VAGINA
VAGINA
Have you ever looked "down there" with a mirror (or had a lover say to you) that there seemed to be a "bulge" or "ball of tissue" at the vaginal opening? The medical name for this condition is pelvic organ prolapse (POP). POP is purported to effect up to 50% of women who have had a vaginal delivery (Maher, 2008). In other studies of women in general, rates of POP with marked symptoms are reported to be 3.6 - 6%.
The first concern is that one's uterus, or other pelvic parts, might be falling out. In one of the more severe forms of POP the uterus can drop so far down into the vaginal canal that the cervix will scrape against the woman's underpants! Fortunately this is one of the least common forms of POP. So if you were to see a "bulge" of tissue what is that likely to mean to you? The goal of this blog is to share facts about the types of POP, the risk factors, and what treatment options you might have if POP seems to be linked to other, bothersome symptoms.
How do I know what type of prolapse I have?
When you go see your GYN or clinic you might expect questions about: urinary or bowel incontinence, difficulty emptying the rectum, or sexual problems. This can suggest areas which are involved with the "bulge". An exam should be done with you standing and/or bearing down when you are on the exam table. If loss of urine is a concurrent problem then a urinalysis may be done along with a Q-tip test and/or a measure of urine left in the bladder after you have go to the bathroom.
There are several types of prolapses. When the upper part of the vaginal canal loses its muscle tone or attachments holding the vagina up (especially common among women with hysterectomies) that is called vaginal prolapse. If muscle support is poor, or interrupted, the bladder can prolapse down through the "roof" of the vagina causing a cystocele. The urethra may drop down as well (urethrocele). If the weakness is in the "floor" of the vagina the rectum can bulge upward. As was mentioned above, the uterus and cervix can slump down through the vaginal canal.
What are the risk factors for pelvic prolapse?
The most consistently cited risk factors are: increasing age, being overweight, and increased number of vaginal deliveries. Number of deliveries by C-section does not increase prolapse risk (Luckacz, 2006). Other associated factors can include irritable bowel syndrome, constipation, and overall poor health (Rortveit, 2007). African American women are less likely to have symptomatic pelvic prolapse (Rortveit, 2007). One small study even found that having a history of stretch marks doubled one's risk for prolapse (Salter, 2006).
"Stretch marks," you might be thinking "why would that be?" The bones of the female pelvis do a great job protecting lower abdominal contents, but they do not provide support. The pelvic organs are supported by the muscles in the pelvic floor and the ligaments which can attach from the organs to the bones. It has been theorized that pelvic muscle and ligament strength may be linked to strength of collagen. Collagen, along with fibrillin, is decreased in women with stretch marks (Mitts,2005).
What can be done if I have a mild form of prolapse, or do not want to have surgery?
According to the American College of Obstetrics and Gynecology (ACOG, 2007): "Pessaries can be fitted in most women with prolapse, regardless of prolapse stage or site of predominant prolapse." A pessary is a doughnut shaped device which can be made of various materials. There are also pessaries shaped like a cube, and similar to a shoe horn. If one has ever used a diaphragm for birth control, inserting and removing a pessary may seem familiar. Like a diaphragm, a pessary should be fit by a GYN as they come in different sizes.
Kegel exercises have been recommended for POP but, unlike urinary stress incontinence, there are few large studies demonstrating the effectiveness of Kegels. According to one recent study of 48 women, pelvic floor exercise/Kegels significantly improved symptoms of prolapse (Hagen, 2009). Kegels may not be as successful as they are with urinary incontinence for once the attachment ligaments are damaged, strengthening the pelvic muscles may not fix the prolapse.
What about surgery?
If one has a prolapse of the uterus, hysterectomy may be suggested. Care is taken to refasten the top of the vaginal canal to other structures so it does not droop down after the hysterectomy.
If the prolapse is coming from the top or "roof "of the vagina, pelvic fascia tissue can be used to bridge the weak area. If the prolapse is coming from the lower or "floor" of the vagina (causing a bulging of the rectum into the vaginal canal), the rectal muscles can be used to close the defect.
More recently synthetic mesh has been used to support the weakened areas. Mesh has been used extensively for repair of abdominal hernias. Overall, the use of mesh seems to decrease the reoccurrence of cystocele when an anterior ("top") of the vagina repair is done (Maher, 2008). The primary concern for mesh is that long term follow up in large numbers of POP women is lacking. Cases of the mesh eroding through vaginal tissues have been reported (Altman, 2007). By October of 2008 the FDA released a notification to GYN surgeons relating adverse events connected to mesh use as reported by manufacturers of different types of mesh. Some of these unwanted events included erosion, infection, and pain. Not surprisingly, the strength and health of the woman's own tissues will have an impact. Her own tissues will have to be incorporated into the mesh to form a strong bond.
In one study of 2,460 of women in their 50's, about 3% of women reported having surgery for POP (Fritel, 2009). Further, women who had such symptoms of POP as problems having a bowel movement or urinating, and abdominal pain reported a much lower quality of life than other women. In one very large study (Barber, 2009), 85% of women considered themselves "much better" when compared to before their surgery. Bottom line, surgery of some type can be very helpful if a woman has symptoms from her prolapse.
My mom and her sisters had prolapse; can I do anything to prevent it happening to me?
We cannot change our genetics, age, or number of vaginal births! Sadly there are not many scientific studies testing different forms of POP prevention. The strategies for prevention that are most often suggested include:
Have you ever looked "down there" with a mirror (or had a lover say to you) that there seemed to be a "bulge" or "ball of tissue" at the vaginal opening? The medical name for this condition is pelvic organ prolapse (POP). POP is purported to effect up to 50% of women who have had a vaginal delivery (Maher, 2008). In other studies of women in general, rates of POP with marked symptoms are reported to be 3.6 - 6%.
The first concern is that one's uterus, or other pelvic parts, might be falling out. In one of the more severe forms of POP the uterus can drop so far down into the vaginal canal that the cervix will scrape against the woman's underpants! Fortunately this is one of the least common forms of POP. So if you were to see a "bulge" of tissue what is that likely to mean to you? The goal of this blog is to share facts about the types of POP, the risk factors, and what treatment options you might have if POP seems to be linked to other, bothersome symptoms.
How do I know what type of prolapse I have?
When you go see your GYN or clinic you might expect questions about: urinary or bowel incontinence, difficulty emptying the rectum, or sexual problems. This can suggest areas which are involved with the "bulge". An exam should be done with you standing and/or bearing down when you are on the exam table. If loss of urine is a concurrent problem then a urinalysis may be done along with a Q-tip test and/or a measure of urine left in the bladder after you have go to the bathroom.
There are several types of prolapses. When the upper part of the vaginal canal loses its muscle tone or attachments holding the vagina up (especially common among women with hysterectomies) that is called vaginal prolapse. If muscle support is poor, or interrupted, the bladder can prolapse down through the "roof" of the vagina causing a cystocele. The urethra may drop down as well (urethrocele). If the weakness is in the "floor" of the vagina the rectum can bulge upward. As was mentioned above, the uterus and cervix can slump down through the vaginal canal.
What are the risk factors for pelvic prolapse?
The most consistently cited risk factors are: increasing age, being overweight, and increased number of vaginal deliveries. Number of deliveries by C-section does not increase prolapse risk (Luckacz, 2006). Other associated factors can include irritable bowel syndrome, constipation, and overall poor health (Rortveit, 2007). African American women are less likely to have symptomatic pelvic prolapse (Rortveit, 2007). One small study even found that having a history of stretch marks doubled one's risk for prolapse (Salter, 2006).
"Stretch marks," you might be thinking "why would that be?" The bones of the female pelvis do a great job protecting lower abdominal contents, but they do not provide support. The pelvic organs are supported by the muscles in the pelvic floor and the ligaments which can attach from the organs to the bones. It has been theorized that pelvic muscle and ligament strength may be linked to strength of collagen. Collagen, along with fibrillin, is decreased in women with stretch marks (Mitts,2005).
What can be done if I have a mild form of prolapse, or do not want to have surgery?
According to the American College of Obstetrics and Gynecology (ACOG, 2007): "Pessaries can be fitted in most women with prolapse, regardless of prolapse stage or site of predominant prolapse." A pessary is a doughnut shaped device which can be made of various materials. There are also pessaries shaped like a cube, and similar to a shoe horn. If one has ever used a diaphragm for birth control, inserting and removing a pessary may seem familiar. Like a diaphragm, a pessary should be fit by a GYN as they come in different sizes.
Kegel exercises have been recommended for POP but, unlike urinary stress incontinence, there are few large studies demonstrating the effectiveness of Kegels. According to one recent study of 48 women, pelvic floor exercise/Kegels significantly improved symptoms of prolapse (Hagen, 2009). Kegels may not be as successful as they are with urinary incontinence for once the attachment ligaments are damaged, strengthening the pelvic muscles may not fix the prolapse.
What about surgery?
If one has a prolapse of the uterus, hysterectomy may be suggested. Care is taken to refasten the top of the vaginal canal to other structures so it does not droop down after the hysterectomy.
If the prolapse is coming from the top or "roof "of the vagina, pelvic fascia tissue can be used to bridge the weak area. If the prolapse is coming from the lower or "floor" of the vagina (causing a bulging of the rectum into the vaginal canal), the rectal muscles can be used to close the defect.
More recently synthetic mesh has been used to support the weakened areas. Mesh has been used extensively for repair of abdominal hernias. Overall, the use of mesh seems to decrease the reoccurrence of cystocele when an anterior ("top") of the vagina repair is done (Maher, 2008). The primary concern for mesh is that long term follow up in large numbers of POP women is lacking. Cases of the mesh eroding through vaginal tissues have been reported (Altman, 2007). By October of 2008 the FDA released a notification to GYN surgeons relating adverse events connected to mesh use as reported by manufacturers of different types of mesh. Some of these unwanted events included erosion, infection, and pain. Not surprisingly, the strength and health of the woman's own tissues will have an impact. Her own tissues will have to be incorporated into the mesh to form a strong bond.
In one study of 2,460 of women in their 50's, about 3% of women reported having surgery for POP (Fritel, 2009). Further, women who had such symptoms of POP as problems having a bowel movement or urinating, and abdominal pain reported a much lower quality of life than other women. In one very large study (Barber, 2009), 85% of women considered themselves "much better" when compared to before their surgery. Bottom line, surgery of some type can be very helpful if a woman has symptoms from her prolapse.
My mom and her sisters had prolapse; can I do anything to prevent it happening to me?
We cannot change our genetics, age, or number of vaginal births! Sadly there are not many scientific studies testing different forms of POP prevention. The strategies for prevention that are most often suggested include:
- Kegel exercises up to four times daily. The hope is that by strengthening muscles in the pelvic floor that those muscles can help delay, or reduce, the onset of prolapse. For information about how to do Kegels correctly check out this article: Kegel Exercises - Topic Overview
- Physical exercise. Regular exercise can help keep one's body weight down, and being overweight is linked to prolapse. Exercise is also reputed to keep muscles and ligaments more flexible.
- Decrease straining to have a bowel movement. Constipation, or having to bear down, increases pressure in the abdomen which "pushes down" on pelvic organs. Eating a healthy diet with whole grains, fruits, and vegetable not only helps constipation, but can improve body weight.
- Treat chronic coughs. If one is a smoker - quit. If there is another reason for a chronic cough - have it treated. A cough increases the pressure inside the abdomen which can "push down" on pelvic organs. There are studies linking smoking with poorer tissue integrity after POP repair (Araco, 2009).
- Use a correct technique for heavy lifting. Straining to lift increases pressure within the abdomen. Here is a good over view of safe lifting: Back Problems - Proper Lifting
- Hysterectomy surgery considerations. If one is having a hysterectomy there are studies which suggest that attaching the uterine ligaments to the top of the vagina may help to keep the vagina from dropping down
