Chapter 6: Declining Pelvic Muscle Tone: Pelvic Prolapse and Urinary Incontinence

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Excerpted pages 93-96

With age, inactivity, and sometimes disease, muscles throughout your body may become flabby, weak, and unable to support your body structures. The muscles of your pelvic floor are no exception. Pelvic muscle weakness can result in incontinence (an inability to control your bladder or bowels) and/or prolapse (the dropping of the uterus, the bladder, and/or the rectum within the vagina or past the vaginal opening). Vaginal vault prolapse is the descent of the top of the vagina, which typically occurs after a woman has had a hysterectomy.156 Prolapse may be caused by inadequate muscle tone. This usually results from childbirth, but there may be other causes.

Pelvic organ prolapse generates between 200,000 and 300,000 inpatient surgical procedures annually in the United States.106, 165, 566 The Pelvic Organ Prolapse Quantification System that was developed in 1996 by the International Continence Society provides a uniform method of scoring the degree of prolapse in order to monitor change in the condition. Table 6.1 lists the stages, which are defined by how protruded (beyond the vaginal hymeneal ring) the leading edge appears on examination.

Notice that the degree can range from invisible to visible. If you’re assessed with one stage, though, it may not get worse. According to Dr. Anne Weber, prolapse is dynamic, rather than progressive. In fact, it often regresses.823 In other words, you can have the condition one year and not the next.92 Obesity is one of the few modifiable risk factors that have been identified as a cause. As usual, it helps to watch your weight.

Prolapse: Fairly Common, but Not Deadly

No populationwide data have been gathered in the United States, but investigators estimate that 30 to 93 percent of mobile women will experience prolapse.566

Examinations of 270 Iowa participants in the Women’s Health Initiative Study revealed that 65.2 percent were at least at stage II or beyond and 25.6 percent had the leading edge of internal structures protruding outside the vagina. The investigators concluded that pelvic organ prolapse is common and some degree of prolapse is normal, especially in women in their mid 60s.566 Neither hormone therapy, the number of pregnancies, nor vaginal delivery were associated with the occurrence of prolapse. But for women who did have prolapse, those with more than two vaginally delivered babies were more likely to experience further descent over time.92 Those most at risk were in poor health status overall.652 African American women have less than half the risk of Caucasians.

What Is the Cause of Prolapse?

There are theories, including a stretching of the vaginal tissue, the thinning of tissue, aging with estrogen deficiency at menopause, and breaks in the fascia of the vagina. But the theories have not been supported by facts.824 Very little is known about the physical and biological manifestations of prolapse. A potential cure at the molecular level appears unlikely.526

The majority of women who undergo pelvic floor reconstructive surgeries have previously had hysterectomies in each of the studies that list prior surgeries.709 Possibly, surgical removal of the uterus further weakens the supporting structures that are needed to hold the pelvic anatomy in place.

Do you need to do anything about prolapse? It really depends on you. Although some authors state that women with prolapse suffer from chronic pelvic pain and pressure, urinary and fecal incontinence, sexual dysfunction and social isolation,526 other experts assert that pelvic pain is not associated with prolapse and, frequently, prolapse is not a problem that requires surgery.823 A stage IV prolapse with internal structures protruding outside the body will obviously be a problem, as well as a medical emergency if the woman is unable to urinate. Fortunately, this is relatively rare,823 occurring in less than 7 percent of women.652 Moreover, the actions you take with stage II or III prolapse may prevent the further descent of the prolapse.

There is no inevitability that the problem will worsen, and prolapse does not demand treatment (or surgery) unless you are currently suffering.

Also in this chapter:

• Nonsurgical Approaches (to prolapse)
• Surgical Repair
• Urinary Incontinence (UI)
• What You Should Know about Surgical Devices and Therapies