What women should know about pelvic floor disorders

A study funded by the National Institutes of Health found that one quarter of all women suffer from pelvic floor disorders. The study further revealed that the problems become more common with age. About 40 percent of women between the ages of 60 to 79 years suffer from it, as do about 50 percent of women ages 80 or older.

“Urinary incontinence and pelvic floor prolapse are two of the most common pelvic floor disorders that patients seek medical care for,” said urogynecologist Xibei Jia, MD.

Dr. Jia, who practices at Urology Associates of Cape Cod in Hyannis, said that both conditions have similar risk factors. They include:

• Vaginal delivery
• Pregnancy
• Family history
• Genetics
• Age
• Chronic cough
• Chronic constipation
• Chronic heavy lifting

“Urinary incontinence is the involuntary leakage of urine,” Dr. Jia said. “The most common ones are stress urinary incontinence and urgency urinary incontinence.”

Stress urinary incontinence occurs when women have leakage while doing certain activities like coughing, sneezing, laughing, exercising or heavy lifting. It is caused by weakened support for the urethra.

Treatment

The first line of treatment for the disorder is to try some behavior modifications, she said. These include weight loss in overweight or obese women and pelvic floor muscle exercises.

The behavioral modifications that can help improve stress urinary incontinence also improves symptoms associated with mild pelvic organ prolapse. Pelvic organ prolapse occurs when there is a weakness in the connective tissue that supports the vagina. Dr. Jia compared it to a “hernia in the vagina” because it presents as a bulge in the vaginal wall.

“We have great pelvic floor physical therapists here on the Cape,” she said. “I recommend it as a first-line therapy for treatment of urinary incontinence and prolapse.”

The next line of treatment for both stress urinary incontinence and pelvic organ prolapse is for the patient to try a pessary. A pessary is a device that can be inserted into the vagina and provides support to either the prolapsed vagina and/or urethra, and it relieves the symptoms of pelvic organ prolapse and/or stress urinary incontinence.

The next step for stress urinary incontinence is surgery.

“Surgery is a very effective treatment for the stress urinary incontinence and there are different types of surgical treatments,” Dr. Jia said. “The most common one is the sling procedure which uses a short piece of mesh that is placed underneath the urethra to give the urethra the support. That is about 90 to 95 percent successful for the treatment of stress urinary incontinence.”

Overactive bladder is a little trickier, mostly because the cause is not always apparent. The symptoms include a sudden urge to urinate and having difficulty holding it long enough to reach the bathroom.

The first line of treatment for overactive bladder also starts with behavior modifications. Dr. Jia advises patients to avoid bladder irritants such as coffee, tea, soda, beverages with artificial sweeteners and alcohol.

The next mode of treatment is to do bladder training and pelvic floor exercises. There are also medications that can lead to up to 60 percent improvement of the symptoms of overactive bladder, Dr. Jia said.

Dr. Jia also does three different procedures that can treat overactive bladder. The first is bladder Botox, which involves a direct injection of Botox into the bladder muscle. The procedure can be done in the office and is repeated every six months. The second procedure is called percutaneous tibial nerve stimulation.

“It is a small needle that is placed near a patient’s ankle and it’s connected to an external device that delivers small electrical pulses to the tibial nerve that can help control the bladder,” she said. “That’s all external and that therapy is usually done once a week in the office for three months.”

The third procedure is called sacral neuromodulation. Dr. Jia compares it to a “pacemaker” for the bladder. It is an implanted device that modulates the bladder function through one of the sacral nerves. A battery is also implanted into the buttocks to send electric pulses to the sacral nerve.

Vaginal Prolapse

There are three compartments in the vagina that can have a prolapse: the anterior vaginal wall that is adjacent to the bladder, the posterior vaginal wall that is adjacent to the rectum and the top of the vagina where the cervix and uterus are located.

“A majority of women would have one or more compartments prolapsing but usually one will be the predominant prolapse Dr. Jia said.

Since it is a quality-of-life, no treatment is needed if a woman does not find her symptoms bothersome. If pelvic floor physical therapy or a pessary don’t provide symptom relief, there are three surgical options. The first one is vaginal reconstruction surgery that uses the patient’s own vaginal tissue and sutures to bring the torn connective tissues together to provide support. That surgery is about 70 percent effective, Dr. Jia said.

The second surgery is a minimally invasive robotic approach that uses mesh to help support the prolapsed vagina. This surgery has a success rate of 90 percent or higher.

The last surgery is called Colpocleisis, also known as vaginal closure surgery. This surgery is only appropriate for an older patient who no longer desires sexual intercourse. The vagina is shortened and partially closed. The success rate of this procedure is about 90 to 95 percent.

Even though pelvic floor disorders may cause embarrassment, Dr. Jia hopes that some of the secrecy and stigma about them can be dispelled with education about the different disorders and their treatments.

“I feel like a lot of women are suffering silently,” she said. “They are not talking to anyone about it and they don’t know there are options that exist.”