Medicosnext
Dr. Anjana Dongol
Professor in Obstetrics and Gynaecology
Urogynecologist, Chief of Education and Training Division, Dhulikhel Hospital
The pelvic floor muscles are a group of muscles in pelvis whose main function is to support pelvic organs. Pregnancy and postpartum dysfunction bring a broad set of symptoms resulting from abnormal function of the pelvic floor musculature, including muscles, nerves, and connective tissues. Lifestyle, medical and surgical conditions also affect pelvic floor function. The disordered function corresponds to either increase activity (hypertonicity) or diminished activity (hypotonicity) or inappropriate coordination of the pelvic floor muscles. Pelvic floor disorders include pelvic organ prolapse, urinary and fecal incontinence, chronic pelvic pain and sexual dysfunctions. These disorders are common after childbirth or with advancing age. The symptoms can present individually however, are often interrelated. The disorders are highly prevalent, and are underdiagnosed and undertreated. In a country like Nepal limited awareness, lack of specialized services and cultural stigma prevent women from seeking timely care. These disorders are often treated in isolation however, optimal management requires a holistic, multidisciplinary approach.
The risk factors are related to pregnancy and frequent childbirth, lack of estrogen hormone with advancing age, obesity, different conditions that give rise to increased abdominal pressure like lifting heavy weight, constipation, chronic cough, mass in abdomen or maybe congenital and connective tissue disorders. Repeated pelvic infections and malnutrition can also aggravate the situation.
Types of pelvic floor disorders
Pelvic organ prolapse (POP): Descent of the uterus, bladder, urethra, rectum and vaginal vault from its normal anatomical position in pelvis due to weakened pelvic support is known as pelvic organ prolapse. Female pelvic organ includes uterus, urinary bladder and rectum.
Uterine prolapse: Downward protrusion of the uterus towards or out of introitus is called uterine prolapse. With uterine prolapse women experience something coming out of vagina that aggravates on increase in abdominal pressure while walking or lifting heavy weight. It gets relieved on lying down. Women sense fullness in vagina and when the mass is inside introitus they sense discomfort, but after it comes out, they face difficulties. They have dragging backache due to stretching of ligaments. Exposure of mass outside leads to dryness and they also experience dyspareunia. Long standing major degree prolapses develop ulcer called decubitus ulcer giving rise to blood stained vaginal discharge.
Cystocele: Descent of urinary bladder through anterior vaginal wall from its normal anatomical position is called cystocele. When bladder descends it gives various urinary symptoms like increased frequency of micturition, difficulty in voiding urine, urinary incontinence, frequent urinary infections and sometimes retention of urine. Women develop habit of pushing mass back to have sensation of complete urinary voiding.
Rectocele: Descent of rectum from posterior vaginal wall is called rectocele. Women will face various symptoms like constipation, difficulty in defecation, sensation of incomplete defecation and fecal incontinence.
Enterocele: Descent of small intestine through upper part of posterior vaginal wall and vault prolapse is descent of cuff of vault after hysterectomy into or out of introitus due to lack of support.
Preventive measures include birth spacing, childbirth to be conducted by skilled attendants avoiding prolonged labour. After childbirth, early ambulation and starting pelvic floor exercises to strengthen muscles will be of help to prevent prolapse. Preventing different conditions that can increase intraabdominal pressure and obesity can also help preventing prolapse development.
Vaginal pessaries used for conservative management are mostly for supporting or space filling purposes. They temporarily do anatomical restoration. It is usually given for women who wish to delay surgery or who are unfit for surgery.
Surgery for POP is done as per need and symptom aiming to restore defect anatomically and correct symptoms. Various surgical options are available based on need. For uterine prolapse, vaginal hysterectomy is done. If uterus preservation is the main aim Sacrohysteroplexy, Manchester repair or Uterosacral suspension is done. For cystocele and rectocele, anterior colporrhaphy and posterior colpoperineorrhaphy is done respectively depending upon need. Over and under correction while doing surgery can both be harmful to the patient.
Urinary incontinence: Involuntary loss of urine is called urinary incontinence. Urinary incontinence can be Stress incontinence, Urge incontinence, Mixed or Overflow incontinence.
Stress urinary incontinence: In stress incontinence there will be escape of urine through urethra when intra-abdominal pressure is raised due to bladder neck deformity. This is the most common form of urinary incontinence occurring while lifting heavy weights, sneezing, coughing, laughing and walking. In severe situations it can happen also while turning position in bed. The leakage of urine occurs in drops.
Management includes Kegel’s exercise to prevent and improve mild symptoms. However, mid urethral sling is the preferred surgical choice. This can be done by using mesh like trans-obturator tape, trans vaginal tape or mini sling. The gold standard nowadays is laparoscopic Burch colposuspension.
Urge urinary incontinence: In urge incontinence women will not be able to hold urine when they have desire to micturate. The etiology is overactivity of bladder muscle giving strong desire to void irrespective of amount of urine collected inside bladder. The leakage of urine occurs relatively in large amount wetting all her undergarments rather than just drops.
Management includes, identification of cause like infection, cholinergic activity, depression or drug induced and treat accordingly.
Mixed urinary incontinence: The mixed incontinence is the combination of stress and urge incontinence.
Overflow urinary incontinence: The overflow incontinence is due to intolerance of large volume of urine by bladder muscle. It happens in extremes of age. Most people experience this during childhood or in elderly age. This is commonly associated with neurogenic situations, drug induced or urethral blockage due to different causes. This is managed by bladder training which includes regular voiding and managing fluid intake. The cholinergic medications can be of help.
Fecal incontinence: Fecal incontinence includes unable to hold bowel or flatus. It is commonly caused by obstetric anal sphincter injury, pelvic floor muscle damage, chronic diarrhoea, inflammatory bowel disease, prior anorectal surgery and anal sex. The other risk factors are neurological and hormonal. Dietary modification, bowel habit training, pelvic floor rehabilitation, biofeedback therapy can help in sphincter control. Other treatment includes sphincter repair and sacral nerve stimulation.
Chronic pelvic pain: Persistent pelvic pain lasting for more than 6 months due to pelvic muscle spasm or dysfunction. Overactive and uncoordinated pelvic floor muscle leads to development of muscle spasm and generates chronic pelvic pain. Treatment of chronic pelvic pain needs coordinated care, integrating pelvic floor physical therapy and pain management will help to improve patient quality of life. In case the cause is multifactorial, multidisciplinary approaches will be required. A combination of muscular, neurologic, urologic, gynecologic, colorectal and psychological therapy can help. Again, the goal of treatment is to reduce pain, improve pelvic muscle function, restore bowel, bladder and sexual function and overall improve quality of life.
