Pelvic Support Problems

Introduction
Cystocele
Enterocele
Rectocele
Uterine prolapse
Signs and Symptoms
Risk Factors
Treatment

A woman's organs can shift position as she ages. Pregnancy, childbirth or being too heavy can stretch and weaken muscles that support your pelvic organs. A sheet of muscles and ligaments called the pelvic floor supports the uterus, small intestine, colon and bladder. If pelvic floor muscles are weak, your organs may drop. When they do, they bulge into the vagina. When that happens, you may feel like something is falling out of your vagina or you may have a sensation of fullness or pain. It can also become difficult to hold urine or have a bowel movement.

Some women with urine leakage can regain control by losing weight, cutting caffeine or doing special pelvic muscle exercises called Kegel exercises. A mechanical support device called a pessary helps some women. Surgery and medicines are other treatments.

A cystocele occurs when the wall between a woman's bladder and her vagina weakens and stretches, allowing the bladder to bulge into the vagina. This may also be referred to as a prolapsed bladder. In some cases, the bladder may come down as far as -or through -the opening of the vagina. A cystocele may occur from excessive straining, such as during childbirth, chronic constipation or heavy lifting. It may also occur after menopause, when estrogen -which helps keep pelvic muscles strong -decreases. Therefore, older women and those who've given birth to several children are more likely to develop a cystocele. For mild and moderate cystoceles, self-care measures or nonsurgical treatments are often effective. In more severe cases, surgery may be necessary to keep the vagina and other pelvic organs in their proper positions.

An enterocele occurs when the muscles and tissues that hold your small bowel in place stretch or weaken, causing your small bowel to drop from its original position and protrude through your vaginal wall, creating a bulge. The result of an enterocele is a vaginal hernia. For a mild or moderate enterocele, special exercises to strengthen your pelvic floor muscles and other nonsurgical treatments may help relieve symptoms. More severe cases of enterocele may require surgical repair.

A rectocele usually results from prior damage to the fascia that causes it to weaken, such as during childbirth or from excessive straining. It's most common after menopause, when estrogen -which helps keep your pelvic tissues strong -decreases. Mild (small) rectoceles may cause no signs or symptoms. More severe (large) rectoceles may cause a noticeable bulge of tissue through the vaginal opening. Though this bulge may be uncomfortable, it's rarely painful. When treatment of a rectocele is necessary, self-care measures and other nonsurgical options are often effective. In severe cases, you may need surgical repair.

Uterine prolapse means your uterus has dropped from its position within the pelvis into your vagina. Normally, your uterus is held in place by the muscles and ligaments that make up your pelvic floor. Uterine prolapse results when pelvic floor muscles and ligaments weaken, providing inadequate support for the uterus. The uterus then descends into the vaginal canal. Uterine prolapse most often affects postmenopausal women who've had one or more vaginal deliveries. Damage to supportive tissues incurred during pregnancy and childbirth plus the effects of gravity, loss of estrogen and repeated straining over the years can weaken pelvic floor muscles and lead to prolapse. If you experience only mild uterine prolapse, treatment usually isn't needed. But if you experience discomfort or interruption of your lifestyle as a result of uterine prolapse, you might benefit from surgery to repair the prolapse, or you may elect to use a special supportive device (pessary), which is inserted into your vagina.

• A feeling of fullness or pressure in your pelvis and vagina -especially when standing for long periods of time.
• Increased discomfort when you strain, cough, bear down or lift.
• A bulge of tissue that, in severe cases, protrudes through your vaginal opening. The resulting soft bulge may feel walnut- or even grapefruit-sized, and often goes away when you lie down.
• A feeling that you haven't completely emptied your bladder after urinating.
• Loss of urinary control with coughing, laughing or sneezing (stress incontinence). In severe cases, you may not be able to control urination at all.
• Recurrent bladder infections.
• Pain or urinary leakage during sexual intercourse.

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Risk Factors

The following factors may increase your risk of experiencing a cystocele:

• Childbirth. Women who have vaginally delivered multiple children have a higher risk of having prolapse.
• Aging. Your risk of experiencing prolapse increases as you age because you naturally lose muscle and nerve function as you grow older, causing muscles to become stretched or weakened. This is especially true after menopause, when estrogen -which helps keep pelvic muscles strong -decreases.
• Having a hysterectomy. Having your uterus removed may contribute to weakness in your pelvic floor.
• Genetics. Some women are born with weaker connective tissues in their pelvic areas, making them naturally more susceptible to a cystocele.

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Treatment

Treatment depends on the severity of the condition. Mild cases -those with few or no obvious symptoms -may require no treatment or simple self-care measures such as special exercises to strengthen your pelvic floor muscles. If self-care measures aren't effective, treatment may include:

• Pessary. A vaginal pessary is a plastic or rubber ring that's inserted in the vagina to support the bladder by pushing it up and back into place. In some cases, your doctor may recommend using a large tampon or vaginal diaphragm instead of a pessary. Most women who use pessaries do so as a temporary alternative to surgery. But some women may use pessaries for years.
• Estrogen therapy. Your doctor may recommend using estrogen -either orally or in a vaginal cream -if you've already experienced menopause. This is because estrogen, which helps keep pelvic muscles strong, decreases after menopause.

When surgery is necessary
Severe or especially uncomfortable cases of cystocele may require surgery. This surgery is elective and designed to relieve symptoms related to the cystocele.

In most cases, surgery consists of a vaginal repair. In this procedure, a surgeon elevates the prolapse back into place and tightens the muscles and ligaments of your pelvic floor. This procedure may require the removal of some stretched tissue. While the benefits of this type of surgery can last for many years, there's some risk of recurrence. This is partly because pelvic muscles and nerves continue to weaken as you age.