What type of patients suffers from pelvic floor disorders? Is it more common in some than the others?
First, we need to understand what the pelvic floor is?
The pelvic floor is almost like a stretchable hammock, which supports all the organs in the pelvis and it is an elastic kind of membrane through which there are different holes:
- For the passage of stools that is the anus,
- The urine which is the urethra, and
- The birth passage for the baby i.e the vagina.
Around these holes, the muscles of the floor are tightly wrapped around. Now, when this support weakens, we develop what is called as a pelvic floor disorder.
Dr. Pooja Jaisal
Specialist Obstetrics and Gynecology
If you have to ask what type of patients suffer from pelvic floor disorders then there are various causes and still, we do not know the exact cause but the most common ones that we encounter in Gynecology are because of,
- Repeated childbirth: Those women who have many deliveries, especially the vaginal deliveries, at the time of delivery encounter stretching of the pelvic floor. Sometimes tears and also stretching of the nerves which are supplying these floors can get damaged leading to weakening of the pelvic floor.
- Another cause could be weakening due to maybe severe obesity.
- There can also be an injury to a muscle, fasciae, or nerve damage
- Patients with repeated straining or increase in the intra-abdominal pressure like lifting heavy weights or constant straining due to chronic constipation are likely to have pelvic floor disorders more than others.
How do you diagnose pelvic floor disorders?
The diagnosis depends upon a detailed history, examination and then followed by a confirmation with the required investigations.
Generally, these patients come with a positive history and most of them are symptomatic. If they are asymptomatic then the diagnosis is picked up on a screening examination. The commonest symptoms are difficulty in passing motions or some kind of leakage in the urine or the stools.
In Gynecology, most often we see a bulge from the vagina that can be an abnormal feeling like something coming out from the vagina, so the patients sometimes have even uterine prolapses and the bladder bulging out from the front wall of the vagina which is called as cystocele or the back passage bulging out from the posterior wall of the vagina which is called as a rectocele and sometimes intestinal loops dangling in a pouch in the roof of the vagina which is called the enterocele. These are the commonest in our gynecologic practice and detailed examination helps in confirmation. Like when we ask the patient to strain, these prolapses can sometimes become more prominent or when the patient is standing because of the gravitational force and also when they are coughing or sneezing at that time there can be leakage of urine. Imaging like USG, MRI and urodynamic studies can be done to confirm diagnosis.
How do you treat pelvic floor disorders?
The management is multipronged and involves:
- Lifestyle modification
- Physiotherapy
- Treatment of predisposing conditions
- Surgical correction
The treatment can be varied. We need to individualize the treatment as per the needs. Most of the time, if it is a mild disorder, a few lifestyle changes can work for the patient like weight loss, having a good healthy diet and routine exercise regularly. The next step is that the patient can be taught specific exercises of the pelvic floor, a part of physiotherapy for women specifically called as Kegel’s exercises. The patient is taught how to contract the muscles and strengthening exercises can be done at home. There are also various biofeedback mechanisms wherein the patient gets response when the muscle is contracting and over time that does strengthen the muscle. If there is a nerve damage or if there is a muscle damage it can be repaired and it can be treated. Also a good diet with good protein content may help losing weight and shedding weight definitely helps, if these are leading to conditions which are predisposing to pelvic floor disorders. For example, if there is a chronic constipation, it can be treated, so that the patient does not strain and if there is a chronic cough it can be treated, so that the patient does not constantly cough and does not have an increase in the intraabdominal pressure.
Finally if conservative methods fail, there are surgeries for definitive management. There are specific surgeries to strengthen the pelvic floor designed for specific muscle group supporting specific organs and pelvic structures . If there is loosening, then it can be tightened and if the pelvic organs are prolapsing through the vagina, they can be lifted up and there are sling surgeries. Sling surgeries can lift up the uterus and if the vaginal wall is lax then it can be repaired and it can be tightened and also if the bladder is prolapsing then the supporting tissue can be tightened. To enhance the strength of weak supports special medical products are available ( suture materials, tapes , mesh etc.) There are different surgeries that we do for pelvic floor repairs like for example a cystocele repair, a rectocele repair, and an enterocele repair. It can be tailor-made as per individual patient requirement. The factors considered are:
- Age of the patient.
- Whether she is sexually active.
- Whether she has completed her family.
- Whether she is menopausal (Stopped her periods)
- Professional commitments and quality of life.
- Any family history of cancers.
We first decide what is the specific need of the woman and her desire and priorities are respected. For instance , If she is a very old patient, and the uterus is atrophic and non-functional , or is completely hanging outside the vagina , or she has a strong family history of cancers , then the most favorable option would be to offer a vaginal hysterectomy along with the pelvic floor repair.
What are the complications of pelvic floor disorder?
The complications could be that constant leakage or organ prolapse can cause maceration of the skin around. The patient can have embarrassment and it can affect the quality of life and it can affect her social life and the constant maceration can cause secondary infection to skin and mucosa around it. Also, long-term ulceration can later on possibly lead to changes of malignancy.
Is there a way to prevent pelvic floor disorder?
The causes of pelvic floor disorders are modifiable and non- modifiable. The non modifiable ones like increased predisposition due to hereditary factors or congenital factors can’t be changed but the modifiable factors are the one that can be worked upon. These include:
- Reducing birth related trauma. Avoiding prolonged labor and taking timely action.
- Proper repair of birth canal after a difficult or instrumental vaginal delivary
- Good muscle tone. This can be achieved by having and active lifestyle with proper diet and exercise.
- Regular health check-up for early detection of predisposing co-morbitdities.
A lot of people believe that it is a part of natural aging and that laxity is unavoidable; however, it is in our hands to prevent such pelvic floor disorders to quite an extent. Proper awareness and timely management can surely reduce the chances of having these disorders.
