Dear Dr. Pat,

I’m writing about an embarrassing problem that I really don’t feel comfortable talking about with my friends. I have been leaking when I do any exercise or cough, and it’s getting worse.It is interfering with everything I do. I now wear big pads just in case and don’t drink before I go out. In fact, I’m limiting the amount of liquids I consume altogether which is probably not so healthy.

I saw my gynecologist. He said I should have a complete hysterectomy while he fixes what he called a dropped bladder. He delivered my children and I do trust him. My biggest child was 9½ pounds and was a forceps delivery when I was 38. (I’m now 40 and menstruate regularly.)

It took me a long time to recover from that episiotomy repair, I can tell you! I developed the leaking urine after that birth but did lots of Kegel exercises and things did get better for a while. But then the urine problem became worse and worse.

I don’t want to talk to my husband about it, but if I have to have surgery I won’t have a choice. This certainly doesn’t make me feel sexy. In fact, since that delivery my husband has remarked that my vaginal opening seems a bit larger. Do I really need surgery?

My uterus is not falling down but the gynecologist said that it would eventually so I might as well prevent it.

Betty

Dear Betty,

You’ve done a great job of describing a condition that many women are intimately familiar with and, like you, embarrassed to talk about. I asked WVFC Medical Advisory Board member Lauri Romanzi, M.D., a specialist in reconstructive pelvic surgery and urogynecology, to respond. Which she did, pulling out a drawerful of medical illustrations to help explain what’s going on in your body, and why a hysterectomy isn’t the answer. —Dr. Pat

Hello Betty.

You have two common pelvic floor disorders: pelvic organ prolapse and urinary incontinence. While these conditions often occur together, there are many women with no prolapse whatever who have severe urinary incontinence, and women with severe prolapse who don’t leak a drop.

You are not alone!

Recent estimates using US Census population projections anticipate a probable 46 percent increase in pelvic organ prolapse among American women over the next 40 years, from 3.3 million in 2010 to 4.9 million. According to a recent study from Duke University, it is possible that the number of women with prolapse will be even greater than this, up to 9.2 million. Prolapse may occur to varying degrees in up to 50 percent of women who’ve given birth.

With our without urinary incontinence, no woman with a cystocele—the medical term for a dropped or prolapsed bladder—needs, or even should undergo a hysterectomy to prevent possible future uterine prolapse. If for no other reason than that you may never develop uterine prolapse, and if you do, you can have it repaired at that time with a uterine re-suspension.

Before you head into the operating room, you may be able take care of both the urinary incontinence and the vaginal laxity with coached Kegel exercises, done with a qualified pelvic floor physical therapist (not on your own). If pelvic floor PT is going to work, 2-3 months of regular visits with home workouts in between should do it.

If the pelvic floor physical therapy doesn’t give you the results you’re looking for, it may be time to plan a reconstructive procedure. Even if you need an operation, there is no reason to remove any body parts. You can take care of the cystocele with a bladder lift, the stress urinary incontinence with a minimally invasive sling, and the vaginal laxity with a combined rectocele repair with perineoplasty. Unless the uterus is falling down, it is best left alone. Even if it is falling down, it can be re–suspended. Let’s look at pelvic anatomy to help you understand the geography of your pelvis with an edited excerpt from my book on incontinence and prolapse, “Plumbing and Renovations” (www.plumbingandrenovations.com):

Pelvic organ, or vaginal, prolapse is an umbrella term for the different components of vaginal prolapse, including uterine prolapse, dropped bladder (cystocele) vaginal laxity (perineal body atrophy), rectocele and enterocele. Some women have a bit of each, others have only one or two components, but which ever and to whatever degree, pelvic organ prolapse is a woman’s hernia.

Normal pelvic anatomy (right) is a harmony of bodily functions buttressed by the Kegel muscles of the Levator ani. The uterus drapes gently over the top of the bladder, and the bladder, vagina and rectum are separated from each other by thin, sturdy fibro–muscular walls composed of collagen, skin cells and smooth muscle. These walls hold the rectum and bladder in place, and tend to weaken with childbearing and age. At the vaginal opening, below the level of the muscles, is the perineum, a connective tissue separator of the anus and vagina which tends to thin out with childbearing and age. Above the muscles we find the uterus, held in place by the uterosacral ligaments much as a chandelier is held up by strong cables. The female pelvic support system is considered in compartments when doctors are figuring out what is out of place and how best to amend the condition. The anterior compartment contains the bladder and urethra; the posterior compartment contains the rectum and anus, the basement is the perineum and the ceiling contains the uterus.

A cystocele (left) is a dropped bladder, often first noticed during sex, or on the toilet, as a soft, balloon–like bulge at the vaginal opening. This results from the connective tissue between bladder and vagina wearing out or pulling off of the sidewall of the pelvis, leaving only the vaginal skin to hold up the bladder, which is too elastic to do the job well, and so the bladder bulges down.

A similar thinning of connective tissue can occur between rectum and vagina causing a rectocele. In the  next illustration (below right), we see a rectocele along with an absence of perineum connective tissue between the anus and vagina, with a bulging of the vaginal opening.

Rectocele and perineum atrophy are often seen together, with symptoms of vaginal laxity, looseness during sex, a bearing-down pelvic pressure with strenuous activity, and difficult defecation. In fact, many women with rectocele will press up on the perineum or backward on the vaginal wall toward the rectum during bowel movements to compensate for the bulging and make defecation easier. Doctors call this “splinting.” If you are doing this, you may have a rectocele or a thin perineum.

When the uterosacral ligaments stretch out, the uterus drops down into the vagina. It feels like a firm mass at the vaginal opening, coming down either on the toilet or during strenuous activities like jogging or heavy lifting. This is uterine prolapse.

It is common for women with uterine prolapse to report that the bulge waxes and wanes—that it’s not there on some days and low and bothersome on others. It usually pulls back in when you lie down, and is often “in in the morning and out by the evening.” It is sometimes associated with a low backache in the area of the tailbone.

The uterus comes with dual support, one robust uterosacral ligament on each side, holding it in place at the top of the vagina.  (See  left). When the ligaments are lax, the uterus drops.

In the event of uterine prolapse, re-suspend – do not remove. Hysterectomy is not a cure for prolapse; hysterectomy is a cure for having a uterus. There are three basic categories of uterine re-suspension:

Re-suspend to the sacrospinous ligament(s)

Re-suspend to native uterosacral ligaments

Re-suspend with artificial uterosacral graft

Betty, at 40 years of age, your reticence about surgery is not only completely understandable, it is wise

When it comes to prolapse, the uterus is a victim, not a perpetrator. Prolapse occurs not because the uterus is heavy, but because the ligaments supporting the uterus gave way. Since uterine re-suspension (hysteropexy) works just as well as hysterectomy-based prolapse repairs, with essentially the same durability, there is no advantage to removing the uterus to repair prolapse— unless you also suffer a separate condition for which hysterectomy may be of clear benefit, such as severe fibroids or endometriosis or high personal risk for gynecologic cancers. Otherwise, it’s best to lift that uterus up into normal position with a re-suspension procedure and get on with life!

To find a surgeon skilled in treatment for pelvic organ prolapse, vaginal laxity and urinary incontinence, visit the ‘Find A Provider’ page on the American Urogynecologic Society website.

Best,

Lauri Romanzi, M.D.