Incontinence | Pelvic Organ Prolapse
Even today, many women are embarrassed to ask their doctor for help with 2 very common problems: urinary incontinence and pelvic organ prolapse.
The fact is that almost half of all women who have given birth have some degree of prolapse. Most have no symptoms, but 40% have various complaints and in some cases a poor quality of life.
However, no woman today has to suffer from incontinence because there are several effective treatment options, thanks to advances in laparoscopic surgery.
Urinary Incontinence
Urinary incontinence is a condition in which there is an involuntary loss of urine to an extent that it becomes a social or hygienic problem. It is estimated that 20-40% of the female population will experience incontinence in their lifetime. Risk factors for incontinence include: gender (2-3 times more common in women than in men), childbirth, menopause, smoking, and obesity.
Types of Incontinence
- Stress Incontinence:
Incontinence that occurs during activities that increase intra-abdominal pressure such as sports, lifting, coughing. - Urge Incontinence (Overactive Bladder):
Incontinence that occurs due to uninhibited bladder contractions or spasm. (Example: Someone feels a sudden need to void but is unable to hold their urine until they can make it to a bathroom.) - Overflow Incontinence:
Incontinence that occurs when the bladder fills to capacity and intermittently spills urine. This occurs in patients with certain neurologic conditions or advanced diabetes who are unable to feel when their bladder is full. - Mixed Incontinence:
Incontinence that occurs when a combination of the above mechanisms are in action in a single patient.
Treatment of Incontinence
Treatment is based on the cause of incontinence:
- Conservative measures such as bladder training and biofeedback are useful in the treatment of urge incontinence, which also responds very well to medical therapy.
- Pelvic floor exercises (Kegel maneuvers, biofeedback, electrical stimulation) can be used to treat stress incontinence which is not very responsive to medical therapy.
- Incontinence surgery (laparoscopic or vaginal procedures which raise the bladder neck- blocking the loss of urine due to increased abdominal pressure). Although not useful in the treatment of urge incontinence, these procedures are very effective in the treatment of stress incontinence. The hospital stay is less than 24 hours and the recovery is fast (usually 1-2 weeks). A proper evaluation and accurate diagnosis coupled with the appropriate surgical corrective procedure and/or medical management, leads to resolution of incontinence in the vast majority of our patients.
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Pelvic Organ Prolapse
Pelvic organ prolapse is the bulging of one or more pelvic structures into the vagina and, at times, out of the vaginal opening.
The vagina is surrounded by a variety of pelvic structures. The rectum is beneath the vagina, the bladder on top of it, and the uterus, bowel, and the rest of the abdominal contents are behind it. When the support between one of these structures and the vagina weakens, prolapse can occur.
Risk factors for all types of prolapse include childbirth, other pelvic trauma, connective tissue disorders, straining, and the aging process.
Prolapse Symptoms
Symptoms include pelvic pressure or a sense of pelvic fullness, or a feeling that something is "falling out" of the vagina.
Types of Prolapse
- Cystocele ("dropped bladder"):
This occurs when the support between the vagina and the bladder weakens and the bladder bulges into the vagina. This type of prolapse can also be associated with urinary incontinence. - Rectocele:
This is similar to a cystocele, but instead of the bladder, a portion of the rectum bulges into it. - Uterine Prolapse:
This occurs when the ligaments that support the uterus weaken, causing the back wall of the uterus to "give way" allowing the uterus and cervix to move towards the front of the vagina. - Enterocele:
This type of prolapse usually occurs in patients who have had a hysterectomy where the support of the pelvic ligaments has been disrupted. The small bowel, enclosed within a hernia sac, can protrude into the vagina. - Vaginal Vault Prolapse:
This can also occur after a patient has had a hysterectomy. A vagina can be viewed as a pants pocket. The bottom of the pocket is the same as the back part of the vagina. If this back part of the vagina loses the architectural support from the pelvic ligaments, the vagina can "turn inside out" like a pants' pocket and bulge through the vaginal opening.
Prolapse Treatment
There are many treatment options for pelvic organ prolapse and these depend totally on the patient's wishes, degree of discomfort, medical condition, and the cause of the prolapse. Treatment options include: observation alone, estrogen supplementation (strengthens the walls of the vagina), pessaries (devices which are placed into the vagina to prevent prolapse), and the various vaginal or laparoscopic corrective procedures listed below.
- Cystocele ("dropped bladder"):
can be repaired either vaginally by a procedure called an anterior repair (or anterior colporrhaphy) or laparoscopically through a paravaginal repair. Both procedures strengthen the supportive fascia between the vagina and the bladder. - Rectocele (bulging rectum):
can be repaired vaginally by a procedure called a posterior repair (or posterior colporraphy). This procedure strengthens the supportive fascia between the vagina and rectum. - Uterine prolapse and vaginal vault prolapse:
if the uterus is present a hysterectomy is performed first (removal of the uterus with or without the cervix). The top of the vagina is then attached by a piece of mesh to the tailbone, preventing it from falling forwards. This procedure is performed by laparoscopy and is called a sacral colpopexy. - Enterocele (hernia containing small bowel):
can be repaired either vaginally or laparoscopically by reduction of the hernia and removal of the hernia sac. The location of the hernia is then closed off by a procedure called a Moschcowitz culdoplasty.
The recovery from all of these procedures is very fast. Patients are discharged from the hospital in less than 24 hours and can resume normal activities within 1-2 weeks. Sexual intercourse is usually not permitted for 6 weeks to allow proper healing of the reinforced tissues.
