Jennifer Berman, MD
When prolapse occurs, and the supporting muscle, ligaments and connective tissue of the pelvic organs begin to lose their supporting ability, the bladder, uterus, rectum and even small bowel can begin to fall, forming a type of hernia or bulge in the wall of the vagina and/or rectum.
To understand the supporting function of the pelvic floor, it must be viewed as a unit, comprised of both contractile and non-contractile elements. There is always a delicate interplay between the actions of the active muscles and the passive supporting connective tissue elements.
All of the pelvic viscera -- urethra, bladder, vagina, uterus and anotrectum -- rest on or are contained within the pelvic floor. If the support offered by the pelvic floor fails, the pelvic viscera will be displaced outward by the pressure within he abdominal pelvic cavity.
Traditionally, the name of any defect in pelvic support is made according to the displaced viscera structure. For instance bulging or herniation of the bladder into the anterior wall of the vagina is referred to as a cystocoele, the rectum (bulging into the posterior wall of the vagina) a rectocoele, the urethra, urethracoele and so forth.
In women, the embryogenesis, anatomy and function of the lower urinary and genital systems are so interrelated that physicians must be knowledgeable about the possible effects that a pathologic condition or surgical procedure involving one system will have on the function of the other, in particular sexual function and responses.
Urinary and sexual function symptoms associated with pelvic floor prolapse
The most common urinary symptoms women experience as a result of pelvic floor prolapse include frequency, urgency and incontinence. Incontinence can occur either at rest (with no warning) or during straining, laughter, sneezing or simply shifting positions. If the prolapse is severe, women will often complain of pressure, fullness and even pain in the vagina and/or rectum. If severe prolpase occurs, difficulty passing urine rather than incontinence can develop. This is because the prolapsing bladder or uterus compresses or kinks the urethra such that the urine cannot easily flow out. Severe prolapse can also be accompanied by pain in the vagina, rectum and pelvis as well as difficulties with bowel movements (constipation, hemorrhoids).
Aside from the urinary and bowel symptoms associated with pelvic floor prolapse, women suffering from prolapse will often have sexual function complaints. The most typical of these sexual complaints include pain in the vagina, pain in the pelvic region, loss of sensation in the vagina and/or clitoris, and difficulty or inability to achieve orgasm with vaginal penetration.
At present, we are evaluating the impact that the surgeries to correct pelvic floor prolapse have on sexual function and responses, with the goal being to restore female pelvic anatomy to its correct position as well as to improve and/or restore sexual function and responses. For example, for vaginal vault prolapse, the goal of surgery is, in addition to supporting the vagina, to maintain the correct length, shape and angle of the vaginal canal to allow for normal sexual relations and minimization potential for pain.
Treatment for pelvic floor prolpase
Treatments for pelvic floor prolapse vary depending on the extent of the problem and the type of symptoms. Methods of prolapse management include medications (anticholinergic agents, antidepressants), biofeedback and surgery. Operative procedures for correction of defective support focus on restoring structures to the correct anatomic position and correcting the defects in the facial and ligamentous supports. Some physicians view prolapse as a normal part of aging, while others are too quick to suggest surgery as the only option. Every patient is different and prolapse can be a sign of larger problems; as such, patients should always seek a second opinion before either dismissing a life-impeding problem or yielding to surgery.