Category — Pelvic Organ Prolapse

Dr. R’s blogpost  A word from the wise on Prolene mesh and your prolapse surgery is featured in the esteemed Grand Rounds Medical Blogsite hosted this week at   FDAzilla by Tony Chen. Included with a dozen or so other blogposts on the complications of interacting with the FDA, we highly recommend a perusal of the participating blogs on topics such as The Great Autism Vaccine Fraud by the “ancient but awesome” Joel Shurkin, Dr. Pullen’s top 6 rules of wicked good medicine, and a A Swedish man forced to amputate his cancer-ridden penis after waiting a year for treatment, to name a few. Enjoy!

Uterine Prolapse – The Facts

Uterine prolapse affects 30% of ALL women, so there’s a good chance that it will touch you or someone you know. But before you can comprehend uterine prolapse, you need to have a basic understanding of a woman’s pelvis.

The vagina is the foundation of female anatomy, while the cervix sits above the vagina, and the uterus above the cervix. Connective tissue called uterosacral ligaments hold the uterus and cervix in place.

When it comes to uterine support, it's all about the uterosacral ligaments...

As the primary support system for the entire female pelvis, the uterosacral ligaments are extremely important! Uterine prolapse occurs when collagen fibers in these ligaments stretch or weaken, causing the cervix and uterus to drop down to the vaginal canal. If it drops far enough, it’s possible to feel and see the cervix, which looks like a small pink donut.

Although this is not usually painful, a woman may experience feelings of heaviness or pulling in the pelvis. Other symptoms of uterine prolapse may include painful sex, low backache, frequent urination, or even vaginal bleeding, although the converse is not always true, i.e; every women with frequent urination or low back pain or vaginal bleeding does not necessarily suffer uterine prolapse, as there are many reasons, prolapse among them, for each of these conditions. Your gynecologist can help sort out whether or not you are suffering uterine prolapse.

Like I said, it's all about the ligaments

A number of things can contribute to uterine prolapse. Women who give birth vaginally are more likely to experience thinning and stretching of the supportive uterosacral ligaments,especially those who experience long labors or deliver big babies. Prolapse is also more likely in women over 50, because muscle tone and onnective tissue integrity decreases with age.

Research also suggests that some women may be genetically predisposed to uterine prolapse. In other words, you can’t always PREVENT uterine prolapse, but you CAN learn about treatment options.

One effective treatment choice is a pessary, which is a vaginal support made of rubber, plastic, or silicone. A doctor fits a woman’s pessary to her body to hold the prolapse comfortably in place.

Surgery is another option, which, unlike a pessary, actually REPAIRS the prolapse. As with all surgeries, complications, including but not limited to recurrence of prolapse, are possible so make sure you understand both the risks and the benefits if you are considering prolapse surgery.

According to US Dept of Health data, one in nine cases of uterine prolapse is severe enough to warrant surgery. The good news is that uterine prolapse IS fixable without resorting to hysterectomy, so if you’re suffering uterine prolapse, understand that you don’t have to choose between hysterectomy or pessary, you have the option of uterine resuspension, hysterectomy-type prolapse repair, or pessary support.

To learn more about this and other pelvic floor conditions, visit Dr R video on HealthGuru.com.

(c) 2010 Lauri Romanzi

In the Hausa/Fulani region of Northern Nigeria and Southern Niger, “Gishiri” is the term for salt, for “tasty” and slang for the genitalia of both sexes. “Yankan” is the word for cutting, and “Yankan Gishiri” (cutting with salt) has been used for generations as a local remedy for all sorts of ailments and conditions, including:
Pain with sex (dyspareunia)

Infertility

Pelvic Organ Prolapse (dropped bladder, rectocele, uterine prolapse…)

Boils

Itching

Urinary Retention (inability to urinate)

Prolonged Labor

Episiotomy

This remarkably harsh home remedy involved rock salt in it’s traditional form, but now, in the new millenium, Gishiri cuts are made either by a barber with a knife, or a local birth attendant with a razor. Seems a bit backwards- you might expect the barber to use the razor and the lay midwife to use a knife, but this is not the case, according to today’s presentation of “Yankan Gishiri” data at the 4^th annual meeting of the International Society of Obstetric Fistula Surgeons by Dr. Amir Yola from Kano, Nigeria.

As you can imagine, these cuts can do damage, including urinary or fecal incontinence from damage to the urethral or anal sphincters, or full thickness holes, or fistula, between bladder and vagina, urethra and vagina, or rectum and vagina.

Fistula after Gishiri cuts result from deep cuts that heal open, creating a fistula defect. Of 1372 fistula patients treated by Dr. Yola and his team in Kano, Nigeria, 78 (5.7%) of the fistula were the result of “Yankan Gishiri”.

How’s that for “pouring salt on the wound”?

A Yankan Gishiri-free view with which to recuperate from this blogpost

NOV 23, 2010

(c) L Romanzi 2010

The Step-Sisters of Fistula – Minimally Invasive Uterine Resuspension- Hysteropexy C’est Arrive au DR Congo.

The Stuff of Prolapse *image courtesy of "Women of the Shadows"

It is difficult to express how impressed I am during each and every Harvard Humanitarian Initiative mission (www.hhi.harvard.edu) by the  skilled, motivated, and wise  pelvic floor – fistula surgeons at Panzi Hospital in Bukavu, DRC.  On these many fistula-repair missions, I’ve come to understand that one of the most important ways to add value to colleagues upon whom we descend in our zealous compulsion to fix every woman with a fistula, is to realize that, in addition to the tragic, fashionable and international charity-funded fistula women found in every developing nation on the planet, there are women in these same villages suffering equal stigma, ostracism, divorce and abandonment as their fistulous sisters because they suffer incontinence of urine or stool, or waddle about in a state of severe pelvic organ prolapse. The prolapsing cervix can look a lot like the head of a penis, and many’s the woman accused of infidelity by the husband to whom she birthed all the children and for whom she’s carried all the loads of wood, water and supplies on her head that caused the prolapse in the first place. As if she had a single ounce of energy with which to seek out and fornicate with a man other than her husband – peeleeze.  Anyhow, this sort of tragi-comic mythology surrounds many medical and surgical conditions when the people suffering said conditions do so without the benefit of education and absolutely zero comprehension of internal anatomy. You have a fistula because you are possessed by evil spirits, you have prolapse because you cheated on your husband, you died from hemorrhage after your clitoris and labia were cut off ritualistically to transform you into a marriageable chattel because you were committing the ultimate sin of pleasuring yourself to the always dangerous female orgasm. Things like that.  Feel free to throw the conditions and myths into a hat to play the game of “mix and match”. It’s all the same, as are the personal ramifications – you’re divorced, thrown out of your house, often permanently separated from your children, and excommunicated from your village, this being the only home you’ve ever known and the only people that ever mattered to you since the day you were born.

The uterosacral/cardinal ligament complex holds the uterus in place

Unlike the condition of fistula, prolapse and incontinence don’t “go away” with modern medicine, new world economics or robust personal health and wealth. Even the well-healed at the Hampton Classic include wealthy ladies who are wetting their pants and wishing their parts would stay all up in there where they belong. While fistula vanished with the advent of ether anesthesia in the mid-1800’s, rendering vaginal fistula nearly obsolete in Europe and North America well in advance of the 1900 centennial, (the world’s first fistula hospital was in New York City, torn down when rendered obsolete by access to Cesarean section, replaced by the still present Waldorf Astoria Hotel on Park Avenue), prolapse and incontinence continue to plague even the wealthiest, best educated, most fashionable of women on the planet.  But fistula virtually disappeared as anesthesia made Cesarean section the cornerstone of optimal obstetrical practice and stellar reduction in Euro-American maternal mortality and morbidity statistics, because fistulas come from obstructed labors, and no one in a developed nation is allowed to suffer through a 2 week labor resulting in a dead baby and a destroyed, fistulous vagina. We just do a Cesarean if it’s taking too long. The luxury of quick, routine, easy access to Cesarean section remains unavailable to the majority of women in Sub-Saharan Africa and other impoverished nations.

So this time, rather than play the “American fistula heroine” game, I decided to back it up into the unglamorous territory of plain old US/European style pelvic floor disorders, these being pelvic organ prolapse and urinary incontinence. While these un-funded (they’re not on UNFPA’s radar at all) women have no international advocate, yet they are equally tortured and punished for these conditions that are beyond their control as is any fistula victim’s.

We started with prolapse patients today. Magically, (there’s a lot of magic in DRC), after being informed that there was only a single prolapse patient, 10 emerged from the ether, each with the most severe form of prolaase, called procidentia. Procidentia (remove the children from the room and erase this link from your laptop history, quickly!) is a total pelvic disaster easily diagnosed by visualizing the cervix dangling between the patient’s thighs, turning the bladder upside down and kinking the urethra and rectum in the process. It’s mortifying.

From Beverly Hills to Bukavu, uterine prolapse is all about the uterosacral ligaments

We started the day with a lecture-discussion where we engaged in robust, healthy debate about current theory and principle held true among international pelvic floor disorder specialists – with the exception of avoiding hysterectomy by utilizing uterine resuspension – in the States, with rare exception, uterine prolapse = hysterectomy unless the woman can find a pelvic floor specialist who understands that the uterus is the victim of prolapse, not the cause.

This notion of preserving the uterus even though it’s falling out my Congolese colleagues understood, given the large number of young women whose lives would be equally destroyed by hysterectomy as they are by the prolapse.  Here at Panzi they use a large abdominal incision to resuspend the uterus by shortening the round ligaments of the uterus, a somewhat dated technique used very rarely inEurope and North America currently because it tends to fail and distorts pelvic and vaginal anatomy. These round ligaments contribute little (or so we believe) to the vector support of the uterus, the starring role of which falls to the ligament pair known as the uterosacral (US) ligaments. These US ligaments are like 2 cables, holding up the uterus and cervix by suspension at the top of the vagina much like a chandelier is held up by cables in the ceiling of a room.

We talked about compartment analysis, evaluating the support of the uterus (Apex), followed by evaluation of the stuff of vaginal prolapse and vaginal laxity below the level of the uterus, bladder for cystocele (Anterior) and rectum for rectocele and perineocele (Posterior), and evaluation of the levator (a.k.a. Kegel) muscles separately. We reviewed the role and evaluation of the Kegel muscles and the support and potential childbirth damage to the all-important and under-appreciated perineal body (connective tissue separating vagina from rectum). We debated and evaluated each continent prolapse patient for occult stress incontinence by filling the bladder, holding the prolapsed parts in proper anatomic position as the might be after surgical reconstruction, and asking the patient to cough and strain to see if urine leaks with abdominal exertion – the finding consistent with stress incontinence. Shocker, just like we find in the States, 40% of these women with bad prolapse and no incontinence symptoms leaked like sieves with full bladders and the prolapse temporarily corrected with vaginal support, and these women will undergo incontinence sling for stress incontinence at the time of their prolapse reconstruction. Tomorrow, in the OR (operating room), the Congolese fistula surgeons of Panzi Hospital (www.panzihospitalbukavu.org) will be the first to perform vaginal uterosacral uterine resuspension (a.k.a. hysteropexy) in Central Africa.

In 2008 the FDA posted a warning (FDA warning on use of mesh in prolapse and incontinence repairs) on the use of prolene mesh in reconstructive female pelvic surgery.  This warning came from the plethora of complaints registered with the FDA from patients with prolapse repaired with various formulations of a plastic mesh called Prolene.  The weft and warp of this mesh has been tweaked by the surgical supply corporations that develop and market “mesh kit” procedures to reconstructive pelvic surgeons worldwide in an effort to address these concerns and assure surgeons and patients that plastic mesh is safe for use in pelvic organ prolapse and urinary incontinence repairs.

Personally, I love using prolene mesh at the top of the vagina for an old-school operation used for decades called a sacrocolpopexy (or its uterine-preserving cousin, the sacrohysteropexy),  and I love using tiny ribbon sized prolene mesh slings for stress urinary incontinence.  When the application for cystocele and rectocele repair first came into the surgical marketplace, I jumped right on board, believing that I’d get superior durability and the same complication rate (almost none) that we see with the older sacrocolpopexy and urethral sling applications. I was wrong, as my first dozen patients quickly began to demonstrate all varieties of complications delineated in the FDA warning that came years later. Immediately pulling it from my armamentarium, I notified the company of my concerns, and was summarily ignored.

I find the bigger, palm-sized surface areas of mesh used in these super-thin layers between bladder/vagina to lift fallen bladders (cystoceles) and rectum/vagina to support bulging rectums (rectoceles),  to be a source of “more harm than good”  since these prolapse “kits” first came out in the late 90′s.  But I love using this material for incontinence slings, and I love using it for supporting uterine prolapse or vaginal vault prolapse after hysterectomy, and I worry that this nightmarish application in the more delicate front and back walls of the vagina (where cystoceles and rectoceles occur) will end not with a “no cystocele or rectocele” limitation on Prolene mesh in the female pelvis, but a wholesale, full on FDA recall of all Prolene mesh for reconstructive pelvic surgery including my beloved urethral sling and sacrocolpopexy applications. Such a complete FDA recall would be,  in my opinion, akin to throwing the baby out with the bathwater. I hope to be wrong, because it sure looks like a recall of some sort is in the making.

Reconstructive pelvic surgeons borrowed the concept of “large surface area prolene grafting” for cystocele and rectocele from our hernia surgeon colleagues, who found Prolene mesh helpful in reducing the recurrence of abdominal wall (groin, inguinal, femoral, incisional) hernias. Cystoceles and rectoceles are, in essence, hernias of the vagina, so borrowing this application from hernia surgeons made since. We did not realize that the thin vaginal skin would not react so obligingly as the abdominal wall does to the presence of plastic mesh, and in short order, we’ve found that Prolene mesh in the vagina erodes, constricts, degrades, and generally wreaks havoc in women whose bodies don’t tolerate it.  Nor does Prolene mesh for cytoceles and rectoceles eliminate prolapse recurrence – I’ve taken prolene mesh for cystocele and rectocele repairs out of many a vagina where not only is the plastic mesh eroding through the vagina, the bladder and/or the rectum, but also hanging out of the body, attached to the recurrent cystocele (dropped bladder) or rectocele (bulging rectum).

The kit-making corporations have responded by initiating all sorts of changes to various mesh parameters, each claiming new-found superiority, most if not all of which can be best categorized as “wishful thinking” or truth by consensus opinion, or the emperor wears no clothes, or whatever other label you’d like to apply.

Below find a review from the founder of Urogynecology, Dr. Donald Ostergard, who continues to champion what’s best over what’s fashionable.

Ostergard, D. Polypropylene vaginal mesh grafts in gynecology. Obstet Gynecol 2010;116:962-6.

This review presents the basic concepts for the use of polyporpylene mesh in the treatment of prolapse and incontinence, discussing clinical and biomechanical prolene mesh factors that contribute to mesh infection, inflammation, scar, contraction, erosion and dyspareunia.

The review begins by pointing out that the use of these mesh grafts gained clinical traction without the benefit of evidence based clinical trials. The factors contributing to complications include infection, pore size, multi vs mono filament mesh, low vs high density mesh, pore depth, neovascularization variability, surface area, rigidity, elasticity, shrinkage, encapsulation wicking, surface character, degradation, toxic prolene compounds, weight, brittleness, oxidation, patient variability (high vs low responders), and surgical technique.

The known pathophysiology of prolene mesh bacterial colonization is detailed to demonstrate the unpredictability of infection risk regardless of technique and manner of antibiotic use, including quiescent infections that can occur even when the mesh is optimized for filament and pore size.

Electron microscope images illustrate degradation of in situ mesh that occurs in response to body heat and macrophage secretion of H202 and hypochlorous acid. Such oxidation may instigate autoimmune rejection and increase mesh brittleness.

Lack of data for the impact of low estrogen levels on rates of erosion and poor healing after prolene mesh insertion is reviewed, as are the lack of evidence that prolene mesh is improved by coating it with other materials, such as porcine derivatives.

The 30-50% shrinkage rate is reviewed as a major factor in neuroma formation, vaginal distortion and dyspareunia that is often clinically challenging to treat successfully once so induced, to the degree that the FDA issued a warning in 2008 stating that patients should be warned that complications of mesh insertion may not be correctable.

Prolene mesh configurations that reduce degradation are reviewed, including monofilament (33% degradation vs  75% multifilament),  and low density (21% vs 48% high density).

Interestingly, one synthetic permanent material, polyester, was found to have no degradation after 3 years implantation in one recent study included in this review.

The need to optimize pore and filament size, reduce degradation,  shrinkage infection and stiffness while allowing for variability among patients (low vs high responders) must all be concomitantly considered and properly evaluated as the development of new mesh grafts continues.

(c) 2010 Lauri Romanzi

Pelvic organ prolapse, difficult urination, frequency, urgency and overactive bladder – for some women, it’s all related.

(C) Lauri Romanzi 2010

Pelvic organ prolapse and overactive bladder. de Boer TA, et al. Neurourol Urodyn. 2010;29(1):30-9.

Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands.

Medical research comes in several forms. This particular study gathered all the research already published on the topic, pooling all the data in one big group for re-analysis. Called meta-analysis, studies that pool data from other studies advance medical science by reviewing smaller clinical trials to figure out if the findings have anything in common that might thereby be considered “true”.

courtesy womensvoicesforchange.org

Look at this picture – what a mess. There’s no way bladders caught in the clutches of severe pelvic organ prolapse can function properly. The urethra, a 2-3 inch straw-shaped tube that allows urine to pass out of the bladder, is often kinked or compressed by the prolapse. The muscles in the bladder wall, normally located above the urethra, are now below the urethra, forced to fight the mighty forces of gravity and the kinked or compressed urethra, in order to empty, and as a result, the emptying is often incomplete. So the bladder fills up more quickly, starting a whole cascade of symptoms, enough to make any bladder crazy.

Not emptying fully, the bladder fills more quickly. Result? Frequency. And a propensity to bladder infections from all that stagnant urine. You used to urinate a few times a day without much thought, but now bladder management is a part-time job. Urine flow is very slow, dribbling, and sometimes stop – and – start.  This condition is called bladder outlet obstruction.

Contracting extra-hard in this upside down position in order to bypass gravity and urethral obstruction from all that kinking or compression, the bladder starts to misfire, suddenly contracting without any warning of fullness, as if it can’t make up it’s mind. Result? Urgency, that horrible sensation of needing to get to the bathroom RIGHT NOW and wondering if you’re going to make it in time. Or not making it in time, literally peeing in your pants on your mad dash to the water closet (urge incontinence). This condition is called overactive bladder.

courtesy "Plumbing and Renovations"

The common findings in the studies included in this meta-analysis showed that any method of successfully managing the prolapse, be it pessary or surgery, allowed the bladder to return to normal function. Anything that un-kinks the urethra, re-positions the bladder so that it’s on top of, instead of underneath, the urethra, and repositions all the pelvic organs to their normal location will normalize bladder function in most cases. Why is this an important finding? Because it helps doctors understand that, in a woman with prolapse and bladder problems, just fixing the prolapse ought to fix the bladder problems, without overactive bladder medications or the need for constant antibiotics to fight all those urinary tract infections.

Here is a synopsis of the data (aka abstract) of this study:

Abstract

AIMS: In this review we try to shed light on the following questions: *How frequently are symptoms of overactive bladder (OAB) and is detrusor overactivity (DO) present in patients with pelvic organ prolapse (POP) and is there a difference from women without POP? *Does the presence of OAB symptoms depend on the prolapsed compartment and/or stage of the prolapse? *What is the possible pathophysiology of OAB in POP? *Do OAB symptoms and DO change after conservative or surgical treatment of POP? METHODS: We searched on Medline and Embase for relevant studies. We only included studies in which actual data about OAB symptoms were available. All data for prolapse surgery were without the results of concomitant stress urinary incontinence (SUI) surgery. RESULTS: Community- and hospital-based studies showed that the prevalence of OAB symptoms was greater in patients with POP than without POP. No evidence was found for a relationship between the compartment or stage of the prolapse and the presence of OAB symptoms. All treatments for POP (surgery, pessaries) resulted in an improvement in OAB symptoms. It is unclear what predicts whether OAB symptoms disappear or not. When there is concomitant DO and POP, following POP surgery DO disappear in a proportion of the patients. Bladder outlet obstruction is likely to be the most important mechanism by which POP induces OAB symptoms and DO signs. However, several other mechanisms might also play a role. CONCLUSIONS: There are strong indications that there is a causal relationship between OAB and POP

(C) Lauri Romanzi 2010

Pelvic floor disorders include problems with urinary incontinence, pelvic organ prolapse, fecal incontinence, fistula, urinary tract infections, and mechanical sexual dysfunction. Who wants to think about this stuff?  Well, for starters, women who suffer these disastrous conditions.

Pelvic organ prolapse, on which I’ve written aplenty, can sometimes induce a rather nasty condition called overactive bladder. Overactive bladder happens when your bladder muscle (yes, the bladder is a muscle, an automatic muscle, like the muscles in your intestines or your heart) decides to EVACUATE, any time it wants to, whether you’re on the toilet or riding the bus. Women with overactive bladder often report a compelling, sometimes sudden urge to void (urinate) that is difficult or impossible to defer. She may find her bladder waking her from deep sleep many times at night with this same horrible urgency. When this urgency control is “difficult”, she’s Kegeling her legs off, squeezing her thighs together and sweating bullets trying to make that horrible urge feeling stop so she can uncross her legs and dash to the nearest powder room. When the urge to void is “impossible” to defer, she wets her pants. It’s messy, horrifying, and terribly unsexy.

Urge Incontinence from Overactive Bladder

While most cases of overactive  bladder are idiopathic (medicalese for “no apparent cause”), some cases are caused by prolapse.  When the bladder or uterus (or both) prolapse, the urethra can be kinked or compressed, obstructing urine outflow and making it difficult for the bladder to empty completely. Obstructed bladders are cranky bladders, often becoming overactive in response to this interference with emptying.

A recent multicenter European study published in Neurourology and Urodynamics showed a distinct correlation between severe pelvic organ prolapse, bladder outlet obstuction, and overactive bladder. Prolapse can obstruct bladder outflow and if it does, the bladder tends to become overactive, reminiscent of that vaudeville song, “The head bone’s connected to the … neck bone…”.  In this timely review, they also found that successful prolapse surgery often, but not always, calmed down bladder overactivity by un-blocking the urethra and normalizing bladder outflow. The connection between prolapse, bladder outlet obstruction and overactive bladder

Women with prolapse and bladder problems often want to know if surgery will fix both. This study helps us understand that it indeed may help fix both the prolapse and the obstructed/overactive bladder disorders in a large portion of women with this unhappy combination. For years, I’ve used pessaries (vaginal widgets that comfortably hold prolapse in place) to help predict whether or not prolapse surgery might also stop obstructed voiding and overactive bladder, and most of the time it correlates well to surgical outcome. And sometimes, the patient is so pleased with the pessary that she cancels the operation.

For a detailed case report on women with prolapse, obstructed voiding and overactive bladder, click on this MedScape review:

Dr R for MedScape- prolapse, overactive bladder, stress incontinence, obstructed bladder

http://cme.medscape.com/viewarticle/700135

One last note for women with prolapse and bladder problems – there is another urinary incontinence condition, called stress incontinence, that may actually increase with pessary use or prolapse surgery, because a stress – incontinent urethra may actually seal better with the kinking and compression caused by prolapse, and may therefore increase when the prolapse and kinking are mechanically corrected. Stress incontinence is caused by poor urethral closure that allows urine to leak out with strenuous physical exertion, like sneezing or coughing or opening a window or lifting heavy grocery bags. No urgency, just “exert and squirt”.

Stress Urinary Incontinence = "Exert and Squirt"

If you have prolapse and stress incontinence, your problems require therapies for prolapse and therapies for stress incontinence. Prolapse therapy options usually involve pessary use or reconstructive surgery. Stress incontinence options include Kegel exercises with pelvic floor physical therapy, medications, or procedures such as urethral bulking injections or minimally invasive sling operations. You can do prolapse reconstruction and urethral sling in one operation, for instance, taking care of both your plumbing and your renovation problems at the same time (on Plumbing and Renovations).

Prolapse or no prolapse, urge incontinence from overactive bladder and stress incontinence from a weak urethral seal can plague any woman at any age. About 13% of women with overactive bladder are under the age of 35, and up to 30% college female athletes report regular urinary incontinence of one sort or another during training and competition. It comes with the territory, and it increases in prevalence as women age.

1/3 of incontinent women suffer only stress incontinence, 1/3 only urge (overactive bladder) incontinence and 1/3 suffer a mixture of both overactive bladder / urge incontinence AND stress incontinence.

If you have incontinence, or prolapse and bladder problems, make sure you don’t undertake any therapeutic measures without first understanding if you have overactive bladder, bladder outlet obstruction, and/or stress urinary incontinence. It is absolutely possible, and not at all uncommon, to have all three conditions if you suffer severe prolapse. Take the time to sort it all out, make sure it’s clear in your mind, then work with your doctor to set a common-sense course of action to restore your core to normal anatomic and physiologic function.

(C) Lauri Romanzi, 2010

Pelvic organ prolapse, the medical term for vaginal bulges caused by damage to the connective tissues supporting the organs above and around the vagina (the uterus, bladder, rectum and vaginal opening), is a silent epidemic affecting women worldwide. Common terms include dropped bladder, dropped uterus, rectocele and vaginal laxity. Recent estimates using US Census population projections anticipate a 46 percent increase in pelvic organ prolapse among American women over the next 40 years, from 3.3 million in 2010 to 4.9 million. According to a recent study from Duke University, it is possible that the number of women with prolapse will be even greater than this, up to 9.2 million. Prolapse may occur to varying degrees in up to 50 percent of women who’ve given birth. Prolapse can even cause depression.

Childbirth contributes to most prolapse conditions, however genetics, medical disorders such as connective tissue disease, diabetes and obesity, and lifestyle habits have all been shown to contribute to pelvic organ prolapse risk. I’ve had many young women in their 30′s with prolapse who’ve never been pregnant, or found themselves suffering a dropped bladder after an easy and quick delivery of their first normal (or even low) weight baby. Even cesarean section is no guarantee against pelvic organ prolapse, with 5% of women in one recent study suffering severe, palpable and visible prolapse even though they delivered by cesarean section before going into labor. The role of Kegel fitness and Kegel exercise in the prevention of treatment of pelvic organ prolapse is just recently getting the research attention it deserves, and Kegel exercise may well play a role in prevention and treatment of prolapse. But for certain, if you suffer prolapse that looks like the image below, no amount of pelvic floor Kegel exercise, or any other kind of exercise, will pull your parts back into place.

Prolapse surgery often comes with a recommendation for hysterectomy, but the latest trends highlight new techniques that fix the prolapse just as well without removing the uterus. When the uterus prolapses it can be resuspended by one of several techniques, and the surgery holds up just as well as when a hysterectomy is included in prolapse repair surgery. This uterine resuspension concept is an exciting new option that allows many women to undergo prolapse repair surgery without removing any organs.

While many women with prolapse believe just one single body part is out of postion, most commonly, prolapse involves hernia-type displacement of several organs. When the bladder drops, formally called a cystocele (siss-toe-seal), it is often accompanied by a rectal bulge, called a rectocele (wreck-toe-seal).  Laxity at the vaginal opening, called a perineocele (pear-in-ee-oh-seal) results when the perineum loses connective tissue bulk as a result of childbirth.  Uterine prolapse is called, well, uterine prolapse. But behind a prolapsed uterus, it is common to find an internal small intestine hernia called an enterocele (en-tare-oh-seal).

When you put all these prolapse possibilities together at their absolute worst, it looks like this:

Courtesy WomensVoicesForChange.org

My role as guest blogger gives me the opportunity to demystify this deeply troubling malady.  For more information, check out this first of 2 posts on pelvic organ prolapse done for my friends at Sweet Talk on The Spot:

Dr R covers Prolapse, Part 1 for Sweet Talk on The Spot

To review Dr R’s book on prolapse, see www.plumbingandrenovations.com

If you have any questions, send in your comments on this post or post your own question to Ask Dr R.

(C) Lauri Romanzi, 2010