Pelvic floor disorders are caused by weakening support of the muscles, ligaments and connective tissue in the pelvic area. Pelvic organ prolapse (POP) and incontinence are two problems women face as a result of pelvic floor dysfunction.
What is Pelvic Organ Prolapse (POP)?
Pelvic Organ Prolapse (POP) occurs when the pelvic floor muscles become weak or damaged and can no longer support the pelvic organs - the uterus (womb), vagina, bladder, rectum and the surrounding muscles. POP is the descent or sagging of the uterus or other pelvic organ into the vagina. There are several different types of pelvic organ prolapsed.
Uterine (womb) Prolapse
The uterus can prolapse (drops) into and even outside the vagina. This condition may cause discomfort and problems with difficulty having bowel movements.
Cystocele and urethrocele
When the top (‘roof’) of the vagina is affected, the bladder and urethra (water-pipe) prolapse into or outside the vagina causing a cystocoele and urethrocoele respectively.
Rectocele and Enterocele
Similarly, the rectum (lower end of the large intestines/bowels) and small intestines can protrude into the bottom (‘floor’) of the vagina causing a rectocoele and enterocoele respectively.
Procidentia
This is the most serious form of prolapse of the uterus and vagina, whereby the whole uterus is situated outside the vagina, pulling/dragging the bladder and rectum along with it. This usually results in a large cystocoele outside the vagina and a large rectocoele just inside the vagina.
Causes and Symptoms
POP is caused by pregnancy, vaginal delivery, aging, menopause and congenital weakness of the pelvic floor muscles, ligaments and fascia. Obesity, chronic cough, constipation and occupations requiring heavy lifting are also contributory factors.
POP patients may experience the following symptoms:
A bulge or lump on the outside of the vagina
Feeling as though something is bulging inside or outside the vagina
Difficulty in walking
Stress incontinence
Difficult or painful sexual intercourse
Difficulty urinating or bowel movements
Patients often feel embarrassed and depressed by this condition, and because of this, it may even cause a strained marriage.
Dr Roy Ng, Gynaecologist at Mount Elizabeth Hospital cautions that one should consult their doctor or gynaecologist for treatment if they have any of the above symptoms as the outcome of conservative and surgical treatment for POP is excellent.
Treatments
There are a number of treatment options available, the choice of treatment depends on a variety of factors such as the type of prolapse, the severity of symptoms, patient’s age and other health issues, whether or not patient want to have children in the future, and patient’s personal preference.
Patient may be treated conservatively with insertion of vaginal pessary (a small plastic or silicone medical device) into the vagina to support the prolapsed. However, they must be changed every 2-3 months to prevent ulceration and infection of the vaginal skin leading to abnormal vaginal discharge and/or bleeding. Oestrogen (female hormone) cream and tablets can also be applied / inserted into the vagina to improve the thickness and blood supply of the vagina. However, if you’re experiencing major discomfort or inconvenience, surgery is the only definitive way to relieve symptoms and improve your quality of life
Surgery
The goal of surgery is to reposition the prolapsed organs and secure them to the surrounding tissues and ligaments. Surgery can be reconstructive, which corrects the prolapsed vagina while maintaining or improving sexual function and relieving symptoms, or obliterative, which moves the organs back into the pelvis and partially or totally closing off the vaginal canal. Surgery may also involve repairs to any pelvic organs.
Hysterectomy
In significant prolapse of the uterus, the uterus can be removed from the vaginal route; this operation is known as Vaginal Hysterectomy. After the uterus is removed vaginally the back of the vagina is then sutured to the ligaments of the pelvis to support it and also to prevent a vault prolapse (prolapse of the back of the vagina).
In Vaginal Hysterectomy, there are no incisions on the tummy. Hence, compared to an open or even laparoscopic (‘key-hole’) hysterectomy, post-operative pain is much less or negligible; recovery would be ‘smoother’ and faster. Dr Ng shares that patient can resume their daily activities like drinking, eating and walking faster. However, it is important that such patients do not exert physically, avoid constipation and abstain from sexual intercourse for at least 6 to 8 weeks to prevent any damage to the tissues repaired and suffering a recurrence of their uterovaginal prolapse.
Dr Ng says, “A vaginal hysterectomy is a relatively safe operation with a very low incidence of injury to the neighbouring organs.”
So, What Exactly is Stress Incontinence?
Stress Urinary Incontinence (SUI) is one of the most common types of urinary incontinence that affects women. It is the uncontrollable leakage of urine on exertion, such as running, jumping, sneezing, laughing and coughing – that puts pressure (stress) on your bladder. Associated causes include child-birth, menopause, obesity, chronic lifting of heavy loads, chronic cough and constipation. While for some women it may just be a few drops while coughing or running, others may experience a sudden and strong urge to urinate prior to eliminating a substantial amount of urine. The effects of urinary incontinence can range from being mildly bothersome to being completely debilitating.
A national survey
How can Stress Incontinence be Treated?
Usually, the first line of treatment involves strengthening the muscles of the pelvic floor by doing pelvic floor exercises. In some cases, apart from the exercises, medication may also be advised. If these treatments do not provide the results and if the problem continues, then surgery may be required.
The surgical methods are used to support or tighten the structures and muscles under the bladder. There are many surgeries for SUI hence, it is very important to select the correct and best surgery for SUI. This is especially so as the success rate for SUI surgery falls with each subsequent surgery.
In Dr Chong’s practice, it is mandatory to perform a computer test of the bladder, called Urodynamics Studies, before any incontinence surgery in order to properly assess the bladder problem, select the best and correct surgery for the patient.
According to Dr Chong, the Tension-free Vaginal Tape (TVT) is now the accepted surgery of choice in the treatment of SUI. The latest technique using the same tape is called TVT_O (TVT-Obturator) and has been used in Singapore for more than 4 years. It uses a polypropylene mesh tape placed around the middle part of the baldder neck (" door" or outlet pipe of the bladder) without any tension or stitches. The exit point is not through the abdomen but through the inner thigh. When a person strains, the bladder neck pushes onto the tape and closes, thus preventing leakage of urine. This tape is left permanently in the body.
The new technique has advantages over the older techniques where there is less risk of bleeding and injury to the bladder, and cystoscopy to check for bladder damage and perforation need not be routinely done. This surgery can be done as a day procedure and the patient can be up and about the same day.
AD:
Don’t Suffer In Silence.
Pelvic floor disorders affect thousands of women and many of them suffering uncomfortably in embarrassment and silence. Today, treatment of female pelvic floor disorders is readily available and helping women of all ages regain their health, confidence and quality of life. If you think you are suffering from pelvic floor disorders, talk to your obstetrician/gynaecologist.
As one of Asia’s largest healthcare providers, ParkwayHealth has an international reputation for its high quality clinical outcomes, and service excellence in various multi-disciplinary specialties including Obstetrics & Gynaecology. We have more than 70 obstetricians and gynaecologists under one roof, specialised in obstetrics, gynaecological, Onco-gynaecological and Uro-gynaecological conditions.
