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Floored by the pelvis

Pelvic floor disorders are caused by pelvic floor muscles becoming weak or the ligaments and tissues becoming stretched or damaged.

IT isn’t easy being a woman,” one of my patients said to me recently. She had come to me complaining of urinary incontinence and pain in the pelvis.   After examining her, I discovered that she had a prolapse of her bladder and uterus, where her bladder and uterus had dropped down into her vagina.  This was due to a pelvic floor disorder, where her pelvic floor muscles had become weak. This condition is quite common among women, with a study in the United States showing that one in three women suffer from pelvic floor disorders.

Women are prone to pelvic floor disorders due to a number of factors, including pregnancy and childbirth. These conditions can have a negative impact on a woman’s quality of life, but can be treated and prevented if women know how.

What is the pelvic floor?

It might seem strange that you would have a “floor” in your body. The pelvic floor is actually a network of muscles, ligaments, and tissues that form the foundation to support the organs of the pelvis, which are the uterus, vagina, bladder, urethra, and rectum.

Women are prone to pelvic floor disorders due to a number of factors, includingpregnancy and childbirth. – Reuters

Pelvic floor disorders are caused by the muscles becoming weak or the ligaments and tissues becoming stretched or damaged. When this happens, it is unable to support the pelvic organs, like the bladder, urethra, small intestines, rectum, uterus or vagina, which may drop down or protrude into the vagina. If the condition is very severe, the organs may protrude all the way through the opening of the vagina and outside the body.

Women who have undergone vaginal deliveries are more prone to weakened or stretched pelvic floor muscles, and the risk increases with each delivery. Women who have caesarean sections are less at risk of pelvic floor disorders. There are also other factors that can contribute to pelvic floor disorders, such as obesity, chronic coughing, frequent straining during bowel movements, and constant heavy lifting. Women who suffer from disorders that affect the nerves of the pelvic floor, or have weak pelvic tissues, injuries or tumours, are also at high risk of developing the symptoms of pelvic floor disorders.

Knowing the symptoms

Pelvic floor disorders cover a range of conditions, depending on which organ is affected. Generally, however, it is characterised by a feeling of heaviness or pressure in the vagina, caused by the prolapse of the bladder, uterus, or rectum. The prolapsed organ will then cause other symptoms, such as incontinence, pain, or bleeding.  If the muscles supporting the rectum become weak, it will cause the rectum to drop down, a condition called rectocele. This condition can cause difficulty in having bowel movements, akin to constipation.

An enterocele is when the small intestine and the lining of the abdominal cavity bulge downward between the vagina and the rectum. This is caused by weakening of the connective tissue and ligaments supporting the uterus. Women who have this condition may feel a sense of fullness or pressure, or pain in the pelvis.   Sometimes, the weakening tissues can cause the bladder to drop down and protrude into the front wall of the vagina. This can cause involuntary urination when coughing, laughing, or any other action that increases pressure within the abdomen (called stress incontinence), or when the bladder becomes too full (called overflow incontinence).

If the nerves to the bladder or urethra are damaged, a woman may also experience an intense, irrepressible urge to urinate. Even after urination, the bladder may not feel completely empty.  Pelvic floor disorders can also cause prolapse of the uterus, which may bulge into the upper part of the vagina, the middle part, or all the way through the opening of the vagina. This condition may cause pain in the lower back or over the tailbone, or pain during walking. If the cervix protrudes out of the vagina, sores may develop and cause bleeding, discharge, and infection.

Sometimes, the vagina may even prolapse, where the upper part of the vagina drops down into the vagina. This only happens in women who have had a hysterectomy. This condition can cause pain while sitting or walking, or sores to develop. All of the symptoms above related to organ prolapse tend to occur only when women are standing upright, straining, or coughing. When you are lying down and relaxing, the symptoms will go away.

Suffering in silence

Although pelvic floor disorders have severe effects on women’s quality of life, it often goes untreated. This is partly because some women think that bladder incontinence or organ prolapse is part of ageing, while others feel too embarrassed to tell their doctors about the problem.   However, pelvic floor disorders can be treated, with or without surgery, and almost all bladder problems can be improved.

When you see a doctor about your problem, he or she will perform a pelvic examination to check which organs are prolapsed and the severity of it. During this examination, the doctor may ask you to bear down, as if you are having a bowel movement, or to cough – this is to make the symptoms more obvious so that the doctor can make a diagnosis.

If you have urinary problems, the doctor can also perform some tests to check the functioning of the bladder and rectum.  All these examinations will help the doctor to determine the best form of treatment for you.

Getting the ‘floor’ back in order

The most basic form of treatment, and prevention, for pelvic floor disorders involve a form of muscle exercise called “Kegel’s exercises”. These exercises strengthen the pelvic floor muscles, particularly the muscles around the vagina, urethra, and rectum – these are the muscles that are used to stop a stream of urine.  To do these exercises, squeeze these muscles tightly (as if you’re trying to stop the flow of urine) and hold for about one or two seconds, then relax for 10 seconds. Gradually, increase these contractions to about 10 seconds each. Repeat 10 times in a row, several times a day.

You can do Kegel’s exercises while sitting, standing, or lying down – even while doing your normal activities. If the prolapse of the organs is more severe, Kegel’s exercises may not be sufficient. The doctor may recommend you to wear a pessary, which is a diaphragm-, cube-, or doughnut-shaped device that is inserted into the vagina to support the pelvic organs.

Pessaries have to be cleaned every night, and changed every two to three weeks. Good care and hygiene is important because pessaries can irritate the vaginal tissues and cause a foul-smelling discharge if they are not cleaned regularly.  The last resort is surgery, if it is found that Kegel’s exercises and pessaries do not solve the problem. Surgery is only recommended for women who do not want to have any more children.

The type of surgery required depends on the severity of the prolapse. If the woman is also suffering from urinary incontinence, surgery to correct the incontinence will also be carried out at the same time.  Many of the surgical procedures are non-invasive and can be done as outpatient procedures.

There are solutions to the problem of pelvic floor disorders, so if you suffer from any of the symptoms, don’t be shy. Seek your doctor or gynaecologist’s advice for proper treatment.

Sunday, 24 January 2010
Dr Nor Ashikin Mokhtar

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