Category — Vaginal Laxity

Vaginal prolapse surgery with synthetic and non-synthetic graft material -

Concerns about the use of graft material, particularly Prolene mesh, continue to mount after the most recent FDA warning on mesh in vaginal surgery.  These diligent authors from Michigan, Texas, Massachussetts, Washington State, New Mexico and Israel combed the international medical literature in all languages from 1950 to present, looking for data on adverse events when graft material is used at the time of vaginal prolapse repair. Three common problems, erosion (graft eroding through the vaginal skin so that it is palpable to touch and/or visible to the examining eye), granulation tissue (“proud flesh” commonly found in wounds as they heal inside and outside of the body), and dyspareunia (painful sex) were the key factors under review.

Granulation, Erosion, Dyspareunia and Prolapse Organ Prolapse Surgery with Graft Materials

What they found is that rates of each of the three complications did not differ between synthetic (such as non-absorbable Prolene or absorbable  Vicryl mesh) vs non-synthetic (such as porcine [Surgisis] or bovine [Xenform] or human cadaver-based) graft material, and that reportage with regard to sexual problems was so spotty and incomplete that it was difficult to figure out if women with sexual pain after surgery had sexual pain before surgery with the problem persisting after reconstruction, or whether it was clear that the surgery definitely caused the dyspareunia (sexual pain).

Of the more than 2000 mauscripts considered, less than 200 were included and most did not report on all three of these possible complications. In more recent years, the reportage tended to be consistent with our modern-day concerns, as one might expect the case to be.

Bottom line: there are no guarantees. Grafts reduce prolapse recurrence rates, but come with their own set of headaches.

To mesh or not to mesh?

Synopsis for the Journal of Sexual Medicine from original manscript published in the July 2011 issue of the International Urogynecology Journal:

Abed H, Rahn DD, Lowenstein L, Balk EM, Clemons JL, Roberts RG

Incidence and management of graft eriosion, wound granulation and dyspareunia following vagianl prolapse repair with graft maeriasl: a stematic review.

Int Urogynecol J (2011) 22:789-98.

This metanalysis reviewed global data published from 1950-2010 from papers  reporting adverse events after vaginal prolapse repairs using graft materials. 2260 citations were identified using Medline search terms including vaginal or uterine prolapse, rectocele, surgical mesh, cystocele, and similar pelvic  floor terms. After review of each, data from 196 manuscripts was included in this analysis. Graft erosion was reported in 110 studies (10.3%) with similar rates for synthetic and biologic grafts.  Diagnosis of erosion occurred between 6 weeks and 12 months. The most common risk factor for erosion was concomitant hysterectomy, as well as patient age, smoking and diabetes, surgeon experience, and use of T incision of vaginal skin during dissection. Granulation tissue as reported in 7.8% of the 16 papers reporting on this outcome in series using a single type of graft material. While not statistically significant, the reported rate of granulation was higher with biologic graft material than with synthetic/permanent graft material (9.1% and 6.8%, respectively). Spontaneous resolution of granulation tissue and resolution with suture removal and silver nitrate treatment were reported treatment options.

Dyspareunia was reported in 71 papers with overall incidence of 9.1%, rates similar between synthetic and biologic grafts, with risk factors including posterior repair and mesh erosion. Listed treatments included vaginal estrogen cream and excision of eroded mesh. The authors point out that many of these studies did not limit reportage to sexually active women, nor make clear whether the painful sex was persistent or de novo. They also remind the readers that dyspareunia is known to occur with native tissue repairs also, operations where no graft material of any sort is used. The authors go on to report that most of the studies did not including what proportion of women sere sexually active, how may had pre-existing sexual dysfunction and how many benefited from improved sexual function. They state that as more studies use the validated quality of life Pelvic Organ Prolapse / Urinary Incontinence Sexual Questionnaire, the quality of  data on the impact of pelvic floor surgery on sexual function will improve in accuracy and clinical relevance.

Content is copyright protected on date of online publication. Content herein does not represent medical advice. To learn more about pelvic floor disorders such as fistula, pelvic organ prolapse, dropped bladder, dropped uterus, hysteropexy uterine resuspension, vaginal laxity, rectocele, postpartum rehabilitation, vaginal rejuvenation, labiaplasty, vaginoplasty, Kegel exercise or incontinence please visit other posts in this blog and the Urogynics website at www.urogynics.org.

Vaginal Prolapse Surgery, Vaginal Contour and Female Sexual Function

This is another manuscript I reviewed for the Journal of Sexual Medicine, published by colleagues from The Mayo Clinic in the International Urogynecology Journal July 2011 issue. These authors looked carefully at the possibility of change in vaginal contour resulting from pelvic organ prolapse surgery with regards to female sexual function. They measured vaginal length and width before, immediately after (patient still in the operating room under anesthesia, case finished), and 6 months after surgery. The women completed a validated questionnaire for prolapse, incontinence and sexual function in women called the PISQ-12 before and 6 months after surgery. In summary, vaginas were a bit shorter and a bit narrower after surgery, and sexual function quality of life questionnaire scores did not change, nor did sexual satisfaction or lack thereof correlate to vaginal measurements either before or after surgery.  This helpful study will no doubt be repeated in various fashion as we in the field of urogynecology do our best to adhere to the mandate of “primum non nocere” (first, do no harm).

Once you’ve done this:

Childbirth - good thing they're so cute

You might need this:

Cutting & Sewing - 2 darts and a dash of facing, voila!

To get back to this:

Anatomy in 3-D - the vagina in relation to the rest of you

Journal summary:

Ochhino JA, Trabuco EC, Heisler CA, Klingele CJ, Gebhart JB.

Changes in vaginal anatomy and sexual function after vaginal surgery.

Int Urogynecol J (2011) 22:799-804

The authors enrolled 92 women undergoing vaginal reconstruction prolapse surgery in study including pre- and post-surgery completion of a validated sexual function questionnaire (PISQ-12) and in measurement of vaginal contour before, immediately after, and 6 months after surgery in order to determine whether changes in vaginal length and caliber correlate to changes in sexual function. All but one of the women was white. 72.8% were menopausal and 16.3% had undergone one prior prolapse operation. 47.8% were sexually active before surgery with a preoperation PISQ-12 score of 33.5. Pre-operation vaginal length was 10.4 cm on average with mean caliber 3.2 cm. Some women had intentional coning (narrowing) of the top of the vagina to correct excessive laxity and some did not – those undergoing coning (N=14) were evaluated separately from those who did not (N=78) for post-op vaginal contour measurements.

Immediately after surgery while still anesthetized, vaginal length of women with no coning was reduced to 7.9 cm with caliber 3.0 cm while coned patients measured 6. 8 cm length with caliber 2.8 cm. At 6 months postop, the no-cone women measured 8.7 cm length with 2.8 cm caliber while coned women continued to measure 6.8 cm length with .2 cm caliber.

74 women completed the PISQ-12 prolapse-incontinence-sexual function questionnaire at 6 months post-surgery, with 52.6% sexually active. Only 34 sexually active women completed the questionnaire before and after surgery, and in this group no change in score was demonstrated (33.4 vs 34.7). Further, no correlation was found between pre0operation score and vaginal length or caliber or between post operation score and vaginal length or caliber. The authors did not comment on the drop-out rate for questionnaire completion. They point out that, according to this data in this first study to look at changes in vaginal contour as correlates to sexual function, changes in vaginal dimensions does not seem to affect sexual function in women who were sexually active before and after the pelvic organ prolapse operation.

Level of evidence: III Count: 325 words

Content is copyright protected on date of online publication. Content herein does not represent medical advice. To learn more about pelvic floor disorders such as fistula, pelvic organ prolapse, dropped bladder, dropped uterus, hysteropexy uterine resuspension, vaginal laxity, rectocele, postpartum rehabilitation, vaginal rejuvenation, labiaplasty, vaginoplasty, Kegel exercise or incontinence please visit other posts in this blog and the Urogynics website at www.urogynics.org.

Understanding Rectocele, Levatorplasty and Site-specific Rectocele surgery techniques

You may be unacquainted with the term “rectocele,” but for almost 19% of women, the condition is all too familiar!

In a normal female pelvis, the rectum rests behind the vagina.

The two are separated by a thin wall of fibrous tissue called fascia.

When the fascia becomes weakened or damaged, the front of the rectum can bulge into the vagina. This is known as rectocele.

Rectocele - how it looks to the patient

Pregnancies and childbirth, chronic constipation and the natural aging process are the most common causes, but other factors can contribute to weakening of the fascia, too, including: chronic cough or bronchitis, repeated heavy lifting, and being overweight or obese.

Whatever the cause, rectoceles may induce a sensation of rectal pressure or fullness.

Difficulty having bowel movements and a feeling that the rectum has not fully emptied afterward are also common.

Severe rectoceles may even become visible, appearing as a ballooning bulge protruding through the vaginal opening.

For more mild cases of rectocele, a vaginal pessary may effectively treat the problem. Pessaries are removable supportive devices that hold the rectum in place.

More often than not, though, treatment for a severe rectocele requires surgery, performed through a small incision in the back wall of the vagina. .

The most common type of rectocele surgery is a levatorplasty, using sutures to bring the inside edges of the levator ani, or Kegel, muscles closer together, reducing the rectocele bulge back to a normal contour.

This method works because the levator muscles support the entire pelvic floor like a sling, and they’re often pulled apart with rectocele.

Some specialists believe, and some clinical research shows, that levatorplasty rectocele surgery may be more likely to result in pain than other rectocele repair techniques.

Knowing this, some doctors choose to do a newer procedure called site-specific rectocele, which uses sutures to close ONLY the holes in the connective fascia tissue, bypassing the levator muscles completely.

Although LESS likely to cause pain, site-specific rectocele techniques are MORE likely to result in recurrence of the rectocele.

Because each procedure has its good and bad points, it’s important to discuss the best rectocele repair for YOU with your surgeon.

For more information, see this video on Understanding Rectocele, courtesy HealthGuru.com

Content herein does not represent medical advice. To learn more about pelvic floor disorders such as fistula, pelvic organ prolapse, dropped bladder, dropped uterus, hysteropexy uterine resuspension, vaginal laxity, rectocele, postpartum rehabilitation, vaginal rejuvenation, labiaplasty, vaginoplasty, Kegel exercise or incontinence please visit other posts in this blog and the Urogynics website at www.urogynics.org.

KEGEL EXERCISE: THE FACTS

If you have a vagina and you’re old enough to vote, then Kegel Exercise belongs in your feminine fitness daily routine. Before you dive into pelvic fitness, it’s important to know what Kegel muscles actually DO. Kegels—or the levator ani muscles—wrap around a woman’s most important parts: her bladder, vagina, and rectum.

Research shows that toned levator ani muscles can reduce urinary incontinence, prevent problems with vaginal laxity and help a woman achieve a stronger orgasm. Clinicians and researchers in urogynecology also suspect, but have yet to prove, that these muscles help prevent pelvic organ prolapse, a condition in which  a woman’s bladder, rectum, or uterus falls into her vagina.

For women looking to live their best lives, strengthening your Kegel muscles—or pelvic floor fitness—just makes sense!

HOW TO CHECK YOUR KEGEL EXERCISE ACCURACY:

To get started, sit in bed relaxed against pillows, knees up and separated, using a hand mirror to look at your perineum,which is the skin between your anus and vagina.

Pull in using the muscles you use to urinate, as if you’re trying to stop urine midstream.

If you’re Kegeling correctly, you’ll see your perineum retract into your body.

You should feel the pull in your urethra and anus, NOT your butt or abs.

If you have trouble with proper Kegeling, talk to your gynecologist about pelvic floor physical therapy.

Pelvic floor physical therapy involves working with a Kegel coach, using biofeedback, and/or pelvic muscle electrical stimulation, each designed to “train” your pelvic muscles to perform correctly.

Once you’ve got the art of Kegeling down, get in the habit of doing tKegels daily.

Here’s Dr. Romanzi’s “Starter Set for Kegel Beginners”:

For the first set, perform 10 controlled, sustained contractions, holding each for five seconds, relaxing out of each slowly, and contracting into the next one without taking a break in between. Don’t forget to BREATH. If you find yourself holding your  breath, count softly or sing while contracting the levator muscles.

For the second set, perform 30 quick contractions, holding for just one second each.

There’s no need for a break between the two sets. Simply move from one right on to the next.

Do 2-3 of each set per day. Be creative! There are many ways and settings in which one can Kegel – no one will know if you’re Kegeling on the bus or in a meeting or while driving your car (at a stop sign, preferably).

In terms of where you should do your Kegel exercises, there’s only one rule: NEVER do them on the toilet!

Not only is 8 seconds of urination too short to really benefit your muscles, but it’s also distracting to your bladder, which has an important job of its own to do!

Other than that, you can fit in a Kegel routine whenever—and wherever—you prefer!

For more information, check out this  video \”Kegel Exercise: The Facts\”, courtesy HealthGuru.com

Content herein does not represent medical advice. To learn more about pelvic floor disorders such as fistula, pelvic organ prolapse, dropped bladder, dropped uterus, hysteropexy uterine resuspension, vaginal laxity, rectocele, postpartum rehabilitation, vaginal rejuvenation, labiaplasty, vaginoplasty, Kegel exercise or incontinence please visit other posts in this blog and the Urogynics website at www.urogynics.org.

DROPPED BLADDER: CYSTOCELE FACTS

Image of the Bladder on X-Ray

At birth, a female’s bladder rests in front of her vagina and just behind the pubic bone. The bladder and vagina are separated by connective tissue called the vesicovaginal fascia. This fascia is anchored to each hip bone by tendons known as the arcus tendineus fascia pelvis.

Vesicovaginal connective tissue is NOT particularly strong. Even in a young woman who has never given birth, the tissue layer is only about as thick as five sheets of paper! When a woman gives birth, the vesicovaginal fascia can weaken and stretch. Other factors that can contribute to the weakening of this and other pelvic supportive tissue include: being overweight or obese, engaging in recurrent heavy lifting, the normal aging process, and repeated coughing or constipation.

Weakened vesicovaginal connective tissue may result in a vaginal hernia that allows the bladder to drop, a condition called cystocele. If the vesicovaginal space wears out in the center, the bladder may bulge into the vagina in what’s called a CENTRAL cystocele. Meanwhile, if the tissue disconnects from the arcus tendineus inside the hip bones on either side, the result is a PARAVAGINAL cystocele.

Cystocele Symptoms

But no matter the type, cystocele can cause unpleasant symptoms, like a vaginal bulge coming out between the labia, or make urinary incontinence worse, or prevent the bladder from emptying fully. Women may also experience chronic pressure in the pelvis or vagina that may be worse when coughing, bearing down, or lifting. Severe cystoceles may even emerge through the vaginal opening, causing a soft bulge that may feel like sitting on an egg.

Cystocele Treatment

While it can be uncomfortable and embarrassing, treatment options DO exist to repair cystocele, or dropped bladder . In mild cases, a removable support device called a pessary can push the bladder back into place. More severe cystoceles may require surgery. Traditionally, bladder lift surgery involved tucking stitches into the remnants of the supportive tissue between the bladder and the vagina during a procedure called anterior colporrhaphy.

This surgery has a recurrence risk as high as 30%, so many surgeons may prefer to insert a graft, which is a thin sheet of body-friendly material, as extra support between the bladder and the vagina. The trade-off for the graft’s sturdier hold is a slightly higher risk of complications including prolonged healing inside of the vagina and slightly longer time on the operating table. The recurrence rate of cystocele repaired with graft material is much lower than traditional colporrhaphy repairs.

Because each procedure has its pros and cons, talk to your doctor about the best repair option for YOU!

For more information on cystocele, visit Cystocele and Pelvic Organ Prolapse information and see this video on Understanding Cystocele, courtesy HealthGuru.com

Content herein does not represent medical advice. To learn more about pelvic floor disorders such as fistula, pelvic organ prolapse, dropped bladder, dropped uterus, hysteropexy uterine resuspension, vaginal laxity, rectocele, postpartum rehabilitation, vaginal rejuvenation, labiaplasty, vaginoplasty, Kegel exercise or incontinence please visit other posts in this blog and the Urogynics website at www.urogynics.org.

Worldwide, “cesarean on demand” continues to increase. In the hopes of avoiding pelvic floor damage associated with birthing, some women have bought into the the trend for elective cesarean before onset of labor. Called “cesarean on demand” because patients demand it in the absence of a maternal or fetal indication, it’s the obstetric equivalent of Erica Jong’s “Zipless F**k”; the maternity version of having your cake and eating it too.

Well, guess what? Just BEING PREGNANT is a risk for all the unhappiness that pelvic floor mayhem can bring, including incontinence and its painfully un-sexy cousin, pelvic organ prolapse. One beautifully executed study evaluated vaginal anatomy before and after 1st pregnancy in three groups of mothers; one who had an easy vaginal birth, another who had a difficult vaginal birth with deep vaginal tearing that required lots of stitching, and third who, whatever the reason, had cesarean before going into labor. Understand that there are medically legitimate reasons for a woman to have cesarean without labor, such as toxemia (pregnancy induced high blood pressure), placenta previa (low-lying placenta blocking the cervix – natural labor with this condition results in the baby bleeding to death before it can be born), or breech presentation (at least in the States, due to out of control obstetric malpractice and the fact that breeches born vaginally have a small but real risk of birth injury that can be almost totally avoided with a cesarean, breech = cesarean until further notice), to name a few.

Looking at the pelvic floor support of these women after first birth, they found NO DIFFERENCE in moderate prolapse between the three groups. Severe prolapse was equivalent in the two vaginal birth groups and much higher than in the cesarean without labor group. But… the cesarean without labor group had a 5% incidence of severe prolapse – I’m talking cervix sticking out of the vagina prolapse, bladder bulging down pushing the labia apart when you walk prolapse.  Thinking a cesarean is the answer to your “I want to be a mother but I don’t want any physical changes in my body anywhere, especially in my vagina” dreams? Think again…

Here’s the study summary prepared for the Journal of Sexual Medicine:

Handa VL, Nygaard I, Kenton K, Cundiff GW, Ghetti C, Ye W, Richter HE. Pelvic organ support among women in the first year after childbirth. Int Urogynecol J (2009)1407-1411.

Increased public awareness of changes in pelvic floor anatomy related to pregnancy continues to foster the growing phenomenon of cesarean on demand, requested in the hopes of maintaining pre-pregnancy sexual function and reducing risk of prolapse and incontinence, two conditions known to negatively impact sexual quality of life in the majority of women so-affected. The true impact of pregnancy on pelvic support may be due to pregnancy itself, regardless of delivery mode, as stated by these authors; “cesarean delivery as a potential prevention strategy remains unproven.” This study prospectively evaluated the impact of first pregnancy on pelvic organ support of 256 women with three pregnancy outcomes – vaginal delivery without anal sphincter tear, vaginal delivery with anal sphincter tear, and cesarean delivery without labor. Pelvic support evaluation done at 6-12 month post-delivery showed stage 2 prolapse in 38% of women delivered vaginally with sphincter tear, 29% in those delivered vaginally without sphincter tear, and in 21% of women delivered by no-labor cesarean with no statistically significant differences between groups.  It is remarkable that 1/5 of the cesarean patients showed clinically significant stage 2 prolapse.  When looking further at stage 3 (true bulging past the hymen, clearly visible and palpable through the vaginal opening), there was a significant difference between vaginal birth and cesarean without labor, with 5% of cesarean women showing visible prolapse as opposed to 14-15% in both of the vaginal delivery groups.  Still, this 5% bulging prolapse despite non-labor cesarean raises the possibility that optimal patient counseling for women seeking elective cesarean for sexual function and pelvic organ protection may best include the realistic prediction of “a small but real risk bad prolapse even if you undergo cesarean before going into labor”. Letting women know that cesarean is NOT a 100% guarantee of avoiding pelvic floor consequences of pregnancy, along with the other risks of cesarean: peri-op morbidity, increased risk of placenta accreta, and increased risk of uterine rupture with subsequent pregnancies. This work adds to the data revealing that the impact of pregnancy on the pelvic floor may not be thoroughly negated by cesarean on demand.

Level of Evidence: IA

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.

(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