Often women who need pelvic floor rehabilitation are suffering from some form of organ prolapse, which is when one or more of the pelvic organs – the bladder, uterus, small bowel and rectum – slips out of place, causing bulging in or emerging from the vagina or rectum. Prolapse often occurs with women who have had children, hormone changes during or after menopause, but can also occur after a hysterectomy, or with chronic bearing down or straining.
There are several different types of pelvic organ prolapse including uterine prolapse, vaginal vault prolapse, cystocele (bladder) prolapse, rectocele (rectal) prolapse, urethrocele (urethra) prolapse and enterocele (small bowel) prolapse. There are different grades of prolapse from mild to severe can impact level of intervention.
Symptoms of Prolapse
While many women with pelvic organ prolapse have no symptoms, some may experience the following:
- Discomfort, similar to pressure or fullness
- Pelvic heaviness
- Difficult bowel movements
- Urinary problems including incontinence or difficulty urinating
- Vaginal bleeding from the exposed skin that rubs on pads or underwear
- Increased discharge
- Sexual intercourse difficulties
- Bulge near the opening of the vagina
- Back pain
As pelvic organ prolapse worsens, you may notice that it feels like you’re sitting on a ball, you have lower back pain or the problems above get worse epecially at the end of the day.
While this can all be uncomfortable and may lead to feelings of embarrassment, loss of self-esteem, and social isolation, there is help available. There are several nonsurgical options that your doctor may recommend first before considering surgery.
Nonsurgical Treatment Options
The following lifestyle changes may help decrease urine leakage:
- Lose weight. Being overweight can put additional pressure on your abdominal wall and bladder. Even losing 5-10% of your body weight may help decrease urine leakage.
- Manage your fluids. If your incontinence issues tend to happen early morning or at night, you may try limiting your intake of fluids several hours before bedtime. Limiting alcoholic and caffeinated beverages may also help. However, continue to drink water as excessive liquid limitation can make urine concentrated and predispose people to constipation and urinary tract infections.
- Train your bladder. The intent of bladder training is to learn how to control your urge to go, as well as increasing the amount of time between urinating. The goal is to go only every three to four hours during the day and once every four to eight hours at night.
- Stop smoking. Smoking increases a person’s chance of developing stress incontinence, as it increases coughing. Smoking also causes most cases of bladder cancer.
Pelvic Floor Physical Therapy
Physical therapists specially trained in pelvic floor theapy are aware of the interplay between the pelvic floor muscles that assist with bowel, bladder, and sexual function, and the hip girdle neuromuclular structures and function that affect mobility and community engagement. Pelvic floor physical therapists treat all genders over the lifespan for a variety of bowel, bladder, sexual dysfunctions in addition of pelvic pain and perinatal orthopedic concerns. They are able to integrate a home exercise program looking at the whole person, not just the pelvic floor muscles. Treatments may include neuromuscular training, manual therapy, behavioral modifications, and education. Even if you decide that surgery is right for you, often physical therapy before and after can help improve surgical outcomes.
Pelvic Floor Muscle Training
Exercises that strengthen your pelvic floor muscles are called Kegel exercises. These are helpful for all types of urinary incontinence. Find the muscles you use to stop the flow of urine – those are the muscles you need to exercise. Contract them for a few seconds and release. Start with holding the contraction for five seconds five times a day, and work up to 10 seconds 10 times a day.
A vaginal pessary is a plastic or rubber device that’s inserted into the vagina to help support the neck of the bladder and relieve stress urinary incontinence associated with prolapse. Pessaries come in many different shapes and sizes, and need to be sized correctly to be effective. They do have to be removed and cleaned frequently. Low estrogen women shoud talk to their doctor before regarding vaginal tissue integrity.
Your doctor will inject bulking agents, like collagen or carbon beads, near the urinary sphincter to treat urgency and stress incontinence. This makes the tissues thicker and helps close the bladder opening.
Nerve Stimulation Procedures
Nerve stimulation procedures send small, electrical impulses to the nerves that signal the need to urinate. There are two different types:
- Sacral Nerve Stimulation is an outpatient procedure that implants a wire under skin which sends painless electrical impulses to block the message of needing to urinate sent by an overactive bladder.
- Percutaneous Tibial Nerve Stimulation (PTNS) is similar to acupuncture, placing a needle near the tibial nerve in the ankle to send electrical signals to the nerves that control the bladder.
There are also several types of medications available to help reduce symptoms of urinary incontinence. Talking with your doctor about your symptoms will determine the prescription for your condition.
A new treatment option for stress urinary incontinence is a tampon-like device that is available over the counter. You can typically wear the device safely for up to eight hours within a 24-hour period, after which it should be removed.
Surgical Treatment Options
Prolapse repairs can be done several different ways: abdominally, transvaginally, laparoscopically or robotically. The goal of the surgery is to reinforce the pelvic floor to keep the pelvic organs in place.
Abdominal repairs are believed to have higher success rates, but the complications and risks are higher, and the recovery time is much longer. Two types of surgeries, sacrocolpopexy and sacrohysteropexy, can be performed abdominally. The upside is that abdominal surgeries may result in less pain during sex than procedures performed through the vagina.
There are a few types of transvaginal surgery options for pelvic reconstruction. The medical terms sound complex, but your healthcare provider with talk with you about which procedure is the best fit for your condition.
Laparoscopic sacrocolpopexy has several advantages including better anatomic visibility for your surgeon due to magnification, shorter hospitalization time and faster recovery. Your doctor makes several small incisions and uses tiny instruments to go in and repair the pelvic organ prolapse.
Robotic-assisted sacrocolpopexy uses robotic arms which the surgeon can manipulate. These robotic arms have a much greater ability to rotate and work in narrow places than the human hand, giving the surgeon more flexibility to repair the pelvic organs.
Robotic-assisted surgery has a faster recovery time and fewer complications than abdominal surgery as well.
What’s Right for You?
The type of procedure that will be best for the reconstruction of your pelvic floor will depend on your specific issues. Discuss all options with your healthcare provider to find out which he or she recommends for your situation.