Pelvic floor SOS

When Lena, age 67, came to Dr. Mallika Anand, she explained she hadn't seen a gynecologist for many years. Still, when Dr. Anand conducted a physical exam, she was startled to find that Lena's uterus was no longer in its proper location within the pelvis. Instead, it was visible from outside.

"I wondered how she managed to live and work for years with a large bulge protruding from her vagina," says Dr. Anand, a urogynecologist in the Division of Female Pelvic Medicine and Reconstructive Surgery at Harvard-affiliated Beth Israel Deaconess Medical Center. "To be sure, it was uncomfortable."

Having given birth several times, Lena also suffered from chronic constipation and leaked urine when she coughed. On top of that, she was a former smoker. These happen to be a constellation of risk factors and consequences linked with Lena's diagnoses: stress incontinence and pelvic organ prolapse. The former develops when the urethral sphincter, the pelvic floor muscles, or both become weak or damaged and cannot dependably hold in urine. The latter happens when the uterus, bladder, small intestine, or rectum bulges into the vaginal wall or drops down through the vagina. What these two conditions have in common is that they both stem from weakness or damage in the pelvic floor.

Lena's case may have been extreme, but pelvic floor weakness in women — which can show up in subtle or dramatic ways — decidedly isn't. Indeed, six in 10 women cope at some point in their lives with symptoms that result from stress on the pelvic floor, a hammock of muscles that stretches from the pubic bone to the tailbone and supports the urethra, bladder, uterus, vagina, and rectum. While symptoms aren't usually life-threatening, they can prove incredibly disruptive.

Why it happens

The very fact that women have an opening in the pelvic floor — the vagina — makes us more prone to pelvic floor disorders than men. Beyond that, however, many other factors can contribute to pelvic floor weakness. These include pregnancy (and especially vaginal delivery), chronic constipation, family history, smoking, aging, menopause, obesity, chronic coughing, connective tissue disorders, and occupations involving heavy lifting. Some of these situations stretch and strain the pelvic floor, while others undermine the strength of its structures and tissues.

See a doctor if you notice these signs your pelvic floor strength has diminished:

You're leaking urine. Often, the first problem resulting from a weak pelvic floor is stress incontinence — urine leakage when you cough, laugh, sneeze, or exercise. That's because pelvic floor muscles weakened or damaged during childbirth can't tighten as strongly around the urethra to hold urine in until you're ready to let it go.

You have trouble using a tampon. This can happen for two reasons: either the vaginal walls (when pressed inward by other organs) "push" the tampon back out, or the vagina is so stretched that a tampon won't stay in place.

You can't fully empty your bladder or rectum. When either of these organs sag into the vagina, they can become "kinked," making it hard to completely expel urine or stool. These problems stem from two common forms of pelvic organ prolapse: cystocele, when the bladder pushes against the front of the vagina, distorting the vaginal wall; and rectocele, when the rectum pushes against the back of the vagina.

You feel a bulge in your vagina. That's a classic sign of pelvic organ prolapse — particularly uterine prolapse, in which the uterus drops down into the vagina. "Some people describe it as the feeling of delivering a baby again or as though an egg or softball is coming out of their vagina," Dr. Anand says. But a prolapse may be so subtle you feel only vague pressure in your vagina or pelvis, and about half the women who have it aren't aware until their gynecologist detects it during an exam. If no symptoms are present, no treatment is necessary.

Prevention and treatment strategies

While we can't change certain factors that may damage our pelvic floor, we're not powerless to reduce our risks, either. Dr. Anand suggests these measures:

• If you're pregnant and are diagnosed with gestational diabetes, work closely with your clinician to treat it (inadequately treated diabetes may result in large babies).
• If you're pregnant with a large baby, discuss with your doctor whether vaginal or cesarean delivery would be best.
• Maintain a healthy weight through exercise and proper nutrition.
• Prevent constipation (and straining in the bathroom) by eating fiber-rich foods and drinking plenty of liquids.
• Carefully manage conditions that contribute to chronic cough, such as asthma or COPD. And don't smoke.

When trouble arises, various treatments can ease or alleviate symptoms. Here are some options.

Pelvic floor physical therapy. This form of physical therapy "is the first-line treatment for all pelvic floor disorders," she says. It coaches women to strengthen muscles in the pelvic floor, along with those in the abdomen, back, and hips, using a variety of techniques.

Pessary. Dating in concept to ancient Egypt but constructed from modern materials, this supportive device is inserted into the vagina to diminish stress incontinence or prop up prolapsed organs.

Surgery. Reconstructing the vagina using a woman's own tissue, synthetic mesh, or a combination of both can elevate a prolapsed vagina, supporting neighboring pelvic organs. Stress incontinence can be surgically treated by supporting the urethra with mesh material or reinforcing the inner lining with an injectable substance.

"Often, we can help someone get the type of treatment they want, especially if they identify the problem early," Dr. Anand says. "It really opens up all the treatment options."

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