Pelvic Floor Relaxation - Prolapse

The pelvic floor is the medical jargon used to describe the group of muscles within the pelvis, which support the bladder, bowel - and in women, the vagina and the womb. When these muscles loose their tone, strength, control and support, they are said to be relaxed. Many people are familiar with "prolapse"; this is the end result of pelvic floor relaxation, if untreated early.

Prolapse is very common particularly as women get older. It may not cause any significant problems and in those women no treatment is needed, except for female sexual cosmetic reasons, when vaginal tightening can be considered.

Two factors are important in the development of prolapse: 1) Childbirth - during childbirth the supports of the vagina and uterus are stretched and often damaged. 2) Menopause - after 'the change', levels of the hormone oestrogen fall. This makes the tissues weaker. Hormone Replacement Therapy and pelvic floor exercises may help prevent prolapse.

There are different types of prolapse and more than one type can be present at the same time. When the front wall of the vagina is affected the bulging caused by the sagging tissues is called a cystocoele or bladder prolapse or urethrocoele (prolapse of urethra - the little tube coming from the bladder) When the back wall of the vagina is affected the bulging caused by the sagging tissues is called a rectocoele or (bulging of back passage) or enterocoele (the bulging of small intestines into the back wall of the vagina). Uterine (Womb) prolapse occurs when the uterus falls or is displaced significantly downwards from its normal position. There are varying degrees of severity depending on the descent. This produces a general feeling of heaviness and fullness, or a sense that the uterus is falling out.

Signs and Symptoms

The commonest symptom complained of is 'something coming down' or a feeling of a bulge or heaviness in the vagina or lower abdomen. This may come on gradually or may have occurred after heavy lifting. Sometimes it can cause lower back pain. Some women complain of leaking urine with cough or sneeze, if the neck of the bladder is also weak. If the prolapse affects the back wall of the vagina there may be problems emptying the bowel fully. A prolapse is more of a nuisance than a serious problem and even if untreated is unlikely to cause any serious problems, apart from the feeling of being "loose" vaginally, which can cause sexual dissatisfaction. Sometimes if the womb is coming right down, it can become ulcerated and bleed or get infected.

Treatment for Prolapse

This depends on the type and degree of prolapse, the general fitness or health of the woman and her choice:

Pelvic Floor Exercises are very useful in minor degrees of prolapse and should be tried first. A physiotherapist will instruct on how to carry out these exercises effectively. Ring Pessary: This is a plastic ring (PVC) that is inserted into the vagina by a doctor. It comes in different sizes and the doctor will choose the correct size. It stays in place on its own and if in the correct place, you should not even know it is there. The doctor will change this at the clinic every 4-6 months. An oestrogen cream may be used once or twice a week, in addition. Shelf Pessaries: Sometimes the prolapse is so much that the ring pessary falls out. In this case the doctor may try a shelf or other types pessary.

Surgical: There are many different operations available to treat prolapse and the one chosen by the specialist will depend on the type and degree of prolapse and whether there are any waterworks (urinary) complaints. Whether your family has been completed or if you are still having sexual intercourse is important. Some of the usual operations include: Anterior Repair - sometimes called a bladder repair it is performed when the prolapse is affecting the front wall of the vagina. At operation the excess vaginal skin is removed and the tissues brought back together. If there is a problem of urine leakage with coughing or sneezing, extra stitches will be placed around the 'bladder neck'. This is sometimes called a 'bladder buttress'.

Vaginal hysterectomy & Repair - performed if the womb is coming down. Posterior Repair - performed if the back wall of the vagina is bulging. At operation the excess skin is removed and the tissues brought back together again. There are other more complex operations for pelvic floor restoration.