If you have an uncomfortable feeling of bulging, drooping, or pressure in your vagina, you may have a condition called prolapse or pelvic support problems. This occurs when the tissues that support the pelvic organs are damaged or stretched allowing the organ to drop down out of normal position and causing a bulge. Women with prolapsed pelvic organs may have a feeling of pelvic pressure or heaviness in the pelvic region. Sometimes it feels as if something is "falling out." Prolapse also may cause incontinence.
Childbirth and aging are the two most common causes of this condition. During childbirth, the tissues of the pelvic organs may be damaged or weakened due to the stretching that can occur. As a result, these tissues may not provide as much support for the organs as necessary. Symptoms may worsen after menopause.
The main types of pelvic support problems include:
Cystocele, when the bladder is not supported properly.
Enterocele, when the small intestine is not supported properly.
Rectocele, when the rectum is not supported properly.
Uterine prolapse, when the uterus is not supported properly.
Vaginal prolapse, when the vagina is not supported properly.
Diagnosis
Incontinence is a common treatable condition. If you have a problem, make an appointment at the UCSF Women's Continence Center. Keep a diary that includes how often you urinate during the day, a record of the times and events surrounding leakage, and what you are drinking. This can help your health care provider make the proper diagnosis and decide on the appropriate treatment.
At your first visit, your UCSF Women's Continence Center provider will do a complete history and physical exam, including a pelvic exam and urinalysis. If your problem is complex, additional tests may be done at a later visit.
Depending on the particular details of your medical history, your doctor may proceed to any or all of the following physical evaluations.
Neurologic examination to evaluate the strength, sensation, and reflexes in your legs.
Pelvic examination to assess pelvic relaxation or prolapse.
Postvoid residual urine assessment will measure how much urine remains in your bladder within 15 minutes of voiding. It offers an estimation of your bladder's ability to efficiently "empty the tank."
Other assessments: At the same time a postvoid residual is checked, the same urine sample may be analyzed for other factors, such as blood, sugar, crystals or signs of infection. Such an evaluation can be accomplished with an office urine dipstick or the hospital laboratory's microscopic urinalysis.
Urine culture: If a urine dipstick or urinalysis suggests signs of acute infection, a urine culture will be sent to the microbiology lab. In approximately 24 to 48 hours, bacterial growth can be detected and the specific strain identified.
Pelvic floor assessment to evaluate the strength of your pelvic floor muscles, and particularly, your ability to contract and relax the appropriate muscle group.
Cough stress test: Your doctor will instill water into your bladder, and then ask you to cough or strain in the same manner that would cause you to leak urine. This test can be performed in the office or incorporated into more elaborate urodynamics testing.
URINARY DIARY: Sometimes details about your fluid intake and urine output are crucial to making the right diagnosis. Because this is not typically the sort of information we take notice of in our daily lives, your provider will give you a bladder diary and a measuring receptacle.
You may be asked to carefully record the time and amount of any fluids you drink and the urine you void over a complete 24-hour period. You may be asked to repeat this 24-hour diary for three to five days. This allows us to notice patterns that might be important to planning your treatment.
When the clinical picture seems less straightforward, or multiple previous therapies have been unsuccessful; your doctor may decide to pursue further diagnostic testing. The purpose of these studies is to evaluate the anatomic and functional status of the bladder and urethra, reproducing your symptoms. Testing may include:
Cystometrogram: Catheters are placed in your bladder and vagina or rectum so that the physician can reproduce your daily urinary symptoms. During the test, fluid will be infused in a controlled fashion to determine various characteristics about your bladder's function, including:
Your perception of water filling the bladder
Any urgency to urinate
Any uncontrollable bladder contractions
The volume at which your bladder cannot comfortably hold any more
The pressures that develop within your bladder during the fluid storage process
Stress testing: You may be asked to perform a number of maneuvers such as coughing, changing positions, or bouncing on your heel with the catheter in place in an effort to reproduce any symptoms of urine leakage or incontinence.
Urethral pressure profile: A catheter in your urethra is manipulated to measure urethral function.
Uroflometry: During urination, a specially devised receptacle will measure the varying rate of urine flow, as well as duration of urination.
Pressure voiding study to identify abnormal voiding patterns or urine obstruction
Other Tests
Cytoscopy: A slender camera is inserted via the urethra into the bladder to enable your doctor to view the interior anatomy of the bladder and urethra. It is typically an outpatient diagnostic procedure performed for the following common symptoms:
Blood or pus in urine with no bacteria present
Bladder infections that are unusually difficult to treat
New onset voiding irritation
New onset bladder pain
Suspected foreign body in the bladder
Urodynamics tests fail to duplicate incontinence symptoms
Radiologic tests identify upper or lower urinary tract structural abnormalities.
Intravenous pyelogram (IVP) involves the administration of intravenous (IV) dye to your bloodstream to obtain X-ray snapshots of the entire urinary tract while the kidneys are processing the injected dye. This test cannot be performed if you have an allergic reaction to IV contrast dye, or abnormal kidney function
CT scan of abdomen and pelvis in which an X-ray machine takes a rapid sequence of two-dimensional thin cross-sections of the body in the area of interest. This exam can be performed with or without contrast dye, depending on what your doctor is looking for. The X-rays provide great detail of most of the internal organs.
Ultrasound doesn't involve X-rays. It uses a skin probe that directs sound waves to bounce off the body's internal organs to produce an anatomic picture. It can be a very useful screening tool.
Treatment
Behavioral therapy, pessaries or vaginal inserts and surgery are the three treatment options for this problem.
Behavioral treatments are simple, self-directed, have no side effects and are often used in conjunction with other treatments. They have been effective for many women with certain types of incontinence.
Bladder Training: Bladder training is an important form of behavior therapy that can be effective in treating urinary incontinence.
The goals are to increase the interval between each time you urinate and to increase the amount of fluids your bladder can hold. This training can help diminish the sense of urgency and leakage.
Bladder training requires a fixed schedule be established, whether or not the urge to urinate is present. If urge occurs before the assigned interval, urge suppression techniques, such as relaxation and Kegel exercises, should be used. As success is achieved the interval is lengthened in 15 to 30 minute increments until it is possible to remain comfortable for 3 or 4 hours. This goal can be adjusted to suit each woman's needs and desires.
Keeping a diary of your bladder activity is very important. This helps your health care provider determine when to start the training and to monitor your progress throughout your program.
Pelvic muscle exercises: Pelvic muscle exercises, also known as Kegels, can help improve incontinence and prevent it from worsening. They can help you suppress the urge to urinate. The exercises strengthen and tone the muscles that support the pelvic organs. These muscles contract and relax under your command to control the opening and closing of the bladder. When these muscles are weak, urine leakage may occur. To achieve the best results, imagine yourself as an athlete in training. You need to build strength AND endurance of your muscles. This requires commitment and regular exercise. Correct technique also is very important.
Biofeedback: Biofeedback takes information about something happening in the body and presents it in a way that we can see or hear and understand. Getting on a scale to check your weight or having your blood pressure taken are very simple examples of biofeedback. Biofeedback can be used to measure any body response such as heart rate or muscle contraction and relaxation. The measurement can be displayed on a computer screen or heard as a tone and used to learn about a subtle body function.
Biofeedback has been effective in treating urinary incontinence. It can help you learn to control and strengthen your pelvic floor muscles and play an important role in bladder control.
Because you cannot see the pelvic floor muscles, you may find it difficult to locate them. Perhaps you are uncertain if you are doing the exercises correctly. This is where biofeedback can help. Biofeedback therapy uses computer graphs and audible tones to show you the muscles you are exercising. It also allows the therapist to measure your muscle strengthen and individualize your exercise program. It is a teaching tool to help you learn to control and strengthen the pelvic floor area.
Urge Suppression: Urge suppression is a way to help control the sudden urge to urinate so that going to the bathroom is not an emergency. Running to the bathroom is the worst thing you can do as it actually causes bladder irritability to increase and interfere with your ability to concentrate on controlling your bladder.
When the urgency strikes, an "urge suppression" technique can help maintain control. Your goal is to maintain bladder control until you reach a toilet. A normally functioning bladder can wait until the appropriate opportunity to empty, an unstable bladder can not.
Vaginal inserts or pessaries are frequently used to treat bladder and pelvic support problems. A pessary is a vaginal insert, similar to a contraceptive diaphragm, which is placed into the vagina to support the uterus as well as bladder and rectum. It is a firm ring that presses against the wall of the vagina and urethra to help decrease leakage. The type and size of the insert is fitted to address your problem and your body. A properly fitted pessary is not noticeable when in place.
Surgery for pelvic support problems attempts to restore the normal anatomic position of the prolapsed areas and to improve symptoms that may be caused by the prolapse. The choice of surgical procedure is individualized. Factors that may influence this choice include examination findings, previous surgery, age, other medical illnesses and patient/physician preference.
The surgery typically includes repair of tears in the fascia or suspension of the prolapsed tissues to stronger structures in the pelvis. In some cases, a graft may be used to help strengthen the area. The surgery may be performed through a vaginal or abdominal incision or a combination of both.
One of the goals of surgery for pelvic organ prolapse is to repair all of the defects that are present in order to prevent the need for surgery in the future. Therefore, many women will require a combination of these procedures.
Vaginal procedures are done through an incision in the vagina. Some of the common vaginal procedures are:
Anterior repairs to help strengthen the front wall of vagina overlying the bladder.
Posterior repairs to correct tears that may exist in the back wall of vagina -- the area directly above the rectum. This type of surgery may involve the use of a graft (taking a piece of tissue from another part of the body) to help strengthen the area.
Vaginal vault suspension procedures, which use sutures (stitches) to attach the top of the vagina to stronger structures in the pelvic region.
Perineorrhaphy, which involves reconstruction of the area between the vagina and rectum.
Colpocleisis, which includes partial or complete closure of the vagina.
Abdominal Procedures are done through an incision in the abdomen. Some of the common procedures are:
Abdominal sacrocolpopexy suspends the top of the vagina to a strong ligament on the front part of the sacrum, or lower back bone, using a piece of tissue, muscle or ligament from another part of the body.
Paravaginal defect repair repairs places where the vagina has torn away from its attachment to the tissue that connects to the pelvic bone.
