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Women's Health Resource Center

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Pelvic Floor Relaxation

Lydia knew something was wrong. "Even though I'm just shy of 70 years old, I enjoy hiking and biking in the countryside. But I've been having this strange pressure in my pelvic area, and last night after a jaunt up Moose Mountain, I had this huge bulge coming out my vagina! What's wrong? Do I have a tumor?"

Lydia went to her gynecologist, who explained that the bulge in her vagina wasn't a tumor at all. It was a prolapse (a dropping) or hernia (a protrusion) of the internal organs through her pelvic floor to the outside, a rather extreme result of pelvic relaxation.

As women lead healthier and longer lives, disorders of pelvic support, usually termed pelvic relaxation, become more common and can interfere with vigorous life styles. Pelvic relaxation refers to a gradual weakening of the muscles and supportive tissues that hold the bladder, rectum, vagina, and uterus in place. Even in women who have not borne children, this weakness can develop due to age, decreasing estrogen levels, genetic factors, obesity, and conditions such as a chronic cough that strain pelvic muscles.

The pelvic floor consists of an interwoven group of muscles and ligament-like tissues that actually hold inside not only the female internal organs, but also the bladder, colon and small intestines. Imagine the bones of the pelvis, which are quite rigid, as the rim of a large wash bowl. The bottom of the bowl corresponds to the muscles and fibrous tissues, which in the female has three openings for the urethra, vagina, and the rectum/anus. With pelvic relaxation, these openings become exaggerated and the organs sag or can even herniate (protrude). These pelvic muscles, in primitive times, were used to wag the tail.

Probably the most common form of pelvic relaxation is weakness of bladder support, resulting in urinary incontinence, which is uncontrolled or unexpected loss of urine. Bladder prolapse is called a cystocele. This can be accompanied by weakness of the rectal wall, which is called a rectocele, and difficulty passing stool may be encountered. When the uterus and cervix begin to fall out, this is called uterine prolapse. An enterocele is the problem when the back of the vagina herniates, and the intestines often accompany this defect. Occasionally, all of these occur at once (usually in older women), and this is called procidentia. None of these disorders are life threatening, but they clearly can interfere with a happy, vigorous lifestyle and in certain circumstances, be embarrassing.

Symptoms

Women with mild pelvic relaxation can be symptom-free, or in moderate to severe cases, they can experience many symptoms, including: a heavy feeling "like things are dropping" in the pelvic area; a loss of urine when coughing, sneezing, laughing, or lifting; frequent urination; pelvic pressure; problems having intercourse; low backache; and in extreme cases, discomfort and difficulty with walking and sitting.

Health care providers can usually feel the degree of prolapse during vaginal examination by pressing down on the abdomen, while the woman coughs or bears down with her abdominal muscles. A woman should be able to feel the protrusion as well, by straining while doing a self-digital examination. If the prolapse is large enough, it can even be seen by putting a mirror between the legs and straining.

Stages of uterine prolapse

  • First degree – The cervix, bladder, or rectum has descended into the vaginal canal, but not yet into the vaginal opening.
  • Second degree – The cervix, bladder, or rectum actually appears in whole or in part, outside the vaginal opening, with straining.
  • Third degree – The cervix, bladder, or rectum descends beyond the vaginal opening at rest.
  • Complete prolapse – The entire cervix and uterus protrude beyond the vagina to the point that it shows outside the vagina entirely. This type is most common in women over 70.

Treatment

Some women endure the discomfort of pelvic relaxation until the last possible moment because it's so difficult to go to the doctor to complain about "this thing" between their legs. But treatment is available. Certain treatments such as hormone replacement therapy combined with Kegel exercises (repetitive tightening and relaxing of the pelvic muscles) can be the simplest remedy for the early stages of the problem. Another non surgical option is a pessary: a ring-shaped device that fits around the cervix and props up the uterus. The pessary must be cleaned frequently and removed for intercourse. But if a woman is not sexually active or not a good candidate for surgery, this could be the right treatment option.

While these techniques can temporarily improve or control pelvic relaxation, surgery affords a more functional and long lasting result. A hysterectomy is performed in severe cases of uterine prolapse when other related surgery (such as for a vaginal hernia) is needed. In this case, hysterectomy improves the results of the associated surgery and prevents the need for a second operation in case prolapse symptoms become worse later. The fact is that about 16 percent of all hysterectomies are done for uterine prolapse. But there are other surgical alternatives.

There is a large of variety of "surgical suspension" operations, depending on the specific problem, that basically lift the internal organs into their correct position by shortening the ligaments that hold them in place. Most of these operations, performed by a trained pelvic floor surgeon, can be accomplished vaginally or with a small incision in the lower abdomen; and some incontinence repairs can be done by laparoscopy (with an optical instrument that is inserted through the abdomen). Before surgery for incontinence, a battery of tests, usually called urodynamics, may be requested. These test your bladder muscles to determine how they react to the bladder filling up, what happens when you cough or sneeze, and how your bladder empties. In choosing the best treatment option, a woman should discuss with her surgeon such factors as the durability of the treatment and the incidence of complications.

Seek professional help

DHMC is fortunate to have well-trained, experienced urogynecologists and pelvic floor surgeons. Women who are bothered with pelvic relaxation should consider contacting their healthcare providers at the Departments of Obstetrics and Gynecology or Urology for an evaluation. In addition, the Women's Health Resource Center has information about these problems and can assist with educational material and referral to the proper specialists.

Resources at DHMC

Learn more about possible causes of gynecological problems, and the therapies and procedures to improve them.