if support is insufficient between the vagina and the rectum. The uterus drops if its supporting ligaments deteriorate (uterine descensus). Inadequate support at the top of the vagina produces vaginal vault prolapse (The vagina turns inside out and protrudes). Finally (Is there no end to this madness?), you can develop an enterocele. An enterocele is a herniation between the walls of the vagina and rectum. We could describe these defects all day and you still wouldn’t be able to visualize them. This is one situation where a picture really is worth a thousand words. Your physician can show you a picture of these defects to give you a better idea of what we’re talking about.

How did this happen?

 Your uterus, bladder, and rectum are supported by fibrous tissue (also called connective tissue) and ligaments (not as firm as ligaments that are in joints). They are also supported by the Levator Ani muscles that comprise the floor of the pelvis, referred to as the pelvic diaphragm. Stretching and tearing of these tissues during childbirth results in permanent damage to your pelvic support. A lifetime of straining and bearing down (pushing and lifting heavy objects) also causes stress on these structures. Connective tissue deteriorates with age and menopause (secondary to decreased estrogen). Over time, the cumulative stress of these factors produces pelvic prolapse.

Inherent constitutional factors (size and shape of pelvis, and the quality of the connective tissue) play a large role in the predisposition for prolapse. Northern Europeans, Egyptians, and women from India are particularly prone to develop prolapse. It appears less frequently in African-American and Asian women. The predisposition for prolapse also appears to be familial. If your mom has pelvic support problems, your risk is increased.

What symptoms will I have from pelvic relaxation?

Symptoms vary according to the size and type of defect. Mild to moderate relaxation of pelvic support is common and usually not associated with any symptoms. As the prolapse progresses, you will begin to feel a bulging sensation, or pressure in the lower vagina. Some women liken this sensation to “sitting on an egg”. You also may experience a “pulling” sensation or cramping in the lower abdomen, groin, pelvis, and lower back. Symptoms are usually accentuated by standing and lifting. You may have difficulty emptying your bladder with a cystocele. This can cause frequent bladder infections. Incomplete evacuation of bowel movements may be secondary to a rectocele. A rectocele does not produce constipation. Constipation commonly coexists with a rectocele, but is not caused by it. Women often find that manual elevation of their cystocele or rectocele facilitates the emptying of these organs.

I lose my urine. Is that because of my dropped bladder?

Patients and doctors often incorrectly attribute incontinence to a cystocele. A cystocele, by itself, does not usually cause incontinence. If the cystocele is massive and totally prolapses beyond the opening of the vagina, you may experience overflow type incontinence. The capacity of the bladder has been exceeded and it cannot empty. Therefore, the urine begins to overflow out the urethra. If there is very poor support of the tissues under the bladder neck, you may have stress incontinence.

 If you have incontinence, don’t assume that it is related to your cystocele. The incontinence must be evaluated as a separate entity as outlined in our section on bladder disorders.

Is this condition dangerous?

There is nothing particularly dangerous about pelvic prolapse. Aggressive treatment is not required for minor degrees of relaxation. Begin preventive measures to keep the descensus from worsening (see below).

A cystocele associated with recurrent bladder infections should be corrected. Bladder infections can ascend to the kidneys, or into the bloodstream, which causes more serious problems.

If there is protrusion beyond the opening of the vagina, ulceration of the tissue will eventually occur. The tissue will deteriorate, ulcerate, bleed, and possibly become infected. This does not happen overnight so don’t panic. However, you should proceed with definitive correction of your prolapse if it extends beyond the outer lips of the vagina.

What can I do to keep this from getting worse?

Mild degrees of pelvic relaxation do not require aggressive intervention. However, you can help prevent it from worsening. A group of muscles, collectively called the Levator Ani, provides support to the rectum, vagina, and bladder. This is also referred to as the pelvic diaphragm or pelvic floor. These muscles are strengthened through Kegel exercises. These exercises, as well as other techniques used to strengthen the Levator Ani, are outlined in our section on bladder disorders.

Post-menopausal women should consider hormone replacement therapy if they have pelvic relaxation. Estrogen prevents atrophy of the vaginal and bladder mucosa. Estrogen also appears to maintain the integrity of pelvic connective tissue (fibrous tissue that provides the majority of the support to pelvic structures). Small amounts of vaginal estrogen will provide these benefits with little or no risk to other areas of the body.

If you have pelvic relaxation, you should restrict heavy lifting, pushing and pulling. Any activity that increases your abdominal pressure is likely to worsen your condition. When lifting, use your legs (squat close to the object and straighten your legs to lift), not your abdominal muscles. Fill your grocery bags and laundry baskets half full. Avoid carrying the grandchildren. Place them on a couch next to you if you want to snuggle. If you go on a walk, use a stroller. Stop moving furniture when you clean. Get your children or husband to do it (They must be good for something). While you’re at it, have them lug that heavy vacuum cleaner upstairs. These are just some examples of activities that you may need to modify.

Medical conditions that induce chronic coughing or constipation may worsen pelvic prolapse. Your doctor and you should try to correct these if possible. Weight reduction may also be of benefit in those who are very heavy. If you have not already done so, stop smoking. Girdles should not be worn in women with pelvic prolapse. The girdle increases abdominal pressure, which places downward pressure on the pelvic organs. How is prolapse corrected?

When your prolapse has progressed beyond the opening of the vagina, it is unlikely that Kegel exercises or other therapeutic techniques will be of much benefit. You must proceed with surgical correction or a pessary. A pessary is a rubber device inserted into the vagina. It is designed to provide support to the pelvic organs. Ring shaped pessaries are most common, but other shapes are also available. Some pessaries are inserted and removed by the doctor. Others are designed to permit self-insertion and removal. The primary advantage of a pessary is that it is not surgery. There is no significant risk in using a pessary. The pessary is fit in the doctor’s office. It should not be uncomfortable, and should relieve some of the pressure you were experiencing from the prolapse. However, the pessary is a foreign object. Because of that, you tend to develop an increased discharge, often with a foul odor. Trimo-san is a cleansing deodorant gel that may be used with a pessary to decrease the discharge. Your doctor will ask you to return to the office on a regular basis (approximately every three months). At that time he will remove the pessary and clean it. He will also clean the vagina and inspect it for any sign of ulceration. Sometimes the pessary will cause an ulceration of the vaginal mucosa (lining). This is particularly true if the mucosa is thin from estrogen deficiency. Post-menopausal women can decrease the likelihood of vaginal ulceration with estrogen replacement. Even small amounts of estrogen cream can help sustain the vaginal walls and decreases the risk of ulceration. Pessaries that are self-inserted are less likely to cause abnormal discharge or vaginal ulceration. Usually, you insert the pessary in the morning and remove it at night. It can also be removed for intercourse.

 Surgery is the most definitive approach to correcting prolapse. Let’s face it. Pessaries can be a pain in the neck. Surgery provides you with the opportunity to get the problem solved conclusively. The type of surgery varies according to the type of prolapse. We’ll briefly review the most commonly used operations. You will have to consult your doctor to assess which of these might be appropriate for you.

• Vaginal hysterectomy -- If the uterus descends significantly, it is removed through the vagina by vaginal hysterectomy. The supporting ligaments of the uterus are then reattached to the top of the vagina for support. If these ligaments appear inadequate, a vaginal vault suspension may also be performed (see below).

Anterior Colporrhaphy (anterior vaginal repair) -- This is an operation for the correction of a cystocele (dropped bladder). An incision is made through the mucosa of the vagina to gain access to the supporting tissue of the bladder. This supporting tissue is then brought under the bladder to lift it higher. Other operative procedures performed at this time might include a separate procedure for bladder neck suspension (to correct stress incontinence) and reattachment of this tissue to the sidewalls of the pelvis (paravaginal repair).

Posterior Colporrhaphy (posterior vaginal repair) -- This corrects a rectocele. An incision is made through the vaginal mucosa overlying the rectum. Supporting tissue is then brought over the rectum to reduce the rectal bulge.

Perineorrhaphy -- This procedure corrects a defective perineum. Your perineum is composed of muscles and connective tissue that provide support for the lower portions of the vagina and rectum. Connective tissue and muscles that help support the vagina, rectum, and bladder connect to this area. Often it has been damaged through childbirth and must be rebuilt at the time of surgery.

Vaginal Vault Suspension -- If there is inadequate support at the apex of the vagina after hysterectomy, the vagina inverts and descends outward (like turning your pocket inside-out). This must be corrected by suspending the top of the vagina. Some doctors open the top of the vagina and attempt to recreate support from ligaments that previously supported the uterus. Other physicians suspend the vagina to the sacrospinous ligament, a firm ligament found in the pelvis. These two operations are done by a vaginal approach (no abdominal incisions). A different approach involves suspending your vagina to your sacrum (tailbone) using mesh.

Enterocele repair -- An incision is made through the vaginal mucosa to expose the enterocele. The hernia sac is excised and the space between the rectum and the vagina closed.

More recent innovations in pelvic support surgery have brought us laparoscopic approaches to correct some of these defects and mesh procedures, in the hope of increasing the long-term success of surgery. Surgical approaches will vary from physician to physician and may be performed by gynecologists, urologists or a new specialist, the urogynecologist. Every approach has its own set of advantages and disadvantages, which you should discuss in detail with your physician.

It is important that your doctor perform a thorough examination prior to surgery. All support defects should be corrected at the time of surgery. Let’s look at an example to illustrate this important point. You may have a profound cystocele that bothers you greatly. In your mind, only the cystocele needs to be repaired. However, other defects (rectocele, uterine descensus, enterocele) may coexist. If they are less pronounced, you will not be aware of them. However, if not repaired, they will worsen and require repair later.

It is also important for your doctor to identify any coexisting bladder problems. If there is poor support at the bladder neck, you may have either overt (obvious symptoms) or occult (hidden) stress incontinence. With occult stress incontinence, you have inadequate support of the bladder neck (refer to our section on bladder disorders ). However, there are no symptoms of incontinence because your cystocele has “kinked” the urethra in a way that prevents leakage. If the cystocele is repaired without adequately elevating the bladder neck, you will have stress incontinence after the surgery (That’s just great! You’ve solved one problem and created another.). If your doctor is aware of this situation, he or she can make certain adjustments or additions to the surgery that will prevent post-operative stress incontinence. A simple test can be performed in the office to diagnose occult stress incontinence. Come to the office with a full bladder. The doctor can introduce his fingers vaginally and elevate the bladder (thereby simulating a surgical repair). He then looks for incontinence while you cough.

Another bladder condition that may be affected by surgery is the unstable bladder. The bladder is likely to be more “spastic” after surgery with increased urgency and frequency. This is usually temporary and controllable with medication. As the inflammation from surgery abates, the bladder function should improve. Many gynecologists recommend urologic evaluation before surgery. This should be mandatory if you have any symptoms of bladder dysfunction (urgency, frequency, incontinence).

So how do you choose between a pessary and surgery? If your general health is good (no obvious contraindications to surgery) and you are looking for a definitive answer, you should probably proceed with surgery. If you want to avoid the risk of undergoing surgery, you’re better off trying a pessary. If you don’t like it, you can always change your mind and proceed with surgery. Women with severe medical problems should try to use a pessary. Your family doctor or internist can tell you if there is any increased surgical risk from your medical conditions.

I hear that surgery doesn’t always work. Why?

First, you need a doctor with extensive experience in vaginal reconstructive surgery. If your gynecologist is not experienced in vaginal surgery, he should refer you to someone else. However, there are factors beyond the control of your doctor. The doctor can only control the quality of your surgery. He cannot control the quality of your tissue. If your connective tissue is particularly weak, the surgery may fail (After all, you probably wouldn’t have the problem to begin with if the tissue was strong). He also cannot control the type of stresses that this tissue will endure after surgery. That’s where you come into the picture. After surgery, you should modify activities that are likely to cause recurrence of the prolapse. These were discussed above in the section on prevention.

Most women who have reconstructive surgery do well. The majority of repairs hold up well over time. However, there are no guarantees with this type of surgery. Nobody can predict if your prolapse will recur after surgery. More recently, doctors have begun inserting graft material or mesh in place of your weak fibrous tissue. We still need long-term data to see if this goal is being accomplished. Ideally, insertion of mesh should provide a permanent repair. However, it is not without its own set of complications, including a 10% risk of erosion into the vagina.

Ideally, you should postpone surgery until you have completed childbearing. Childbirth will damage the reconstructed pelvic support. Pelvic muscle exercises and pessaries may provide you with enough relief to get by in the meantime. If surgery really becomes necessary, there are procedures that resuspend the uterus (similar to those performed for vaginal vault prolapse). You should also suspend surgery if you are in a position that requires repetitive heavy lifting or straining, whether that be at home or work. .