As women age various things work against us; gravity, aging body tissues, poor life style habits and injuries during childbirth.
As a result not only do we go grey and develop wrinkles our pelvic floor and other muscles become weaker and stretched. We also tend to gain more weight than is healthy, drink too much caffeine and possibly even smoke.
Urogynaecology is a specialist field of gynaecology that deals with problems of the female pelvic floor, usually either incontinence or prolapse.
Common problems of pelvic floor failure
- Urinary leakage with exercise. Some women may not leak urine at all but nonetheless feel that their life is dominated by their bladder and the need to “find a loo”. Some may have a mixture of symptoms. This may start relatively young, or only later at the time of the menopause
- Bulge in the vagina
- Reduced sensation during sex
- Difficulty emptying the bowel
Many women believe that these problems are inevitable and are not aware that effective treatment is available. Although most commonly associated with a history of a difficult vaginal birth, women who have never been pregnant may develop problems.
The pelvic floor
The pelvic floor:
- Is a complicated sheet of muscle and connective tissue that forms the base of the pelvis
- It prevents our insides; including bladder, uterus and rectum, from hanging between our legs
- It can be injured, get weak and lazy but also be strengthened again
Management options
- Physiotherapists are able to teach strengthening of the pelvic floor and correction of bad posture, lower backache and poor bladder and bowel habits. Exercises done incorrectly can make things worse
- Vaginal ring pessaries can alleviate the symptoms of prolapse and incontinence
- Surgery is sometimes the only cure
Women with bladder and bowel symptoms should see a gynaecologist with a special interest in urogynaecology
Incontinence surgery and TVT
For many women, the only cure for urinary incontinence is surgery. In the past, surgery for incontinence involved a major operation and many days in hospital. Fortunately only a few women still require this type of major surgery to cure their problem.
Today, most urinary incontinence can be improved or cured by the insertion of a sling or piece of tape:
- A tape is threaded via a small incision in the vagina, under the urethra (pipe from the bladder) and out past the pubic bone
- The tape forms a hammock that supports the urethra without blocking it off
- The operation requires only a short general anaesthetic
- Most women can go home the same day. Most choose to be off work for two weeks to recover properly
- For best results our patients are also referred to a physiotherapist for bladder retraining and to learn pelvic floor exercises
Whether you will benefit from a sling procedure will depend on the reason for incontinence. After taking a thorough history and examination, your specialist may request a urodynamics test prior to making a final decision.
Urodynamics
Although the bladder is a simple organ, the function of filling and not leaking; but then emptying when needed, is complex. The cause of urinary leakage is not always immediately apparent. Urodynamics studies gives the specialist urologist or gynaecologist a better understanding of what is going on with a particular person’s bladder. Urodynamics is uncomfortable but not painful.
Urodynamics involves:
- Bladder diary: completing a “bladder diary” for at least two days. A bladder diary provides information on how the bladder “behaves” during a normal day
- Ultrasound of the bladder and pelvic floor muscles: this is sometimes useful to determine the extent of the problem
- Measurement of bladder capacity, bladder pressures, and pressures at which the bladder leaks: a small catheter and pressure sensor is placed into the bladder and another into the rectum
Vaginal Repair
Vaginal repair refers to operations done to restore normal vaginal anatomy in women with vaginal, bladder or bowel prolapse. Vaginal repair is also called colporraphy.
Reasons for needing vaginal repair vary and include:
- Urinary incontinence
- Difficulty emptying the bowels
- awareness of a bulge/lump in the vagina
- sex that has become uncomfortable or less satisfying
Most vaginal repairs:
Require admission to hospital – Are done with a general anaesthetic – Are performed vaginally – Usually require 1-2 days in hospital. During this time you may have an indwelling urinary catheter, particularly if you have had an incontinence operation at the same time – Usually require 6 weeks off work to allow the pelvic floor to heal properly.
Vaginal repair with mesh
Traditional vaginal repair involves making an incision through the vagina and using dissolvable stitches to support the part that has prolapsed. This type of procedure has been done for decades and for many women is very successful. Unfortunately however, with this technique the failure rate and recurrence of the prolapse is quite high.
For this reason some gynaecologists now use a synthetic piece of material or “mesh” to support the vagina.
Although mesh has been very successful in the repair of abdominal hernias, the results for vaginal repair have been varied. The use of mesh in vaginal repair and prolapse surgery needs to be individualized. The decision to use mesh is made with great care and many factors need to be taken into consideration.
A urogynaecologist will need to assess these many factors and discuss what will be the most appropriate surgery for you.
Vaginal ring pessary
Vaginal ring pessaries are used if:
- Surgery is not an option
- A temporary solution is required while awaiting surgery
A ring pessary is fitted in much the same way as the old diaphragms used for contraception. The pessary sits at the top of the vagina and if fitted correctly cannot be felt once it is in.
The disadvantage of a ring is that it needs to be replaced every six months. The advantage is being able to avoid surgery.
GLOSSARY
Rectocele
Prolapse of the rectum into the vagina.
Urogenital prolapse
Weakness of the pelvic floor resulting in a prolapse of uterus, bladder or rectum into the vagina.
Urogynaecologist
A gynaecologist with a special interest in bladder problems and prolapse.