Facts About Urinary Stress Incontinence And Uterine Prolapse
Author: Dr Daryl Greebon with Women’s Specialists of Plano
There are many forces that work on the pelvic floor in women living in the communities of Plano, Frisco and Dallas, Texas. Lifting, laughing, coughing, sneezing, and having babies all have the effect of exerting downward pressure on the floor of the pelvis and in some women this leads to symptomatic problems such as urinary incontinence. These disorders are referred to as pelvic floor disorders, or as disorders of pelvic support. These disorders include urinary stress incontinence (urinary leakage), uterine prolapse (dropped uterus), cystocele (dropped bladder), rectocele (bulging of the back wall of the vagina), enterocele (a form of internal hernia), and vaginal vault prolapse (dropped vagina after hysterectomy).
The common thread in all of these conditions is a loss of support of the uterus, bladder, or vaginal walls. While the forces listed above can cause problems, some women may do heavy work and have two or three babies and not have too much trouble, and others may not do particularly heavy work and have only one baby and still have a problem, so there is clearly more to this story than just the external forces. I believe that some women, or some families inherit a tendency to have weakness in the connective tissues that provide pelvic support. It is this weakness that allows these problems to occur.
It is therefore, no surprise that if a woman has generalized weakness of the pelvic floor, these problems are seldom isolated to one organ. While this is not always true, if a woman has urinary incontinence the odds are pretty high that she will have other issues as well, such as uterine prolapse or rectocele. Furthermore, since these organs are in close proximity, a problem in one may aggravate problems in others, so that a prolapsed uterus (dropped uterus) may over time make a cystocele (dropped bladder) get worse. This is one reason that in some cases if the bladder is repaired, but the uterus is not removed, recurrence of urinary incontinence is more likely. It is important when evaluating these problems for surgical correction that the entire pelvis is evaluated and that all problems are corrected at the same time. Every gynecologist, particularly early in his or her career has done a hysterectomy and repair of bladder, only to have the patient return six months or a year later with a newly developed rectocele because after the repair the forces of pressure were directed in a different place causing the new problem to develop. This could be avoided by choosing the best group of procedures at the start.
Let’s talk for a few moments about the various conditions. First, is a dropped uterus (uterine prolapse). While this can occur at almost any age (the earliest I have seen was a 21 year old nurse), it is more common in the 40’s and 50’s and beyond, after having had children and often after menopause. Uterine prolapse sometimes causes no symptoms until it is quite severe, but can cause pressure and discomfort. If the uterus is enlarged for any reason it is even more likely to cause pressure symptoms as it drops lower. This pressure may be felt in the lower abdomen, in the rectal area, on the bladder, or on the lower vagina. In extreme cases, the uterus can protrude completely outside of the vagina such that the vagina is almost turned inside out.
Urinary Stress Incontinence
Second, a dropped bladder (cystocele, or bladder prolapse) can sometimes be subtle. There are two versions of this, one is when the neck of the bladder is dropped or weakened. The bladder neck is the important urinary control element, so when the bladder neck is dropped urinary stress incontinence develops. Urinary Stress Incontinence is a leakage of urine that occurs with coughing, sneezing, lifting or laughing. This is usually a small volume of leakage, maybe just a few drops, but can occur repeatedly throughout the day and can be a major problem. Most women would recognize this since mild versions may be a bit of leakage that occurs with running or sneezing.
There are other kinds of urinary incontinence which are not necessarily caused by a cystocele and which would not necessarily respond to surgical correction, so it is important to have preoperative assessment to decide if urinary stress incontinence is really the problem. The second sort of bladder problem is prolapse or weakness of the upper part of the bladder so that the bladder bulges into the vagina to a large extent. This can cause urinary retention and an increased risk of urinary tract infection. Sometimes this “pouch effect” can prevent urinary leakage, but if the mistake is made to fix the bulging bladder but not support well the neck of the bladder, having surgery might actually create urinary incontinence that a woman did not have before her surgery.
Third, a rectocele is a bulging of the back wall of the vagina over the rectum. This can be quite large at times, and can cause constipation, pelvic pressure, and in some cases a woman may have to place a finger in the vagina and press down to initiate a bowel movement. Different specialties may look at this problem differently. Some colorectal surgeons view this primarily as a bulging of the rectum and will offer a transrectal repair of this problem. Gynecologists on the other hand tend to view this as a defect of support, and it is my belief that any procedure that does not in some way provide better support of the back wall of the vagina is doomed to failure. I had a case in which a young gynecologist correctly diagnosed a rectocele, but his plan of action was to refer the patient to his friend the colorectal surgeon. The surgeon performed a transrectal repair. Immediately after the surgery the patient was concerned that the “bulge” for which she had originally gone in was still present. After six weeks of being told that this was swelling she asked the colorectal surgeon about it only to be told, ”Oh, that is a vaginal problem, you need to see your gynecologist for that”. She chose another doctor.
Fourth, an enterocele is much like an internal hernia in which the abdominal contents try to push their way down between the vagina and the rectum. This is fairly common with large rectoceles, but it is important for the surgeon to recognize this problem, know what it is, and repair it appropriately. Enteroceles are sometimes difficult to diagnose with certainty before surgery and tend to present like and act like a rectocele.
Last, is vaginal vault prolapse. This occurs after a hysterectomy in women who have severe disorders of pelvic support. The normal anchors that hold the vagina in place after a hysterectomy do not hold and the top of the vagina comes down and often protrudes at the vaginal opening. This is often accompanied by pressure and discomfort. It is important in the initial evaluation to be sure what is coming down, is it the bladder, the top of the vagina, or the rectum. This distinction is important because the appropriate repairs might be significantly different.
This concludes our discussion of Urinary Incontinence and Uterine Prolapse – The Problem. Please continue your study of these problems with “Facts About Urinary Incontinence and Uterine Prolapse – The Solution”. Part II continues our discussion of Pelvic Floor Disorders and Disorders of Pelvic Support focusing on the surgical correction of these problems.
To learn more about urinary stress incontinence, or for additional resources on uterine prolapse, please contact the Plano, Frisco and Dallas, Texas area office of Women’s Specialists of Plano.