On this episode of Kentucky Health, host Dr. Wayne Tuckson welcomes Dr. Johnnie Wright Jr., a urogynecologist with UK HealthCare and an associate professor of obstetrics and gynecology at the University of Kentucky College of Medicine. They discuss causes of and treatments for pelvic prolapse. Here are key takeaways from the discussion.
1) Pelvic prolapse in women occurs when a weakness or a tear in the pelvic muscles allows an organ to protrude into a space normally occupied by another organ. In some cases, tissue may push outside the body.
Dr. Wright explains that the pelvic floor is a muscular area in the midsection that is connected by ligaments to adjacent bones such as the hip bones and tail bone. “That muscle serves as a platform and a backboard for the organs that protrude through them,” he says. Organs that are supported by the pelvic floor are the rectum in the rear, the bladder in front, and for female patients, the uterus and cervix in the center.
Muscles in the pelvic floor can lose strength due to a variety of causes discussed below. If that occurs, there’s a risk that organs in the pelvic area can descend and protrude to the point where part of an organ could put pressure on the vaginal area and cause parts of that to bulge outside of the body.
In addition to the organs in the pelvic region, Wright says that the intestines could also descend in women who have had their reproductive organs removed via a hysterectomy.
“What I invite my patients to do is to think of the vaginal tube as an inverted sock,” Wright says. “There’s potential space and connective tissue between that sock and all of those organs – the bladder, the bowel, and the rectum. And any time there’s a break in that connective tissue, you can get a herniation or an avenue for those organs to push directly onto the sock. And then that front wall, if it’s the bladder, uterus or cervix, or the back wall if it’s the rectum, protrudes out beyond the opening of the vagina.”
Wright says in extreme cases when all pelvic support is lost, the protruding tissue can reach a patient’s middle thigh. Symptoms of pelvic prolapse include the protrusion itself as well as urinary incontinence and pain during intercourse. But Wright notes that “the beauty with prolapse and incontinence is that it’s not going to kill you.
“It’s not like cancer where you’ve got to be concerned and worried that you have to intervene quickly,” he explains. “Whatever you need to do to alleviate that initial pelvic pressure and heaviness, go for it.” Wright advises patients to manually push the protruding tissue back inside the vagina as a temporary remedy.
2) Causes of pelvic prolapse are varied but are usually associated with age and/or pregnancy.
“Every patient has a unique set of potential associations or triggers for pelvic prolapse,” says Wright. “The most common that we see in the United States is age – it’s a process we see with patients that are mature.”
Other causes include activities that put a strain on the pelvic muscles such as heavy lifting and accidents that damage the muscles. Wright adds that becoming pregnant and delivering an infant vaginally increase the risk of developing pelvic prolapse.
“There’s a natural relaxant hormone called progesterone that is super high, and it’s great and allows women to carry mature babies to birth,” he explains. “However, that relaxing also allows those (pelvic) ligaments to give a little bit. And then, birth itself – with that passage of the baby – there’s stretch on the ligaments, there’s stretch on the nerves that provide innervation to those muscles.”
Having a lengthy birth in and of itself is not associated with an increased risk of pelvic prolapse. But Wright says some difficult births that require the use of forceps or a vacuum to deliver the infant may put pressure and strain on the mother’s pelvic floor. In addition, Wright says, “We do see that the more babies, the more vaginal deliveries a woman has, the greater the risk of relaxation (of the muscles). However, make no mistake about it, one pregnancy and/or one delivery can also result in significant trauma or damage.” He adds that there is sufficient research to help women with existing pelvic floor weakness make an informed decision about delivering their baby through Caesarean section in order to avoid additional strain and potential trauma.
There are no proven methods that can completely prevent pelvic prolapse, but Wright advises that keeping weight down, refraining from smoking, and learning how to lift properly (using the legs instead of the back and midsection) can reduce the risk.
3) Treatment options begin with a patient consultation and may end in the operating room – but not always.
While he is paid to perform surgeries, Wright says it’s typical for him to tell patients with pelvic prolapse who can use the restroom normally and have sexual relations without any problems to simply observe the prolapse and follow up if it gets worse.
“After that, then we talk about non-surgical options for intervention,” he says. “Probably the biggest option for management of prolapse is a pessary, and that is a space-occupying device. We put it in the vaginal tube itself to reduce those areas that bulge in the ‘sock,’ if you will.”
Wright explains that pessaries come in various shapes and sizes, and he will advise patients on which one should fit best. “If the patient is able to manage the pessary herself, then we educate her on how to replace it, clean it, and take it out,” he says. Patients who are elderly and may lack manual dexterity due to osteoarthritis can visit the clinic regularly to have their pessary removed and cleaned.
Pelvic floor physical therapy can help patients with prolapse but Wright says he does not consider it a treatment. He says muscle contracting through Kegel exercises can strengthen the pelvic floor but that won’t necessarily cause organs that are already bulging to recede.
Patients with extreme pelvic prolapse that affects their quality of life are recommended for surgical procedures, Wright says. These usually involve inserting a polymer mesh screen in the vagina to hold organs in place, or using the patient’s native tissue or fascia (through stretching and stitching) to firm up the affected area. “We here at the University of Kentucky are huge fans of native tissue repair,” Wright says.
To explain the native tissue procedure, Wright refers to his concept of the vaginal “sock” and says, “if the top of the sock is falling down, we go inside the belly and attach a sleeve of that fascia on the front wall of the sock and the back wall of the sock, and then we attach it to a ligament that runs on the front of the patient’s tail bone, to create like a suspension bridge.”
