Introduction
Up to half of the normal female population will develop pelvic floor weakness which may lead to either pelvic organ prolapse or urinary incontinence during their lifetime. Population studies have shown that a woman up to the age of 80 years has an 11% risk of needing surgery for pelvic floor weakness.
What are the functions of the pelvic floor?
The pelvic floor performs the following functions: It provides a base or floor to the bony pelvis. When the pelvic floor is weaker the contents of the pelvis (the uterus, bladder and bowel) descend lower in the pelvis and may appear at the entrance to the vagina as a “bulge”. This is commonly called prolapse.
It helps control of the bladder and bowel by helping tighten the sphincter muscle of the urethra (the tube leading from the bladder) and the anus. Weakness can result in incontinence of urine or faeces.
It is involved in the normal mechanism of sex. Weakness can result in a loss of enjoyment from sexual intercourse.
What causes pelvic floor weakness?
Ageing and childbirth are the most common causes of pelvic floor weakness. A more difficult vaginal delivery is more likely to result in pelvic floor weakness. Some women are more likely to develop prolapse due to an inherent weakness in their pelvic ligaments. Such women also tend to have more mobile joints and may even be “double-jointed”.
What are the symptoms of pelvic floor weakness?
1. Prolapse Prolapse classically produces a sensation of fullness in the vagina or a visible or palpable lump at the entrance to the vagina. This sensation is always posture dependant as are many prolapse symptoms. If the symptoms do not resolve when lying down an alternative cause should be considered. Low backache is a common symptom but is also commonly experienced by women who do not have prolapse.
Prolapse of different parts of the vagina may occur:
Prolapse of the front wall of the vagina: the bladder lies under the vaginal skin of the front wall and when this prolapses it is often called a cystocoele Prolapse of the back wall: the rectum lies under the back wall of the vagina and when this area prolapses it is often called a rectocoele (or enterocoele).
Prolapse of the top of the vagina: if the uterus (womb) is still present the cervix will be the leading part of the prolapse. If the uterus has been removed the vagina is a blind ending tube and the top is called the vaginal vault and the prolapse is called a vault prolapse.
2. Incontinence a. Urinary incontinence Urinary incontinence secondary to pelvic floor weakness is called stress incontinence. Stress incontinence occurs when a woman coughs, laughs or sneezes or may occur with any type of physical exertion. A small amount of urine is usually lost with each episode.
b. Faecal incontinence Loss of solid faeces,fluid or flatus may result from pelvic floor weakness.
Treatment of pelvic floor weakness
1. Prolapse a. Pelvic floor physiotherapy Exercising the pelvic floor (often guided by a specialist physiotherapist) can improve the muscle tone and improve support.
b. Vaginal pessary Ring pessaries may be inserted into the vagina to improve support. They may be used in women of all ages and if fitted correctly the woman will not feel the pessary in place and it will not interfere with normal function of the bladder or bowel. Sex can also continue normally. The pessary needs to be replaced every six months.
c. Surgery
Surgical correction is usually offered if non-surgical treatment is not successful. It may be performed through the vagina or through the abdomen. Sometimes it is necessary to remove the uterus (womb) as part of the prolapse repair.
2. Incontinence Stress incontinence is usually managed by pelvic floor physiotherapy in the first instance. If this fails the drug duloxetine may be tried. If this does not help surgery may be employed. There are a number of different surgical procedures available but currently the most popular is the Tension free Vaginal Tape (TVT). The tape is inserted through a small vaginal incision and two very small (5mm) incisions below the pubic hair line. It has a high success rate but can fail or produce difficulty emptying the bladder.