What urogynaecology, prolapse and incontinence mean to women
Affects one out of three women
Pelvic floor disorders are very common affecting approximately one out of two woman. The main forms of pelvic floor disorders include pelvic organ prolapse, urinary incontinence and/or fecal incontinence. It is estimated that approximately one out of every three women in Western societies will have to undergo surgery for pelvic floor disorders in their lifetime.
The function of the pelvic floor
The pelvic floor includes the muscles, connective tissue and ligaments in the lowest part of the pelvis. These structures support the organs that includes the bowel, bladder, uterus, vagina and that rectum. The function off the pelvic floor is to support these structures. When a patient experiences a weakening of the pelvic floor her symptoms may include prolapse into the vagina of any of the above-mentioned organs and/or incontinence of urine and stool.
Effect on quality of life
Pelvic floor disorders can have a major impact on a woman’s quality of life. Woman with prolapse often complain of pressure or a feeling of heaviness or fullness in the vagina. In more severe cases a mass will be visible protruding out of the vagina.
The urge and the leak
There are two forms of incontinence that often affect woman with pelvic floor disorders. Urge incontinence otherwise known as overactive bladder causes woman to wake up frequently at night to void. They also have frequency of urination and/or sudden sensation to void that would can happen without any warning. Woman often then leak on the way to the bathroom. On the other hand stress incontinence happens when there is an increase in abdominal pressure with subsequent leaking. Woman often leak with coughing, laughing, sneezing or physical activity.
Risk factors
Risk factors for pelvic floor disorders include pregnancy, vaginal and instrumental birth, obesity, older age, menopause and ethnicity (Caucasians more affected then Africans).
Preventative steps
Woman can prevent pelvic floor disorders by avoiding activities that increase intra-abdominal pressure (like weightlifting, constipation and chronic coughing). Weight loss or maintenance of a healthy weight is also important. Lastly woman should actively start doing pelvic floor muscle strengthening exercises (also known as Kegal’s excercises) in their forties.
Treatment
Conservative treatment options for woman with incontinence and prolapse include medication, physiotherapy and the use of vaginal pessaries depending on the specific diagnosis.
Woman with symptomatic pelvic floor disorders that do not respond to conservative therapy should be seen by an urogynaecologist or a gynaecologist with an interest in female pelvic floor disorders. Urogynaecology is a new and expanding field that can offer symptomatic woman effective, evidence based treatment with the aim of improving their quality of life.
There are very effective surgical options for woman that suffer from stress incontinence. The current gold standard is the placement of a transvaginal sling. A small sling made out of a non-allergenic, non-absorbable synthetic material is placed underneath the bladder neck through a small incision in the vagina. This is usually done as a day procedure.
It is important to distinguish between stress incontinence and an overactive bladder (urge incontinence) since the treatment differs. First line treatment for overactive bladder normally involves medication that aim to relax the bladder wall. Recently the use of Botox has gained worldwide momentum as a very effective treatment for this condition. This treatment can be administered in a office setting.
Surgery
Vaginal prolapse requires surgery if conservative management is not effective. Depending on which part of the vagina is prolapsed, surgeons will utilize the vaginal or abdominal approach. Surgeons now have the ability to offer the laparoscopic approach rather then the abdominal approach when necessary. Although pelvic organ prolapse surgery is a major surgery the use of the laparoscopic and or vaginal approach is considered minimally invasive and most woman can return home the day following surgery with return to normal activities in 2-6 weeks.
Woman who consider surgery should seek out surgeons with the necessary expertise to perform the correct surgery for the correct diagnosis.
In summary
The key message for pelvic floor disorders is that it is very common amongst woman older then 40. Effective treatment is available. Woman no longer need to suffer in silence. Take the courage to discuss this issue with your health care provider.
Pieter Kruger
Urogynaecologist: University of Cape Town/ Life Vincent Pallotti Hospital
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