Actress Kate Winslett’s recent public disclosure of a very personal problem with bladder control was, in my view, an extraordinary gesture of kindness and support for millions of women around the world who suffer with a similar condition. Past generations of women have been reluctant to discuss such problems, even with their physicians—many believing they alone endured the discomfort and embarrassment. Such openness from a celebrity like Ms. Winslett is helpful; at least, I hope that my patients find encouragement from her message.
In reality, the condition affects millions of women who usually begin to notice symptoms around menopause. As baby-boomers pass into this age group, the prevalence of pelvic organ prolapse (POP) is on a steep rise. The actual fact is that Americans buy more incontinence products than menstrual pads (Washington Post, Dec. 22, 2015).
Pelvic organ prolapse (or pelvic relaxation) is a very general term that describes the weakening of support structures, the muscles and connective tissue that hold the pelvic organs in place. As a result, pelvic organs slip downward from their normal position, to some degree. Such displacement may involve the uterus (uterine prolapse), the front wall of the vagina adjoining the bladder (cystocele or bladder prolapse), or the back vaginal wall (rectocele). In women with a prior hysterectomy, the upper portion of the vagina may also slip downward (vaginal vault prolapsed). One of these problems may occur alone, or a woman may have a combination of conditions. You can click this link to American Congress of Obstetricians and Gynecologists’ website to view a series of interactive diagrams that illustrates these changes in the normal anatomy.
Symptoms of Pelvic Organ Prolapse
What symptoms an individual notices will depend on the specific organs involved and how much displacement has occurred. Symptoms may include uncontrolled loss of urine (urinary incontinence), low pelvic pressure or discomfort (especially with prolonged standing), or difficulty having bowel movements. Childbirth injuries to the muscles that control the rectum can also lead to loss of bowel control (fecal incontinence). Women should know that some degree of pelvic organ prolapse is very common after childbirth, especially after a difficult vaginal birth (a large baby relative to the size of the birth canal). All obstetricians know that birth trauma to the vaginal structures varies greatly and is generally related to “difficult deliveries.” But occasionally even a simple delivery can result in significant trauma to the mother. Birth trauma to the mother cannot be accurately predicted, but concern for possible trauma to mother and baby may be a reason for a cesarean delivery when labor is not progressing normally. Forceps-assisted deliveries do increase the risk of future POP, but in reality a delivery that requires forceps would generally be more difficult and possibly traumatic without the use of forceps. This excludes “outlet forceps” that are sometimes applied very low in the birth canal, just before the birth, to gently assist mom in delivering the baby’s head.
An important part of a woman’s annual exam with her gynecologist is the evaluation of the pelvic anatomy and support for the pelvic organs. Your doctor’s findings may prompt questions regarding possible symptoms of POP. An experienced gynecologist will offer you guidance about evaluating and treating relaxation or prolapse that is causing you discomfort or interfering with your normal activities.
Treatment
Your doctor will advise you about conservative measures to improve your symptoms. Simple remedies like limiting caffeine may help urinary incontinence. Increasing dietary fiber and using a stool softener or fiber laxative may improve bowel symptoms. Some women are helped by weight loss. We will recommend Kegel exercises to help strengthen your pelvic support muscles, and we can refer you to a physical therapist for supervised pelvic support therapy or biofeedback training. Sometimes a small device (pessary) inserted into the vagina can provide enough support to relieve symptoms. If these conservative measures do not provide adequate improvement, we will discuss surgical options to restore the vagina and surrounding organs to a more correct position. If surgery is necessary, all of our physicians have expertise in minimally invasive procedures for correcting this problem. problPelvic organ prolapse and the symptoms it causes are not something a woman just needs to live with.
I hope that Kate Winslett’s message will assure women that they are not alone with this problem and will encourage them not to be silent. Too many simply resign themselves to the discomfort, the reliance on incontinence protection, and even give up the active lifestyle they once enjoyed. Your gynecologist wants to help you enjoy many healthy, active post-menopausal years.