Many women have changes in their pelvic organs and their function as they age. They have a feeling of pelvic pressure or heaviness. It may feel like "something is falling out of the vagina."
These symptoms may be caused by pelvic support problems. These problems appear to begin with childbirth and become more apparent with aging.
The parts of the body affected by pelvic support problems include the urethra and bladder, the small intestine, the rectum, the uterus, and the vagina. The bladder receives and stores urine from the kidneys and expels it through the urethra, a short narrow tube. The uterus is located at the top of the vagina. Behind the uterus is a space within the pelvic cavity called the cul-de-sac. This space contains some of the small intestine. Along the back of this space is the rectum, which continues down the back of the vagina and ends at the anus. The perineum is the tissue between the opening of the vagina and the anus.
The pelvic organs are held in place by three types of support:
1.) Layers of connecting tissue called endopelvic fascia.
2.) Thickening of the fascia called ligaments.
3.) A paired group of muscles that lies on either side and around the openings of the urethra, vagina, and rectum.
When the tissues that support the pelvic organs are stretched and damaged, they allow the organ that they support to drop down and press against the wall of the vagina, causing a bulge. Sometimes the organ will drop down so much that the bulge sticks out though the vaginal opening.
The main cause of pelvic support problems are childbirth and aging. As the baby passes though the vagina during childbirth, the fascia and ligaments may be damaged. They may become weak.
In later years, when a woman goes through menopause, the loss of the female hormone estrogen may make these problems worse. Sometimes pelvic support problems occur in women who have never had children. In these women, the cause may be:
*Unusual weakening of the vaginal tissues after menopause (when menstrual periods end).
*Abnormal increases in abdominal pressure due to a chronic cough (often linked to smoking or lung disorders), heavy lifting, obesity, or constipation.
*A weakness of the tissues that is inherited.
The symptoms of pelvic support problems depend on which organs are involved. They can range from minor discomfort to major problems in the way organs work. They include:
*Feeling of pelvic heaviness or fullness, or as though something is falling out of the vagina (often described as a "bearing-down" sensation")
*Pulling or aching sensation in the lower abdomen, groin, or lower back, especially at the end of the day.
*Leaking of urine or problems having a bowel movement.
*Bulging of organs against the vaginal wall, which may stick out of the vaginal opening.
*Pain after sexual intercourse.
All of the symptoms may be more noticeable after you have been standing for a long time or at the end of the day. They may be worsened by repeated coughing, lifting, or straining. In severe cases, the pelvic organs may bulge into the vagina. This bulge may stick out of the vaginal opening, where it may be seen with a mirror or felt with the fingers. Sometimes a woman may need to the push the organs back up into the vagina to empty the bladder or have a bowel movement. The uterus itself may stick out though the vaginal opening. If the uterus or a part of the vaginal wall stays outside the vaginal opening, it may become irritated. It may develop small sores or ulcers that bleed or become infected.
TYPES OF PELVIC SUPPORT PROBLEMS
The main types of pelvic support problems are named according to which organ is bulging into or out of the vagina. Although each is described separately, they most often occur in combination.
*Cystocele-bladder: When the bladder drops from its normal place into the vagina, it is called a cystocele. Some cystoceles cause urine leakage when you sneeze, lift objects, or even walk. Large cystoceles may kink the urethra and interfere with the passing of urine. It this occurs, you may have to strain or push the bladder up by reaching into the vagina in order to pass urine. If there is a very large cystocele and if the bladder loses some of its ability to contract, it may not completely empty. Small cystoceles are common. They usually do not interfere with urination and do not need surgery.
The place where the bladder joins the urethra is called the bladder outlet or bladder neck. When the tissues that support the bladder neck are
damaged, it may drop and push against the vaginal wall. A dropped bladder neck is called a cystourethrocele. It may cause urine to leak. Urine is more likely to leak when there is a sudden increase in abdominal pressure caused by walking, jumping, coughing, sneezing, laughing, lifting, or making sudden movements. The amount of urine lost may only be a few drops, or it may be enough to require the changing of clothes or the wearing of pads. Sometimes leakage is not caused by a cystourethrocele. It may be due to urinary tract infection, bladder problems, or to other medical conditions, which are not corrected by surgery.
*Enterocele-small intestine: When the intestine bulges into the upper vagina, it forms an enterocele. In order to diagnose an enterocele, a doctor may have to place a finger inside the vagina and a finger in the rectum while you are standing.
*Rectocele-rectum: When the rectum bulges into or out of the vagina, it is called a rectocele. It is caused by a weakness of the back of the wall of the vagina. A large rectocele may make it very hard to have a bowel movement, especially if you have constipation. Some women have to push the bulge back into the vagina in order to complete a bowel movement.
*Uterine prolapse-uterus: When the uterus drops down into the vagina, it is called uterine prolapse. The distance the uterus drops may vary. Mild degrees of prolapse are common. If often does not cause any symptoms and does not need surgery. Women with more severe forms of this condition often will have a feeling of pelvic pressure or a pulling feeling in the groin or lower back. The cervix (the opening of the uterus) may stick out from the vagina, causing discomfort or interfering with sex. Uterine prolapse most often occurs when other pelvic organs are also out of place.
*Vaginal prolapse-vagina: Sometimes after a hysterectomy (removal of the uterus), the top of the vagina loses its support and drops. This is called vaginal prolapse. The degree of prolapse may vary. The top of the vagina may drop part of the way into the vagina and remain there, or it may extend part or all the way through the vaginal opening. Most women who have vaginal prolapse also have an enterocele. Women who have complete vaginal prolapse can also have problems with bladder and bowel function.
Diagnosis of pelvic support problems can range from a pelvic exam, to cystoscopy and urethroscopy-where the inside of the bladder and urethra is viewed through a small, lighted telescope, to cystometry-where bladder capacity and control are measured, and uroflowmetry-where the urine flow is measured.
SOLUTIONS
Exercises called Kegel exercises, or pelvic muscle exercises, are used to strengthen the muscles that surround the openings of the urethra, vagina, and rectum.
Drinking fruit juices and emptying your bladder after sexual intercourse may help to reduce the risk of bladder infection. You may also need to cut down on caffeine, which acts as a diuretic. It is found in coffee, tea, and soft drinks. A high-fiber diet may be prescribed to help with bowel control to avoid constipation.
Sometimes a drug that softens stools is given along with a special diet to help control intestinal symptoms. A drug that puts bulk into the stool may also be given along with a high-fiber diet. There are special medicines that control urination. These drugs suppress bladder contractions. Other drugs will help prevent leakage by increasing the pressure inside the urethra. If there is a urinary tract infection, antibiotics may be needed. Some of these drugs may have side effects.
Pelvic support problems may be corrected by surgery. The type of support problem will have an influence on whether surgery is done through the vagina or abdomen. It is best for a woman to put off surgery for pelvic support problems until she has had all of her children. This is because if she has uterine prolapse, the doctor may suggest that the uterus be removed as part of the procedure. If the uterus is left in place, a later vaginal delivery may increase the chances that a cystocele or rectocele will recur.
Surgery may relieve some, but not all, of the symptoms caused by pelvic support problems. In a few cases, symptoms may return. The doctor has to use the already weakened fascia, ligaments, and muscles that are within your pelvis to improve your pelvic support. In some cases, synthetic materials that the body accepts well may be used to help correct the problems. If you have had prior surgery or radiation there is a much lower success rate.
Sometimes surgery is too risky because of a woman's general health. In such cases, a pessary may be used to support the pelvic organs. When a pessary is used, it must be removed, cleaned, and reinserted on a regular basis. Otherwise, it might cause a bad-smelling discharge and ulcers in the vagina. If used correctly, a pessary can last for years.
