Tuesday, August 16, 2016

Pelvic Organ Prolapse at Menopause

Hot flashes, mood swings and no desire to have sex - all are common symptoms of the menopause.
It is a stage in life that the majority of women dread, it signaling the end of their reproductive years.
But, a new piece of research has shed light on how more than half of women who go through the change; secretly grapple with an embarrassing set of symptoms rarely discussed. 

Researchers from Dartmouth, Yale and Connecticut Healthcare Symptoms found that 51 per cent of post-menopausal women deal with vaginal and vulvar problems. Those problems include itching, burning, pain, discharge or odor.  While others suffer from problems with urinary frequency, fecal incontinence and pelvic organ prolapse as well.

Despite the severity of the symptoms, researchers warn the majority of women do not seek the medical help they need.

In this post, we will review the pelvic organ prolapse, the symptoms, implications, and the treatment options.

Menopause & pelvic organ prolapse at a glance

Changes in a woman’s pelvic floor function often accompany menopause. Weakening of the pelvic support structures can lead to pelvic organ prolapse, in which one or more organs (bladder, uterus, urethra, vagina, small bowel or rectum) of the pelvic area drops out of place.

While there are many causes of pelvic organ prolapse (heavy lifting, vaginal birth, hysterectomy), the lack of estrogen during menopause thins the support structures and tissue that hold pelvic organs in place, causing them to fall.

What is going on?

The pelvic organs are kept in place by the muscles and connective tissues of the pelvis (pelvic diaphragm). The vagina of an adult woman is normally a round-topped, muscular tube that also supports the other pelvic organs. The pelvic muscles and tissues can be stretched or damaged, most commonly by childbirth. When they don't recover, they lose their ability to support the organs.

The location and severity of pelvic organ prolapse is related to where in the pelvis the injury or muscular damage has occurred. You may have several areas of injury that contribute to prolapse. Prolapse may occur after surgery to remove the uterus (hysterectomy) if the procedure removes or damages support of the bladder, urethra, or bowel wall. If other conditions, such as childbirth, damage muscles or nerves in the pelvis, the pelvic diaphragm may lose its dome shape. It may become more like a funnel and then bulge down into or out of the vagina.

Pelvic organ prolapse may increase pressure on the vagina and interfere with sexual activity, sometimes leading to sexual dysfunction.

Additionally, the thinning and the lack of vaginal moisture associated with menopause can also cause problems with sexual function. The vaginal tissue becomes frail and less supple, and stretching from intercourse can be very irritating or even painful at times.

Lower estrogen levels during and after menopause make pelvic organ prolapse significantly more likely. Estrogen helps your body to make collagen, a protein that enables the supportive tissues of the pelvis to stretch and return to their normal positions. When estrogen levels go down, so do collagen levels. Less collagen makes it more likely that those supportive tissues will tear.

Types of pelvic organ prolapse

Different types of pelvic organ prolapse affect different parts of the vagina:

*    Cystocele and urethrocele.
A cystocele occurs when the bladder protrudes into the front wall of the vagina. A similar defect, known as a urethrocele, develops when the urethra presses into the front vaginal wall.

*     Rectocele.
Part of the rectum bulges into the back wall of the vagina, sometimes causing difficulty with defecation.

*     Uterine prolapse.
The uterus drops down into the vagina. In women who have undergone a hysterectomy, a similar condition known as vaginal vault prolapse can occur: the top of the vagina protrudes into the lower vagina.

Menopausal pelvic organ prolapse symptoms

Symptoms associated with pelvic organ prolapse can range from minor pain and difficulty urinating to emotional distress. Unlike other symptoms of menopause, such as hot flashes, pelvic organ prolapse symptoms can increase with age.

Symptoms related to varying types of pelvic organ prolapse include:

* Pain or a feeling of pressure in the pelvis or vagina
*  Feeling that something is coming out of your vagina or sight of tissue protruding from the vagina (which may bleed or feel tender)
*  Difficulty urinating or a feeling that the bladder will not empty (incomplete voiding); bowel movement difficulty
*  Lower back pain
*  Urinary incontinence (urine leakage during sneezing, coughing or exertion)
*  Frequent bladder infections
*  Painful sexual intercourse (dyspareunia)

Treatments for menopausal pelvic organ prolapse

Since lack of estrogen is the primary cause of menopausal pelvic organ prolapse, treatment in postmenopausal women involves hormone therapy (HT). These can help restore the vagina to premenopausal condition and may help to strengthen the vaginal structures supporting the pelvic floor. The most common HT is low-dose vaginal estrogen replacement, utilizing creams, tablets or vaginal rings.

Women with no or very mild symptoms don't need treatment, although they should avoid anything that might worsen the prolapse. Losing weight if necessary, avoiding lifting heavy objects, and quitting smoking all prevent prolapses from progressing. Prolapse doesn't necessarily worsen over time, so there's no need to seek aggressive treatments, unless your symptoms are really bothersome.

If you're experiencing major discomfort or inconvenience, surgery is the only definitive way to relieve symptoms and improve your quality of life. But if your symptoms are mild or you want to delay or avoid surgery, less invasive treatments can help:

Kegel exercises

A woman with prolapse but no symptoms may be urged to practice Kegel exercises to reduce the chance that her condition will progress. Kegel exercises are a series of contractions that strengthen the pelvic floor. You squeeze two sets of pelvic floor muscles at the same time: those you would use to prevent yourself from passing gas and those you would tighten to stop urinating. Avoid contracting your stomach muscles.

Try to do 30–40 pelvic contractions each day; you may want to divide them into three or four groups of 10 each, spread throughout the day. Squeeze and hold the contraction for 3–5 seconds; then rest for the same length of time. Build up to 10-second contractions, with 10 seconds of rest in between.


For women who aren't good surgical candidates or want to delay surgery (perhaps if planning to have more children), one alternative is a vaginal pessary — a device similar to a diaphragm or cervical cap that's inserted in the vagina to help support the pelvic area (see illustration).

Surgical treatment

Before undergoing surgical repair of a prolapse, you'll need to have a thorough pelvic exam, to ensure that all problems have been identified. Be sure your surgeon has expertise in the field of pelvic reconstruction, as new procedures and anatomical knowledge have led to better results.

Surgical techniques. Pelvic reconstruction surgery may be performed through the vagina or abdominally; both procedures are equally effective. A newer option is laparoscopic surgery, in which repairs are made with instruments, including a camera, inserted through a few tiny abdominal incisions. The prolapsed organ will be repositioned and secured with stitches to the surrounding tissues and ligaments. The vaginal defect will be repaired, sometimes using a piece of synthetic material, called a graft. Women can usually leave the hospital within one to three days.

Complications. Possible complications of pelvic reconstructive surgery include urinary tract infection, temporary or permanent incontinence, infection, bleeding, and — rarely — damage to the urinary tract that requires additional corrective surgery. Some women may develop chronic irritation or pain during intercourse from a suture or scar tissue.

There's also a risk of recurrence, which seems to be highest for cystocele and lowest for rectocele. Fortunately, recurrence rates are dropping as surgical techniques and preoperative planning improve. The chance of recurrence will also be reduced if a woman avoids stress, such as heavy lifting or straining during a bowel movement, and performs Kegel exercises regularly before and after surgery.

Some of the prevention tips

Pelvic organ prolapse is most often a result of tissue damage caused by labor and childbirth. Although you may not be able to prevent the damage to your pelvic organs caused by childbearing, you may be able to control the progression of the prolapse. Lifestyle changes that may slow the prolapse process include:
*  Reaching and staying at a weight that is healthy for your height.
*  Not smoking. The chronic cough associated with smoking may cause or speed pelvic organ prolapse.
*  Correcting constipation. The straining caused by constipation weakens and damages the connective tissue and muscles in the pelvis.
*  Avoiding heavy lifting and jumping.
*  Doing pelvic strengthening exercises (Kegel exercises) every day. These exercises help strengthen the muscles of the pelvis.

Sources and Additional Information:

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