Urogynecology & Pelvic Health

Patient Information


Pelvic Health

Pelvic health is an emerging field of medicine that focuses on the diagnosis and treatment of pelvic floor disorders. A multidisciplinary team of doctors, nurses, and physical therapists, specialize in problems related to the muscles, ligaments, and connective tissues that support the pelvic floor, the bladder, vagina, uterus, and rectum. Treatment of these complex problems requires recognition of the interconnected nature and importance of pelvic structures, and a wide set of specialized knowledge provided at our center by a team of urogynecologists, urologists, colon and rectal surgeons, physical therapists, psychologists and others. 

Injuries to the pelvic support structures occur during childbirth, heavy lifting, straining such as constipation, menopause, which leads to a weakening of the pelvic floor and a variety of pelvic floor disorders. Symptoms can include sexual dysfunction and pain, pressure, abdominal pain, anemia, and depression.

Pelvic health disorders may be extremely uncomfortable, embarrassing, activity limiting, and painful. Avoidance of treatment can negatively impact the quality of life not just for the patient, but their family, as well. Fortunately, recent national recognition of these underreported and treated problems by the National Institute of Health (NIH) has prompted new interest in the ongoing development our understanding of the disorders of this field. Both medical and surgical treatments are available that can successfully improve and restore pelvic health and continence

The term “pelvic floor” refers to the group of muscles that form a sling or hammock across the opening of a woman’s pelvis.  These muscles, together with their surrounding tissues, keep all of the pelvic organs in place so that the organs can function correctly. 
A pelvic floor disorder occurs when the pelvic muscles and connective tissue in the pelvis weaken or are injured. An estimated one-third of all U.S. women are affected by one type of pelvic floor disorder in her lifetime.  Disorders may result from pelvic surgery, radiation treatments, and, in some cases, pregnancy or vaginal delivery of a child. 

There are a variety of problems related to the pelvic floor.  The most common include:

Pelvic organ prolapse – A “prolapse” occurs when the pelvic muscles and tissue become weak and can no longer hold the organs in place correctly.  In uterine prolapse, the uterus can press down on the vagina, causing it to invert, or even to come out through the vaginal opening.  In vaginal prolapse, the top of the vagina loses support and can drop through the vaginal opening.

Some symptoms of pelvic organ prolapse may include:

  • A feeling of heaviness or fullness or as if something falling out of the vagina.
  • Some women also feel a pulling or aching or a “bulge” in the lower abdomen or pelvis.
  • Prolapse may also cause a kinking in the urethra, making it harder for a woman to empty her bladder completely, or causing frequent urinary tract infections.

Urinary Incontinence – This can occur when the bladder drops down into the vagina.  Because the bladder is not in its proper place symptoms may include uncontrolled leaking of urine, urgency to urinate, frequent urination, and painful urination.

Fecal Incontinence – This can occur when the rectum bulges into or out of the vagina, making it difficult to control the bowels.  It can also occur when there is damage to the anal sphincter, the ring of muscles that keep the anus closed.

Some women don’t need treatment for their pelvic floor disorder. In other cases, treatment for symptoms includes changes in diet, weight control, and other lifestyle changes. Treatment may also include surgery, medication, and use of a device placed in the vagina called a pessary that helps support the pelvic organs. 
Recent NICHD research has found that combining repair surgery with a second surgical procedure can help prevent urinary incontinence later.

Exercises for the pelvic floor muscles (known as Kegel exercises) can often help strengthen the muscles around the openings of the urethra, vagina, and rectum.  Treatments for incontinence can also include medication and bladder or bowel control training.

The team at the UTMB Pelvic Health and Continence Center can evaluate you, advise and assist with all these conditions and treatments. 


Common Terms

Pelvic Health

Some foods and beverages can irritate your bladder, and aggravate or compound an existing pelvic ailment. Depending on your conditions, here are some substances your health care provider at UTMB may advise you to limit or avoid:

  • Alcoholic beverages
  • Apples and apple juice
  • Artificial sweeteners (saccharin and Aspartame)
  • Cantaloupe
  • Carbonated beverages
  • Spicy foods
  • Caffeine
  • Citrus fruit and juices
  • Chocolate
  • Coffee (including decaffeinated)
  • Cranberries and cranberry juice
  • Dairy products
  • Grapes and grape juice
  • Pineapple and pineapple juice
  • Strawberries
  • Sugar
  • Tea (except caffeine free herbal tea)
  • Tomatoes and tomato juice or sauce
  • Vinegar
Refers to infrequent bowel movements, straining, incomplete evacuation, and the need for stool softeners, laxatives, and enemas.

What is a cystocele?

A cystocele occurs when the wall between a woman’s bladder and her vagina weakens and allows the bladder to droop into the vagina. This condition may cause discomfort and problems with emptying the bladder.

A bladder that has dropped from its normal position may cause two kinds of problems—unwanted urine leakage and incomplete emptying of the bladder. In some women, a fallen bladder stretches the opening into the urethra, causing urine leakage when the woman coughs, sneezes, laughs, or moves in any way that puts pressure on the bladder.

What causes a cystocele?

A cystocele may result from muscle straining while giving birth. Other kinds of straining—such as heavy lifting or repeated straining during bowel movements—may also cause the bladder to fall. The hormone estrogen helps keep the muscles around the vagina strong. When women go through menopause—that is, when they stop having menstrual periods—their bodies stop making estrogen, so the muscles around the vagina and bladder may grow weak.

How is a cystocele diagnosed?

A doctor may be able to diagnose the grade of your cystocele from a description of symptoms and from physical examination of the vagina because the fallen part of the bladder will be visible. A voiding cystourethrogram is a test that involves taking x rays of the bladder during urination. This x ray shows the shape of the bladder and lets the doctor see any problems that might block the normal flow of urine. Other tests may be needed to find or rule out problems in other parts of the urinary system.

A cystocele is mild—grade 1—when the bladder droops only a short way into the vagina. With a more severe—grade 2—cystocele, the bladder sinks far enough to reach the opening of the vagina. The most advanced—grade 3—cystocele occurs when the bladder bulges out through the opening of the vagina.

How is a cystocele treated?

Treatment options range from no treatment for a mild cystocele to surgery for a serious cystocele. If a cystocele is not bothersome, the doctor may only recommend avoiding heavy lifting or straining that could cause the cystocele to worsen.

If symptoms are moderately bothersome, the doctor may recommend:

  • Pessary—a device placed in the vagina to hold the bladder in place. Pessaries come in a variety of shapes and sizes to allow the doctor to find the most comfortable fit for the patient. Pessaries must be removed regularly to avoid infection or ulcers.
  • Surgery to move and keep the bladder in a more normal position. This operation may be performed by a gynecologist, a urologist, or a urogynecologist. The most common procedure for cystocele repair is for the surgeon to make an incision in the wall of the vagina and repair the area to tighten the layers of tissue that separate the organs, creating more support for the bladder. The patient may stay in the hospital for several days and take 4 to 6 weeks to recover fully.

National Kidney and Urologic Diseases Information Clearinghouse

This publication is available at www.kidney.niddk.nih.gov. NIH Publication No. 07–4557
August 2007

For More Information

American Urological Association Foundation
1000 Corporate Boulevard
Linthicum, MD 21090
Phone: 1–866–RING–AUA (746–4282) or 410–689–3700
Fax: 410–689–3800
Email: patienteducation@auafoundation.org
Internet: www.urologyhealth.org
www.UrologyHealth.org

American Urogynecologic Society
2025 M Street NW, Suite 800
Washington, DC 20036
Phone: 202–367–1167
Fax: 202–367–2167
Email: info@augs.org
Internet: www.augs.org

National Association for Continence
P.O. Box 1019
Charleston, SC 29402–1019
Phone: 1–800–BLADDER (252–3337) or 843–377–0900
Fax: 843–377–0905
Email: memberservices@nafc.org
Internet: www.nafc.org

This publication may contain information about medications. When prepared, this publication included the most current information available. For updates or for questions about any medications, contact the U.S. Food and Drug Administration toll-free at 1–888–INFO–FDA (1–888–463–6332) or visit www.fda.gov. Consult your doctor for more information.


National Kidney and Urologic Diseases Information Clearinghouse

This publication is available at www.kidney.niddk.nih.gov.


NIH Publication No. 07–4557
August 2007

Uncontrolled, involuntary leaking of stool or gas.

Facts About Hysterectomy:

  • More than 600,000 hysterectomies are performed in the US each year.
  • Hysterectomy is the second most common major operation in women of child bearing age.
  • The most common conditions for hysterectomy are fibroid tumors, endometriosis, and uterine prolapse.

What is hysterectomy?

Hysterectomy is the surgical removal of the uterus.

Reasons for having a hysterectomy:

The following are several possible causes or reasons for hysterectomy:

  • Fibroid tumors
    Non-malignant tumors may grow and become large, causing pressure on other organs and possibly heavy bleeding or pelvic pain.
  • Endometriosis
    Endometrial cells sometimes grow outside of the uterus, attach themselves to other organs in the pelvic cavity, and bleed each month in accordance with an ovarian cycle. This can result in chronic pelvic pain, pain during sex, and prolonged or heavy bleeding.
  • Endometrial hyperplasia
    A cause of abnormal bleeding, this over-thickening of the uterine lining is often due to the presence of very high levels of estrogen.
  • Cancer
    Approximately 10 percent of hysterectomies are performed to treat cancer - either cervical, ovarian, or endometrial.
  • Blockage of the bladder or intestines
    A hysterectomy may be performed if there is a blockage of the bladder or intestines by the uterus or a growth.

What are the different types of hysterectomy?

  • Total hysterectomy
    Includes the removal of the entire uterus, including the fundus (the part of the uterus above the openings of the fallopian tubes) and the cervix, but not the ovaries. This is the most common type of hysterectomy.
  • Hysterectomy with bilateral oophorectomy
    Includes the removal of one or both ovaries, and sometimes the fallopian tubes, along with the uterus.
  • Radical hysterectomy
    Includes the removal of the uterus, cervix, the top portion of the vagina, most of the tissue that surrounds the cervix in the pelvic cavity, and may include the removal of the pelvic lymph nodes. This is done in some cases of cancer.
  • Supracervical hysterectomy (partial or subtotal hysterectomy)
    Removal of the body of the uterus while leaving the cervix intact.

What are the procedures for performing hysterectomy?

  • Abdominal hysterectomy
    The uterus is removed through the abdomen via a surgical incision about six to eight inches long. This procedure is most commonly used when the ovaries and fallopian tubes are being removed, when the uterus is enlarged, or when disease has spread to the pelvic cavity, as in endometriosis or cancer. The main surgical incision can be made either vertically, from the navel down to the pubic bone, or horizontally, along the top of the pubic hairline.
  • Vaginal hysterectomy
    The uterus is removed through the vaginal opening. This procedure is most often used in cases of uterine prolapse, or when vaginal repairs are necessary for related conditions. No external incision is made, which means there is no visible scarring.
  • Laparoscope-assisted vaginal hysterectomy
    Vaginal hysterectomy is performed with the aid of a laparoscope, a thin, flexible tube containing a video camera. Thin tubes are inserted through tiny incisions in the abdomen near the navel. The uterus is then removed in sections through the laparoscope tube or through the vagina.

The type of hysterectomy performed and the technique used to perform the procedure will be determined by your physician, based upon your particular situation.

For women who have not yet reached menopause, having a hysterectomy means that menstruation will no longer occur, nor will pregnancy be possible.

Is a common disorder that is referred to as spastic colon, spastic colitis, mucous colitis or nervous stomach.
Overactive bladder (OAB) is a condition characterized by a sudden, uncomfortable need to urinate with or without urine leakage usually with daytime and nighttime frequency.
Symptoms of pelvic floor dysfunction include constipation and the sensation of incomplete emptying of the rectum when having a bowel movement. Incomplete emptying may result in the individual feeling the need to attempt a bowel movement several times within a short period of time.
Pelvic organ prolapse is the descent of female pelvic organs, including the bladder, uterus and the small or large bowel which results in the protrusion of the vagina, uterus, or both. Factors such as vaginal child birth, advancing age and obesity, vaginal delivery, hysterectomy, and other abnormalities predispose some women to develop pelvic organ prolapse.

Types of pelvic organ prolapse:

  1. Cystocele: occurs when the wall between the bladder and vagina weakens and allows the bladder to protrude into the vagina

  2. Rectocele: is a bulge of the front wall of the rectum into the vagina.

  3. Enterocele: occurs when the small intestine protrudes into the vagina.

  4. Uterine Prolapse: is when the uterus descends from its normal position in the pelvic cavity into the vaginal canal.

In order to restore normal functioning to our patients we offer a variety of individually tailored services.

Symptoms

Vaginal:

  • Sensation of a bulge or protrusion
  • Seeing or feeling a bulge or protrusion
  • Pressure
  • Heaviness

Urinary:

  • Incontinence
  • Frequency
  • Urgency
  • Weak or prolonged urinary stream
  • Hesitancy
  • Feeling of incomplete emptying
  • Manual reduction of prolapse to start or complete voiding
  • Position change to start or complete voiding

Bowel:

  • Incontinence of flatus, or liquid or solid stool
  • Feeling of incomplete emptying
  • Straining during defecation
  • Urgency to defecate
  • Digital evacuation to complete defecation
  • Splinting, or pushing on or around the vagina or perineum, to start off complete defecation

Sexual:

  • Dyspareunia (painful sexual intercourse)
  • Decreased sexual desire due to decreased body image associated with prolapse
Treatment

Women have several options to treating pelvic organ prolapse. Listed below are explanations of those offered by our Pelvic Health Center team.

Non-surgical

Pelvic floor physical therapy is offered by specially trained physical therapists to strengthen the pelvic floor muscles, which are the foundation of lifelong pelvic organ support.

Pessary use is the only currently available, non-surgical intervention for women with pelvic organ prolapse. These devices are inserted into the vagina to reduce prolapse inside the vagina, to provide support to related pelvic structures, and to relieve pressure on the bladder and bowel. Approximately 20 different types of pessaries are available, made either of silicone or plastic. Use of these devices has been reserved for patients with symptomatic pelvic organ prolapse who decline surgery, are poor surgical candidates because of medical conditions or who need temporary relief of pregnancy-related prolapse or incontinence.

Gynecologists fit a patient's pessary based on the nature and extent of the prolapse and the patient's cognitive status, manual dexterity and level of sexual activity. The size of the vagina is estimated and the appropriate size and shape of pessary is inserted such that the prolapse is effectively reduced and the woman is comfortable with the device in place. Follow-up visits are necessary to ensure the pessary is functioning effectively. The most common side effects are vaginal discharge and odor.

Surgical

Traditional

Reconstructive surgery for prolapse aims to correct the prolapsed vagina while maintaining (or improving) vaginal sexual function and relieving any associated pelvic symptoms. Surgery can be undertaken by either an abdominal, laparoscopic (with or without robotic assistance) or vaginal route.

Sacrocolpopexy

The abdominal sacrocolpopexy can be done through an abdominal incision, laparoscopically, and robotically and suspends the upper vagina with synthetic mesh.

Vaginal Approach

For prolapse repairs that are performed vaginally, the surgeon attaches either the upper vagina or cervix to the ligament between the ischial spine and the sacrum (sacrospinous ligament) or to the ligaments between the sacrum and uterus (uterosacral ligaments).

An alternative to reconstructive surgery is obliterative surgery, which closes off the vaginal canal either partially or totally. This procedure is typically reserved for women who are no longer sexually active.

What is pelvic pain?

Pelvic pain is a common complaint among women. Its nature and intensity may fluctuate, and its cause is often obscure. In some cases, no disease is evident. Pelvic pain can be categorized as either acute, meaning the pain is sudden and severe, or chronic, lasting over a period of months or longer. Pelvic pain may originate in genital or extragenital organs in and around the pelvis, or it may be psychological, which can make pain feel worse or actually cause a sensation of pain, when no physical problem is present.

What causes pelvic pain?

Pelvic pain may have multiple causes, including:

  • inflammation or direct irritation of nerves caused by acute or chronic trauma, fibrosis, pressure, or intraperitoneal inflammation
  • muscular contractions or cramps of both smooth and skeletal muscles
  • psychogenic factors, which can cause or aggravate pain

Some of the more common sources of acute pelvic pain, or pain that occurs very suddenly, may include:

  • ectopic pregnancy - a pregnancy that occurs outside the uterus
  • pelvic inflammatory disease (PID) - an infection of the reproductive organs
  • twisted or ruptured ovarian cyst
  • miscarriage or threatened miscarriage
  • urinary tract infection
  • appendicitis
  • ruptured fallopian tube

Some of the conditions which can lead to chronic pelvic pain, pain that may last for several months or longer, may include:

  • menstrual cramps
  • endometriosis
  • uterine fibroids - abnormal growths on or in the uterine wall
  • adhesions - scar tissue between the internal organs in the pelvic cavity
  • endometrial polyps - protrusions attached by a small stem in the uterine cavity
  • cancers of the reproductive tract

This long-term and often unrelenting pain may cause a woman's defenses to break down, resulting in emotional and behavioral changes. This occurrence is often termed "chronic pelvic pain syndrome."

What are the different types of pelvic pain?

The following are examples of the different types of pelvic pain most commonly described by women, and their possible cause or origin. Always consult your physician for a diagnosis.

Type of Pain Possible Cause
localized pain may be due to an inflammation
colicky pain may be caused by spasm in a soft organ, such as the intestine, ureter, or appendix
sudden onset of pain may be caused by a temporary deficiency of blood supply due to an obstruction in the circulation of blood
slowly-developing pain may be due to inflammation of the appendix or an intestinal obstruction
pain involving the entire abdomen may suggest an accumulation of blood, pus, or intestinal contents
pain aggravated by movement or during examination may be a result of irritation in the lining of the abdominal cavity

How is pelvic pain diagnosed?

Diagnostic procedures and tests will be performed in order to determine the cause of the pelvic pain. In addition, your physician may ask you questions regarding the pain such as:

  • When and where does the pain occur?
  • How long does the pain last?
  • Is the pain related to your menstrual cycle, urination, and/or sexual activity?
  • What does the pain feel like (i.e., sharp, dull, etc.)?
  • Under what circumstances did the pain begin?
  • How suddenly did the pain begin?

Additional information about the timing of the pain and the presence of other symptoms related to activities such as eating, sleeping, sexual activity, and movement can also help the physician in determining a diagnosis.

Diagnostic tests for pelvic pain:

In addition to a complete medical history and physical and pelvic examination, diagnostic procedures for pelvic pain may include:

  • blood tests
  • pregnancy test
  • urinalysis
  • culture of cells from the cervix
  • ultrasound - a diagnostic imaging technique which uses high-frequency sound waves to create an image of the internal organs.
  • computed tomography (CT) - a non-invasive procedure that takes cross-sectional images of the internal organs; to detect any abnormalities that may not show up on an ordinary x-ray.
  • magnetic resonance imaging (MRI) - a non-invasive procedure that produces a two-dimensional view of an internal organ or structure.
  • laparoscopy - a minor surgical procedure in which a laparoscope, a thin tube with a lens and a light, is inserted into an incision in the abdominal wall. Using the laparoscope to see into the pelvic area, the physician can determine the locations, extent, and size of the endometrial growths.
  • x-ray - electromagnetic energy used to produce images of bones and internal organs onto film.

Treatment for pelvic pain:

Specific treatment for pelvic pain will be determined by your physician based on:

  • your overall health and medical history
  • extent of condition
  • cause of the condition
  • your tolerance for specific medications, procedures or therapies
  • expectations for the course of the condition
  • your opinion or preference

Treatment may include:

  • antibiotic medications
  • anti-inflammatory and/or pain medications
  • relaxation exercises
  • oral contraceptives (ovulation inhibitors)
  • surgery
  • physical therapy

If a physical cause cannot be found, pelvic pain may be diagnosed as a psychological defense or coping mechanism for some type of trauma. In some cases, psychotherapy is recommended. In other cases, physicians may recommend a multi-disciplinary treatment utilizing a number of different approaches including nutritional modifications, environmental changes, physical therapy, and pain management.


Refers to the condition in which the rectum slips so that it protrudes from the anus.
Refers to the condition in which weakening of the lower vaginal wall causes the rectum to bulge into the vagina.

Millions of women experience involuntary loss of urine called urinary incontinence. For some women, the risk of public embarrassment keeps them from enjoying many activities with their family and friends. Urine loss can also occur during sexual activity and cause tremendous emotional distress.

Women experience urinary incontinence twice as often as men. Pregnancy and childbirth, menopause, and the structure of the female urinary tract account for this difference. But both women and men can become incontinent from neurologic injury, birth defects, stroke, multiple sclerosis, and physical problems associated with aging.

Older women experience urinary incontinence more often than younger women, however incontinence is not inevitable with age.  It is a medical problem. No single treatment works for everyone, but you can find improvement without surgery. Your doctor or nurse can help find you a solution.

Common Causes:

Incontinence occurs because of problems with the muscles and nerves which help to hold or release urine. The body stores urine (water and wastes that are removed by the kidneys) in the bladder (a balloon-like organ). The bladder connects to the urethra which is the tube through which urine leaves the body.

During urination, muscles in the wall of the bladder contract, forcing urine out of the bladder into the urethra. Some women may lose a few drops of urine while running or coughing which is called Stress Urinary Incontinence (SUI). Others may feel a strong, sudden urge to urinate just before losing a large amount of urine, which is called Urge Urinary Incontinence (UUI). Many women experience both symptoms which is called Mixed Urinary Incontinence (MUI).

At the same time, sphincter muscles surrounding the urethra and pelvic floor muscles relax, letting urine pass out of the body. Incontinence will occur if your bladder wall muscles suddenly contact as seen in UUI or the sphincter muscles are not strong mouth to hold back urine as seen in SUI. Urine may escape with less pressure than usual if the muscles are damaged, causing a change in the position of the bladder. Obesity, which is associated with increased abdominal pressure can worsen incontinence. Fortunately, weight loss can reduce its severity.

Types of Urinary Incontinence: 

  • Stress (SUI) - leakage of small amounts of urine during physical movement (coughing, sneezing, exercising).
  • Urge (UUI) - leakage of large amounts of urine at unexpected times, including during sleep.
  • Mixed (MUI) - usually the occurrence of stress and urge incontinence together.
  • Overactive bladder (OAB)- urinary frequency and urgency, with or without urge incontinence.
  • Functional - untimely urination because of physical disability, external obstacles, or problems in thinking or communicating that prevent a person from reaching a toilet.
  • Overflow - unexpected leakage of small amounts of urine because of a full bladder.
  • Transient - leakage that occurs temporarily because of a situation that will pass (infection, taking a new medication, colds with coughing).

Stress incontinence (SUI)

If coughing, laughing, sneezing, lifting or other movements that put pressure on the bladder cause you to leak urine, you may have stress incontinence. Physical changes resulting from pregnancy, childbirth, and menopause often cause stress incontinence. This type of incontinence is common in women and, in many cases, can be treated.

Childbirth and other events can injure the scaffolding that helps support the bladder in women. Pelvic floor muscles, the vagina, and ligaments support your bladder (see figure 2). If these structures weaken, your bladder can move downward, pushing slightly out of the bottom of the pelvis toward the vagina. This prevents muscles that ordinarily force the urethra shut from squeezing as tightly as they should. As a result, urine can leak into the urethra during moments of physical stress. Stress incontinence also occurs if the squeezing muscles weaken. 

Stress incontinence can worsen during the week before your menstrual period. At that time, lowered estrogen levels might lead to lower muscular pressure around the urethra, increasing chances of leakage. The incidence of stress incontinence increases following menopause.

Urge Incontinence (UUI)

If you lose urine for no apparent reason after suddenly feeling the need or urge to urinate, you may have urge incontinence. A common cause of urge incontinence is inappropriate bladder spasms or contractions. Abnormal nerve signals might be the cause of these bladder spasms.

UUI can mean that your bladder empties during sleep, after drinking a small amount of water, or when you touch water or hear it running (as when washing dishes or hearing someone else taking a shower). Certain fluids and medications such as diuretics or emotional states such as anxiety can worsen this condition. Some medical conditions, such as hyperthyroidism and uncontrolled diabetes, can also lead to or worsen urge incontinence.

Involuntary actions of bladder muscles can occur because of damaged bladder muscles or to the nervous system including the bladder, spinal cord and brain or the bladder. Medical conditions which affect the nervous system such as Multiple sclerosis, Parkinson’s disease, Alzheimer’s disease, stroke, and injury—including injury that occurs during surgery—all can harm bladder nerves or muscles and lead to  UUI.

Mixed Urinary Incontinence (MUI)

Stress and urge incontinence often occur together in women. Combinations of incontinence—and this combination in particular—are sometimes referred to as mixed incontinence. Most women don’t have pure stress or urge incontinence, and many studies show that mixed incontinence is the most common type of urine loss in women.

Overactive Bladder (with or without incontinence)

Overactive bladder occurs when abnormal nerves send signals to the bladder at the wrong time, causing its muscles to squeeze without warning. Voiding up to seven times a day is normal for many women, but women with overactive bladder may find that they must urinate even more frequently.

Specifically, the symptoms of overactive bladder include:

  • Urinary frequency - bothersome urination eight or more times a day or two or more times at night
  • Urinary urgency - the sudden, strong need to urinate immediately
  • Urge incontinence - leakage or gushing of urine that follows a sudden, strong urge
  • Nocturia - awaking at night to urinate

Functional Incontinence

People with medical problems that interfere with thinking, moving, or communicating may have trouble reaching a toilet. A person with Alzheimer’s disease, for example, may not think well enough to plan a timely trip to a restroom. A person in a wheelchair may have a hard time getting to a toilet in time. Functional incontinence is the result of these physical and medical conditions. Conditions such as arthritis often develop with age and account for some of the incontinence of elderly women in nursing homes.

Overflow Incontinence

Overflow incontinence happens when the bladder doesn’t empty properly, causing it to spill over. Your doctor can check for this problem. Weak bladder muscles or a blocked urethra can cause this type of incontinence. This is a common cause of incontinence immediately after surgery. Outside of surgery, overflow incontinence is rare in women.

Transient incontinence

Transient incontinence is a temporary version of incontinence. Medications, urinary tract infections, mental impairment, and restricted mobility can all trigger transient incontinence. Severe constipation can cause transient incontinence when the impacted stool pushes against the urinary tract and obstructs outflow. A cold can trigger incontinence, which resolves once the coughing spells cease.

How is incontinence evaluated?

The first step toward relief is to see a doctor who has experience treating incontinence to learn what type you have. Urogynecologist and urologists specialize in the urinary tract.  In addition, physical therapists, often provide rehabilitation services and teach behavioral therapies such as fluid management and pelvic floor strengthening (Kegel exercises).

To diagnose the problem, your doctor will first ask about symptoms and medical history. Your pattern of voiding and urine leakage may suggest the type of incontinence you have. Thus, many specialists begin with having you fill out a bladder diary over several days. These diaries can reveal obvious factors that can help define the problem—including straining and discomfort, fluid intake, use of drugs, recent surgery, and illness. Often you can begin treatment at the first medical visit.

If your diary and medical history do not define the problem, they will at least suggest which tests you need.

Your doctor will physically examine you for signs of medical conditions causing incontinence. In addition, weakness of the pelvic floor leading to incontinence may cause a condition called prolapse, where the vagina or bladder begins to protrude out of your body. This condition is also important to diagnose at the time of an evaluation.

Your doctor may measure your bladder capacity. The doctor may also measure the residual urine for evidence of poorly functioning bladder muscles. To do this, you will urinate into a measuring pan, after which the nurse or doctor will measure any urine remaining in the bladder. Your doctor may also recommend other tests:

  • Urinalysis and urine culture - Laboratory technicians test your urine for evidence of infection, urinary stones, or other contributing causes.
  • Cystoscopy - The doctor inserts a thin tube with a tiny camera in the urethra to see inside the urethra and bladder.
  • Urodynamics - Various techniques measure pressure in the bladder and the flow of urine.

How is incontinence treated?

Behavioral remedies: Bladder retraining and Kegel exercises

By looking at your bladder diary, the doctor may see a pattern and suggest making it a point to use the bathroom at regular timed intervals, a habit called timed voiding. As you gain control, you can extend the time between scheduled trips to the bathroom. Behavioral treatment also includes Kegel exercises to strengthen the muscles that help hold in urine.

How do you do Kegel exercises?

  • The first step is to find the right muscles. One way to find them is to imagine that you are sitting on a marble and want to pick up the marble with your vagina. Imagine sucking or drawing the marble into your vagina.
  • Try not to squeeze other muscles at the same time. Be careful not to tighten your stomach, legs, or buttocks. Squeezing the wrong muscles can put more pressure on your bladder control muscles. Just squeeze the pelvic muscles. Don’t hold your breath. Do not practice while urinating.
  • Exercise routine. Pull in the pelvic muscles and hold for a count up to ten. Then relax for a count of up to ten. Perform a set of 10 exercises in each position- standing, sitting and lying down. Do one set of these exercises in the morning and one set in the evening.
  • Be patient. Don’t give up. It takes just 5 minutes a day. You may not feel your bladder control improve for 3 to 6 weeks. Still, most people do notice an improvement after a few weeks.

Some people with nerve damage cannot tell whether they are doing Kegel exercises correctly. If you are not sure, ask your doctor or nurse to examine you while you try to do them. If it turns out that you are not squeezing the right muscles, you may still be able to learn proper Kegel exercises by doing special training with biofeedback, electrical stimulation, or both.

Overactive Bladder Medications

If you have an overactive bladder, your doctor may prescribe a medicine to block the nerve signals that cause frequent urination and urgency.

Several medicines from a class of drugs called anticholinergics can help relax bladder muscles and prevent bladder spasms. Their most common side effect is dry mouth, although larger doses may cause blurred vision, constipation, a faster heartbeat, and flushing. Other side effects include drowsiness, confusion, or memory loss. If you have glaucoma, ask your ophthalmologist if these drugs are safe for you.

Some medicines can affect the nerves and muscles of the urinary tract in different ways. Pills to treat swelling (edema) or high blood pressure may increase your urine output and contribute to bladder control problems. Talk with your doctor; you may find that taking an alternative to a medicine you already take may solve the problem without adding another prescription.

Scientists are studying other drugs and injections that have not yet received U.S. Food and Drug Administration (FDA) approval for incontinence to see if they are effective treatments for people who were unsuccessful with behavioral therapy or pills.

Biofeedback

Biofeedback uses measuring devices to help you become aware of your body’s functioning. By using electronic devices or diaries to track when your bladder and urethral muscles contract, you can gain control over these muscles. Biofeedback can supplement pelvic muscle exercises and electrical stimulation to relieve stress and urge incontinence.

Neuromodulation

For urge incontinence not responding to behavioral treatments or drugs, stimulation of nerves to the bladder leaving the spine can be effective in some patients. Neuromodulation is the name of this therapy. The FDA has approved a device called InterStim for this purpose. Your doctor will need to test to determine if this device would be helpful to you. The doctor applies an external stimulator to determine if neuromodulation works in you. If you have a 50 percent reduction in symptoms, a surgeon will implant the device. Although neuromodulation can be effective, it is not for everyone. The therapy is expensive, involving surgery with possible surgical revisions and replacement.

Vaginal devices for stress incontinence (SUI)

One of the reasons for SUI may be weak pelvic muscles, the muscles that hold the bladder in place and hold urine inside. A pessary is a stiff ring that a doctor or nurse inserts into the vagina, where it presses against the wall of the vagina and the nearby urethra. The pressure helps reposition the urethra, leading to less stress leakage. If you use a pessary, you should watch for possible vaginal and urinary tract infections and see your doctor regularly.

Injections for stress incontinence (bulking)

A variety of bulking agents, such as collagen and carbon spheres, are available for injection near the urinary sphincter. The doctor injects the bulking agent into tissues around the bladder neck and urethra to make the tissues thicker and close the bladder opening to reduce stress incontinence. After using local anesthesia or sedation, a doctor can inject the material in about half an hour. Over time, the body may slowly eliminate certain bulking agents, so you will need repeat injections. Before you receive an injection, a doctor may perform a skin test to determine whether you could have an allergic reaction to the material. Scientists are testing newer agents, including your own muscle cells, to see if they are effective in treating stress incontinence. Your doctor will discuss which bulking agent may be best for you.

Surgery for stress incontinence SUI

In some women, the bladder can move out of its normal position, especially following childbirth. Surgeons have developed different techniques for supporting the bladder back to its normal position. Today, the main type of surgery for SUI includes two types of sling procedures.

Midurethral slings procedures can be performed on an outpatient basis. These procedures use synthetic mesh materials that the surgeon places midway along the urethra. The two general types of midurethral slings are retropubic slings, such as the transvaginal tapes (TVT), and transobturator slings (TOT). The surgeon makes small incisions behind the pubic bone or just by the sides of the vaginal opening as well as a small incision in the vagina. The surgeon uses specially designed needles to position a synthetic tape under the urethra. The surgeon pulls the ends of the tape through the incisions and adjusts them to provide the right amount of support to the urethra.

If you have pelvic prolapse, your surgeon may recommend an anti-incontinence procedure with a prolapse repair and possibly a hysterectomy. Talk with your doctor about whether surgery will help your condition and what type of surgery is best for you. The procedure you choose may depend on your own preferences or on your surgeon’s experience. Ask what you should expect after the procedure. You may also wish to talk with someone who has recently had the procedure. Surgeons have described more than 200 procedures for stress incontinence, so no single surgery stands out as best.

Catheterization

If you are incontinent because your bladder never empties completely—overflow incontinence—or your bladder cannot empty because of poor muscle tone, past surgery, or spinal cord injury, you might use a catheter to empty your bladder. A catheter is a tube that you can learn to insert through the urethra into the bladder to drain urine. You may use a catheter once in a while or on a constant basis, in which case the tube connects to a bag that you can attach to your leg. If you use an indwelling—long-term—catheter, you should watch for possible urinary tract infections.

Other helpful hints

Many women manage urinary incontinence with menstrual pads that catch slight leakage during activities such as exercising. Also, many people find they can reduce incontinence by restricting certain liquids, such as coffee, tea, caffeinated soda, and alcohol.

Finally, many women are afraid to mention their problem. They may have urinary incontinence that can improve with treatment but remain silent sufferers and resort to wearing absorbent undergarments, or diapers. This practice is unfortunate, because diapering can lead to diminished self-esteem, as well as skin irritation and sores. If you are relying on diapers to manage your incontinence, you and your family should discuss with your doctor the possible effectiveness of treatments such as timed voiding and pelvic muscle exercises.

Source: National Institutes of Health; The National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC) is a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). 

 

Uterine prolapse is falling or sliding of the uterus from its normal position in the pelvic cavity into the vaginal canal.

Causes

The uterus is held in position in the pelvis by muscles, special ligaments, and other tissue,. The uterus drops into the vaginal canal (prolapses) when these muscles and connective tissues weaken.

Uterine prolapse usually happens in women who have had one or more vaginal births. Normal aging and lack of estrogen hormone after menopause may also cause uterine prolapse, Chronic cough and obesity increase the pressure on the pelvic floor and may contribute to the prolapse.. Uterine prolapse can also be caused by a pelvic tumor, although this is rare.

Chronic constipation and the pushing associated with it can worsen uterine prolapse.

Symptoms

  • A feeling as if sitting on a small ball
  • Difficult or painful sexual intercourse
  • Frequent urination or a sudden, urgent need to empty the bladder
  • Low backache
  • Pain during intercourse
  • Protruding of the uterus and cervix through the vaginal opening
  • Repeated bladder infections
  • Sensation of heaviness or pulling in the pelvis
  • Vaginal bleeding or increased vaginal discharge

Many of the symptoms are worse when standing or sitting for long periods of time.

Exams and Tests

A pelvic examination performed while the woman is bearing down (as if trying to push out a baby) will show how far the uterus comes down.

  • Uterine prolapse is mild when the cervix drops into the lower part of the vagina.
  • Uterine prolapse is moderate when the cervix drops out of the vaginal opening.

The pelvic exam may reveal that the bladder, front wall of the vagina (cystocele), or rectum and back wall of the vagina (rectocele) are entering the vaginal area. The urethra and bladder may also be positioned lower in the pelvis than usual.

A mass may be noted on pelvic exam if a tumor is causing the prolapse (this is rare).

Treatment

Treatment is not necessary unless the symptoms are bothersome. Most women seek treatment by the time the uterus drops to the opening of the vagina.

Uterine prolapse can be treated with a vaginal pessary or surgery.

  • Pessary
    • A vaginal pessary is a rubber or plastic donut-shaped device that is inserted into the vagina to hold the uterus in place. It may be a temporary or permanent form of treatment. Vaginal pessaries are fitted for each individual woman. Some pessaries are similar to a diaphragm device used for birth control. Many women can be taught how to insert, clean, and remove the pessary herself.Pessaries may cause an irritating and abnormal smelling discharge, and they require periodic cleaning, sometimes done by the doctor or nurse. In some women, the pessary may rub on and irritate the vaginal wall ( mucosa), and in some cases may damage the vagina. Some pessaries may interfere with normal sexual intercourse by limiting the depth of penetration.
  • Lifestyle changes
    • Weight loss is recommended in women with uterine prolapse who are obese.
    • Heavy lifting or straining should be avoided, because they can worsen symptoms.
    • Coughing can also make symptoms worse. Measures to treat and prevent chronic cough should be tried. If the cough is due to smoking, smoking cessation techniques are recommended.
  • Surgery
    • Surgery should not be done until the prolapse symptoms are worse than the risks of having surgery. The specific type of surgery depends on:
  1. Degree of prolapse
  2. Desire for future pregnancies
  3. Other medical conditions
  4. Desire to retain vaginal function
  5. Age and general health
  • There are some surgical procedures that can be done without removing the uterus, such as a sacrospinous fixation . This procedure involves using nearby ligaments to support the uterus. Other procedures are available.
  • Often, a vaginal hysterectomy is used to correct uterine prolapse. Any sagging of the vaginal walls, urethra, bladder, or rectum can be surgically corrected at the same time.

Prognosis

Most women with mild uterine prolapse do not have bothersome symptoms and don't need treatment.Vaginal pessaries can be effective for many women with uterine prolapse.Surgery usually provides excellent results, however, some women may require treatment again in the future.

Possible Complications

Ulceration and infection of the cervix and vaginal walls may occur in severe cases of uterine prolapse.

Urinary tract infections and other urinary symptoms may occur because of a cystocele. Constipation and hemorrhoids may occur because of a rectocele.

Prevention 

Tightening the pelvic floor muscles using Kegel exercises helps to strengthen the muscles and reduces the risk of uterine prolapse.

Estrogen therapy, either vaginal or oral, in postmenopausal women may help maintain connective tissue and muscle tone.

URL of this page: http://www.nlm.nih.gov/medlineplus/ency/article/001508.htm 

References

Lentz GM. Anatomic defects of the abdominal wall and pelvic floor: abdominal and inguinal hernias, cystocele, urethrocele, enterocele, rectocele, uterine and vaginal prolapse, and rectal incontinence: diagnosis and management. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, eds. Comprehensive Gynecology. 5th ed. Philadelphia, PA: Mosby Elsevier;2007:chap 20.

Update Date: 5/12/2008 

Updated by: Linda J. Vorvick, MD, Medical Director, MEDEX Northwest Division of Physician Assistant Studies, University of Washington, School of Medicine; Susan Storck, MD, FACOG, Chief, Eastside Department of Obstetrics and Gynecology, Group Health Cooperative of Puget Sound, Redmond, Washington; Clinical Teaching Faculty, Department of Obstetrics and Gynecology, University of Washington School of Medicine. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

In vaginal prolapse the vagina stretches or expands to protrude on other organs and structures. The situation seldom involves the vagina alone. Supports for the uterus often stretch allowing it to also prolapse when a woman strains during a bowel movement.

Vaginal childbirth, especially multiple births and aging are the primary risk factors. Prolonged labor and large children can stretch and weaken pelvic floor muscles leading to weakened support for the vagina. This does not happen in all women but does happen in many who may not recover completely from the birthing process. Menopause initiates a host of changes in a woman’s body, which can affect pelvic region muscle tone.

Aging in general weakens muscles throughout the body including the pelvic region. Other factors such as obesity and chronic coughing associated with asthma, smoking and respiratory disease are also associated with weakening these muscles. Chronic constipation and bearing down to expel waste can weaken pelvic muscles.

Symptoms

Many women do not have any symptoms. Those that have symptoms may note a fullness or discomfort in the vagina, a sensation of heaviness or pulling in the pelvis and/or low backache that is relieved when lying down.

  • Urinary frequency and/or stress incontinence.
  • Difficulty with bowel movements is associated with rectocele.
  • Intercourse may be difficult or painful in women with prolapse.

Women without symptoms are often diagnosed with the problem during routine gynecological examinations. Symptomatic women are also usually diagnosed by their gynecologist. The problem is apparent to these specialists who can diagnose it with a thorough medical history and physical exam. Laboratory testing or imaging studies are rarely needed.

As with most medical conditions, conservative approaches are employed first. These are primarily pelvic exercises designed to strengthen the muscles in the entire region. Women whose age or physical condition may prohibit exercise may be fitted with a pessary, a vinyl ring inserted in the vagina to hold the prolapse in place.

Surgical options

If conservative measures fail, surgery may be employed after thorough consultation with specialists. Subjects that may be discussed during consultation include the woman's age and general health, desire for future pregnancies, her wish to preserve vaginal function, the degree of prolapse and anatomic conditions that affect decisions as to which surgical procedure to pursue. For instance, a hysterectomy (removal of the uterus) may be required when significant prolapse is present.

There are two primary approaches depending on the condition. Many surgeries are conducted through the vagina. This approach leaves no scars. Laparoscopy is an increasingly sought after method of repairing prolapse. These surgical procedures are conducted through narrow tubes inserted through incisions less than an inch long. These procedures have been shown to reduce scarring, blood loss, and hospital stays, and speed recovery times.

A surgical procedure called anterior colporrhaphy tightens the front walls of the vagina. Posterior colporrhaphy tightens the back walls. Laparoscopic procedures are employed to relieve stress incontinence, repair hernias at the top of the vagina, and to create support for vaginas that have become weakened by a hysterectomy. In instances in which supporting tissues have been weakened, additional natural tissue or artificial materials (mesh) may be placed to support the repair.

Hospitalization is brief, usually a day, sometimes two and seldom more than four. Patients are released with prescriptions for pain killers and antibiotics to prevent infection.

Urogynecology & Pelvic Health Locations

Female Anatomy

Endometrium- the lining of the uterus.

Uterus- also called the womb, the uterus is a hollow, pear-shaped organ located in a woman's lower abdomen, between the bladder and the rectum.

Ovaries- two female reproductive organs located in the pelvis.

Cervix- the lower, narrow part of the uterus (womb) located between the bladder and the rectum. It forms a canal that opens into the vagina, which leads to the outside of the body.

Vagina- the passageway through which fluid passes out of the body during menstrual periods. It is also called the "birth canal." The vagina connects the cervix (the opening of the womb, or uterus) and the vulva (the external genitalia).

Vulva- the external portion of the female genital organs.


Source, and additional information on pelvic floor disorders, are available from the National Institutes of Health.