The Pelvic Organs

The parts of the body affected by pelvic support problems include the urethra and bladder, the small intestine, the rectum, the uterus, and the vagina. The urethra and bladder lie in front of the vagina. The bladder receives and stores urine from the kidneys and expels it through the urethra (a short, narrow tube). The uterus is at the top of the vagina. Behind the uterus is a space within the pelvic cavity called the cul-de-sac. This space contains some of the small intestine. Along the back of this space is the rectum, which continues down the back of the vagina and ends at the anus. The perineum is the tissue between the opening of the vagina and the anus.

The pelvic organs are held in place by 3 types of support:

1. Layers of connecting tissue called endopelvic fascia
2. Thickened parts of the fascia called ligaments
3. A paired group of muscles that lies on either side and around the openings of the urethra, vagina, and rectum

When the tissues that support the pelvic organs are stretched and damaged, the organ that they support may drop down and press against the wall of the vagina. This causes a bulge. Sometimes the organ will drop down so much that the bulge sticks out through the vaginal opening.

Causes

The main causes of pelvic support problems are pregnancy and childbirth. As the baby passes through the vagina during childbirth, the fascia and ligaments may be damaged. They may become weak. However, pelvic support problems can occur in women who have never had children.

Symptoms

The symptoms of pelvic support problems depend on which organs are involved. They can cause minor discomfort or major problems in the way the organs work. Symptoms include:

• Feeling of pelvic heaviness or fullness, or as though something is falling out of the vagina
• Pulling or aching feeling in the lower abdomen or pelvis
• Leakage of urine or problems having a bowel movement

In severe cases, the pelvic organs may bulge into the vagina. This bulge may stick out of the vaginal opening, where it may be seen with a mirror or felt with the fingers. Sometimes a woman may need to push the organs back up into the vagina to empty the bladder or have a bowel movement.

In some cases, the uterus may stick out through the vaginal opening. If the uterus or a part of the vaginal wall stays outside of the vaginal opening, it may become irritated. It may develop small sores or ulcers that bleed or become infected.

Types of Pelvic Support Problems

The main types of pelvic support problems and the pelvic organ that can cause bulging are as follows:

• Cystocele–bladder
• Vaginal vault prolapse with enterocele–vagina and small intestine
• Rectocele–rectum
• Uterine prolapse–uterus

Although each problem occurs in different pelvic organs, they often occur at the same time.

Cystocele

A cystocele, sometimes called anterior wall prolapse, occurs when the bladder drops from its normal place into the vagina. Some cystoceles cause urine to leak when you cough, sneeze, lift objects, or walk. Large cystoceles may create a kink in the urethra and cause problems with the passing of urine. If this occurs, you may have to strain or push the bladder up by reaching into the vagina to pass urine. If there is a very large cystocele and if the bladder loses some of its ability to contract, it may not empty as completely as it should.

Small cystoceles are common. In most cases, they do not cause problems with urination and do not need surgery. If a cystocele is causing symptoms, your doctor can suggest ways to relieve them.

Urine may leak when there is a sudden increase in abdominal pressure caused by walking, jumping, coughing, sneezing, laughing, lifting, or making sudden movements. The amount of urine lost may be only a few drops. In other cases, it may be enough to require changing clothes or wearing pads.

There are many reasons why a woman may leak urine. In some cases, leakage of urine may be caused by a urinary tract infection, bladder problems, or other medical conditions. You should see your doctor if leakage of urine is a problem for you. Your doctor can help you sort out whether a cystocele is causing the leakage.

Vaginal Vault Prolapse With Enterocele

Sometimes after hysterectomy (removal of the uterus), the top of the vagina loses its support and drops. This is called vaginal vault prolapse. The degree of prolapse varies. The top of the vagina may drop part of the way into the vagina and remain there, or it may extend part or all of the way through the vaginal opening. Women who have complete vaginal prolapse also may have problems with bladder and bowel function. Most women who have vaginal vault prolapse also have an enterocele. An enterocele is a type of support problem that forms when the small intestine drops through supporting tissue and bulges into the vagina. To diagnose an enterocele, a doctor may examine you while you are standing.

Rectocele

When the rectum bulges into or out of the vagina, it is called a rectocele. It is sometimes called a posterior wall prolapse. It is caused by a weakness of the back wall of the vagina. A large rectocele may make it hard to have a bowel movement, especially if you are constipated. Some women must push the bulge back into the vagina to have a bowel movement.

Uterine Prolapse

When the uterus drops down into the vagina, it is called uterine prolapse. The distance the uterus drops may vary. Mild degrees of prolapse are common. They often do not cause symptoms and do not need surgery.

Women with more severe forms of this condition often will have a feeling of pelvic pressure or a pulling feeling in the vagina or lower back. The cervix (the opening of the uterus) may stick out from the vagina. This may cause discomfort or problems with sex. Uterine prolapse most often occurs when other pelvic organs also are out of place.

Diagnosis

Proper diagnosis is key to treating pelvic support problems. However, diagnosis is not always simple because the symptoms of pelvic support problems often are the same as those of other conditions. In most cases, a woman with these symptoms will know that she has a problem, but the cause may be unclear. The exact cause of the problem must be found before the best treatment can be given.

Your doctor will take your medical history and do a thorough exam, including a vaginal and rectal exam. You may be examined while you are lying down and again while you are sitting and standing. You may be asked to strain or cough during this exam. Your bladder function also may be tested.

Kegel Exercises Kegel exercises tone your pelvic muscles. They strengthen the muscles that surround the openings of the urethra, vagina, and rectum. Just like doing sit-ups to flatten your abdomen, these exercises work only if the right muscles are used, the "squeeze" is held long enough, and enough repetitions are done. This is how they are done: Squeeze the muscles that you use to stop the flow of urine. This movement pulls the vagina and the rectum up and back. Hold for up to 10 seconds, then release. Do this 10–20 times in a row at least 3 times a day. Make sure you are not squeezing your stomach, thigh, or buttocks muscles. You also should avoid holding your breath as you do these exercises. After doing these exercises on a regular basis for at least 12 weeks, you may be able to better hold your urine. Some women may use the wrong muscles. To check if you are using the correct muscles, insert a finger into your vagina and squeeze as if you were trying to stop urine from coming out. If you are using the correct pelvic muscles, you should be able to feel the muscles work as they squeeze around your finger. It also is a good idea to have your doctor check to make sure that you are doing the exercises correctly.

Treatment

Many women do not need treatment. Some women find symptoms are relieved by exercising, making changes in their diet, keeping their weight under control, not smoking, and avoiding heavy lifting and straining. Medication or use of a device called a pessary also may be helpful. Pelvic support problems sometimes may be treated by surgery.

No form of treatment is guaranteed to solve the problem. However, the chances for getting some degree of relief are quite good.

Special Exercises

Exercises called Kegel exercises, or pelvic muscle exercises, are used to strengthen the muscles that surround the openings of the urethra, vagina, and rectum (see box). Do these exercises 3 or more times a day. In time, you may be better able to hold urine. To learn these and other exercises that can help strengthen the pelvic muscles and organs, you may be referred to a physical therapist.

Diet

You should cut down on caffeine, which acts as a diuretic. Caffeine can be found in coffee, tea, and soft drinks. A high-fiber diet may help bowel function and prevent constipation.

Medicines

There are special medicines that help treat urinary and bowel symptoms. Sometimes a medication that softens stools is prescribed along with a special diet to help control intestinal symptoms. A medication that puts bulk in the stool may be given with a high-fiber diet. Hormonal treatment also may help strengthen vaginal tissues.

Vaginal Pessaries

A pessary may be inserted into the vagina to support the pelvic organs. When a pessary is used, it must be removed, cleaned, and reinserted on a regular basis. If it is not cleaned, it might cause a bad-smelling discharge and ulcers in the vagina. If used correctly, a pessary can last for years.

There are many types of pessaries. Your doctor can fit you with the right one for you. You may have to try a few types to get a good fit.

Surgical Repair

Pelvic support problems may be corrected by surgery. The surgery can be done through the vagina or abdomen based on your type of support problem.

Women who want to have children often decide to have them before they have surgery for pelvic support problems. This is because if a woman has uterine prolapse, her doctor may suggest that her uterus be removed as a part of the procedure. If the uterus is left in place, a later vaginal delivery may increase the chances that a cystocele or rectocele will recur. If you have severe pelvic support problems and wish to keep your uterus, discuss the options with your doctor.

Surgery may relieve some, but not all, of the symptoms caused by pelvic support problems. In a few cases, symptoms may return or persist. During the surgery, the doctor has to use the already weakened fascias, ligaments, and muscles that are within your pelvis to improve your pelvic support. Synthetic or natural materials may be used to help correct the problems.

The factors that caused you to have prolapse in the first place can cause it to occur again. After surgery, you should control your weight, avoid constipation, not smoke, and avoid activities that put pressure on these muscles. There is still a chance that more surgery may be needed later.

Finally...

Many women have pelvic support problems. If you have any symptoms, talk to your doctor about them. The right diagnosis and treatment can offer relief.

Glossary

Cystocele: Bulging of the bladder into the vagina.

Diuretic: A drug given to increase the production of urine.

Enterocele: Bulging of the intestine into the upper part of the vagina.

Fascia: Tissue that supports the organs and muscles of the body.

Pessary: A device inserted into the vagina to support sagging organs.

Rectocele: Bulging of the rectum into the vaginal wall.

Uterine Prolapse: Falling of the uterus into the vagina.

This Patient Education Pamphlet was developed under the direction of the Committee on Patient Education of the American College of Obstetricians and Gynecologists. Designed as an aid to patients, it sets forth current information and opinions on subjects related to women's health. The average readability level of the series, based on the Fry formula, is grade 6–8. The Suitability Assessment of Materials (SAM) instrument rates the pamphlets as "superior." To ensure the information is current and accurate, the pamphlets are reviewed every 18 months. The information in this pamphlet does not dictate an exclusive course of treatment or procedure to be followed and should not be construed as excluding other acceptable methods of practice. Variations taking into account the needs of the individual patient, resources, and limitations unique to the institution or type of practice may be appropriate.

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