Prolapse and Incontinence

The pelvic floor is a muscular partition that supports the pelvic organs, such as the uterus, bladder, and intestines. It is necessary in maintaining optimal pressure within the abdomen and ensuring a safe birth-passage during conception.

Urodynamic testing

Urodynamic testing mostly focuses on the bladder and its ability to store and release urine and looks for any problems which may lead to urine leakage. A urodynamic test is recommended if any symptoms such as urine leakage, or frequent and painful urination is detected.

Types of Tests

Urodynamic tests vary from a simple observation to precise measurements which require complex instruments:

  • Uroflowmetry is used to measure the speed and volume of urine.
  • Cystometric test focuses on the capacity of the bladder for holding urine and also when the urge to urinate begins relative to bladder fullness.
  • Post void residual measurement is used to measure the amount of urine left after urination in the bladder.

The availability of results after urodynamic tests depends on the complexity of the tests. For instance, a cystometric test results are available immediately after the test. Whereas results of more complex tests may take up to a few days.

Treatments

If urinary problems remain untreated, there might result in frequent infections, or damaging the functionality of kidneys. Treatments vary but can include:

  • Antibiotics or antiseptics – used in case of any infection or surgery in case of severe disorders.
  • Clean intermittent self catheterisation (CISC) is another treatment option which enables patients to efficiently empty the bladder. In this procedure, patients are required to insert a urinary catheter under clean conditions at regular intervals.

Urinary Tract Infections (UTIs)

A Urinary Tract Infection can take place in different parts of the urinary tract system including the kidneys, bladder and urethra. There are two main types of infections of the urinary tract:

  • Urethritis – This type of UTI normally occurs when gastro intestinal bacteria distributes from anus to the urethra. Sexually transmitted infections including herpes, chlamydia and mycoplasma can cause urethritis.
  • Cystitis – This type of UTI caused by E. coli, can be found in gastrointestinal tract. Sexual intercourse is an important factor which may lead to cystitis. Women are at higher risk of cystitis due to their anatomy.

Symptoms

UTI signs and symptoms include:

  • a strong, persistent urge to urinate
  • a burning sensation when urinating
  • strong-smelling urine
  • pelvic pain especially in the centre of the pelvis and around the area of the pubic bone.

However, these signs and symptoms are not always present or an indication of infection.

Causes

Urinary tract infections take place when the defence mechanism keeping bacteria out of the urinary tract system fails to function properly. Once bacteria get into the system, they start to multiply and result in an infection in the urinary tract

Risk Factors

The risk of developing a UTI is higher in women than men. There are also some other factors which increase the risk of UTIs, especially in women including:

  • sexual activity
  • Menopause
  • certain types of birth controls
  • urinary tract abnormalities

Treatments

Untreated UTIs may lead to consequences such as recurrent infections, permanent kidney damage or increased risk in pregnant women of delivering low birth weight or premature infants. Untreated UTIs can be potentially life-threatening, leading to Sepsis, a complex and hard-to-treat infection.

The treatments and drugs are dependent on the severity of the infections. Typically, antibiotics are the first line treatment for UTIs. Drugs which are commonly used for simple UTIs include

  • Ampicillin
  • Nitrofurantoin (Macrodantin, Macrobid)
  • Cephalexin (Keflex)

In case of severe UTIs, treatment with intravenous antibiotics in a hospital may be required.

Uterine (Womb) Prolapse

Prolapse after childbirth occurs in women as the pelvic floor muscles and ligaments stretch and weaken. Since there is not enough support for the uterus, it slips down into the vagina.

Symptoms

Symptoms of uterine prolapse can vary due to the severity of the problem. Patients with moderate to severe uterine prolapse may experience:

  • Sensation of heaviness in the pelvis.
  • Urine leakage or retention.
  • Tissue protruding from vagina.

Causes

Uterine prolapse can occur in women at any age and it can be caused by factors including:

  • Damage to muscles and other supportive tissues due to pregnancy and childbirth.
  • Repeated straining over the years
  • Loss of oestrogen

Treatments

Uterine prolapse treatments in mild cases do not require any specific instruction for recovery. However, pelvic floor exercises should be done in order to prevent any further problem. In the case of advanced uterine prolapse, a prolapse mesh implant in the vagina can be used to hold the uterus in place. Alternatively, uterine prolapse surgery to repair damaged or weakened pelvic floor tissues may need to be considered.

Incomplete Emptying of Bladder

This problem is most common in women and it is defined by abnormally slow flow rate of urine, or a sensation of incomplete emptying post voiding. In addition, patients with this disorder may have other symptoms such as frequency, urgency, and urinary tract infection.

Causes

There are different causes of this disorder in women which can be temporary or permanent:

  • Pelvic surgery or vaginal delivery
  • Acute inflammation such as genital or urinary tract infection
  • Drug such as epidural anaesthesia, detrusitol and antidepressants
  • Psychological influences such as anxiety, hysteria and depression
  • Inability to relax the urethral sphincter during voiding

Treatments

If problems remain untreated, there might result in frequent infections, or damaging the functionality of kidneys.Treatments can include:

  • Antibiotics or antiseptics may be used in case of any infection or surgery in case of severe disorders.
  • Clean intermittent self catheterisation (CISC) is another treatment option which enables patients to efficiently empty the bladder. In this procedure, patients are required to insert a urinary catheter under clean conditions at regular intervals.

Urge Incontinence (Leakage of Urine)

In the case of urge incontinence, the patient suddenly and strongly has an urge to urinate. The patient often needs to urinate during the night. There are different reasons that can lead to urge incontinence.

  • Infections which caused minor problems or diabetes and neurologic disorder can lead to severe conditions.
  • Urinary tract infections, constipation, pregnancy, menopause, hysterectomy and prostate cancer are medical conditions which may cause persistent urge incontinence.
  • Temporary urge incontinence can result from:
    • Alcohol
    • Caffeine
    • Carbonated drinks
    • Foods which include high amount of sugar, acids and spices.

Risk Factors

There are four factors which affect the risk of developing urge incontinence including:

  • Gender
  • Age
  • Obesity
  • Other medical conditions

Treatments

If urge incontinence problem is not treated properly it may cause skin problems and urinary tract infections as well as affecting patient’s personal life.

There is a wide variety of treatments for urge incontinence based on the severity of the disease. The treatments can be as simple as managing food and beverage intake, or the application of vaginal pessary or surgery in severe cases.

Vaginal Wall Prolapse

Vaginal vault prolapse occurs when the muscles that hold the internal pelvic organs in their correct position become weakened. This allows organs to drop or prolapse into the vagina. It could be the uterus, bowel or bladder.

 

Symptoms

  • Sensation of heaviness or pulling in your pelvis
  • Tissue protruding from your vagina.
  • Urinary problems, such as urine leakage or urine retention.
  • Trouble having a bowel movement- such as incomplete evacuation and constipation
  • Low back pain.
  • Feeling as if you’re sitting on a small ball or as if something is falling out of your vagina.
  • Sexual concerns, such as sensing looseness in the tone of your vaginal tissue.
  • Symptoms that are less bothersome in the morning and worsen as the day goes on.

Causes

  • Pregnancy and child birth are considered to be the main causes. A prolapse may occur during or shortly after the pregnancy or may take years to develop.
  • Age and menopause are further factors for weakening of the pelvic support structures.
  • Obesity, chronic cough, chronic constipation, heavy lifting and smoking
  • Inherited weakness of connective tissues such as Marfan syn and joint hyper mobility

Complications

If the prolapse causes the cervix or the skin that lines the vagina to protrude from the vagina, this can lead to ulceration, bleeding and infection. If the prolapse affects the bladder or the urethra, incontinence complications may occur. If the prolapse affects the rectum, there can be difficulty passing stool and incontinence of stool.

Treatments

  • Removal of any exacerbating factors
  • Pelvic floor exercises
  • Vaginal pessaries
  • Vaginal oestrogen creams
  • Laparoscopic surgery or vaginal surgery with or without MESH
  • Pelvic floor exercises are essential for all women with or without prolapse. It is recommended before and after surgery to improve the outcome of surgical and conservative management.

Prevention of vaginal prolapse is also key. Below are some strategies to help prolapse from occurring:

  • Do regular pelvic floor exercises with a physiotherapist
  • Avoid soap in genitalia
  • Use oestrogen cream if post-menopausal
  • Prevent constipation (eat a high fibre diet)
  • Stop smoking
  • Lose weight if necessary
  • Do weight lifting at the gym in lying or semi- sitting position
  • Avoid any exercises that increase the abdominal pressure such as full sit-ups and crunches
  • Carry your grocery shopping one bag at a time and do not overload it!