Pelvic Floor Disorders

What Are Pelvic Floor Disorders (PFD’s)?

Pelvic floor disorders
 are a set of disorders related to the woman’s pelvis and the pelvic floor, and to the different organs and support systems in that area, (muscles, ligaments, fasciae, etc.). Weakness of or injury to the various support systems or pelvic organs, may affect the normal function of surrounding organs, such as the bladder, urethra, vagina, uterus, vulva and rectum. Women with PFDs may experience various symptoms:

  • Urinary problems, such as urinary incontinence, mainly following a stressful event (stress urinary Incontinence, SUI) but also an urgent need to urinate, urge incontinence, painful urination, incomplete emptying of their bladder, etc.
  • Pelvic organ prolapse – where weakness of the pelvic support system causes various surrounding organs to prolapse into the vaginal cavity with various resultant complaints
  • Rectal problems such as fecal incontinence, constipation, straining or pain during bowel movements.
  • Sexual dysfunction
  • Pain or pressure in the vagina or rectum.
  • Other less frequent complaints

The most prevalent PFDs are urinary incontinence and pelvic organ prolapse which affect around 50% of the female population, worldwide, and are associated with huge financial burden on both patients and medical systems.

Pelvic Organ Prolapse

Pelvic organ prolapse (POP) is a condition in which vaginal wall support is lost, and various pelvic organs prolapse into the vagina.  Symptoms of POP may vary from being completely absent to a combination of various complaints which may be very bothering and influence everyday life. including:

  • Feeling of pelvic heaviness
  • Bulging out of the vagina
  • Vaginal discomfort / pains
  • Pelvic and/or lower back pain
  • Recurrent bladder infections
  • Voiding difficulties up to retention
  • Difficulty emptying the bowels
  • Difficulty inserting or keeping a tampon in place
  • Vaginal-cervical mucosa hypertrophy, excoriation, ulceration, and bleeding

While minor degrees of POP affect up to 75% of women who have had a vaginal delivery, symptomatic POP with descent beyond the hymen affects 3% to 6% of the population ~10% of them will require surgery to correct the prolapse, of whom ~30% will require at least another one (1-5) operation. In the US, every year, 210,000 – 300,000 women undergo surgical interventions for POP.

The most commonly reported figure is that ~3.5 million USA women (range 1.36-5.33) currently suffer from symptomatic POP. This figure equates to ~2.9% of the US female population over the age of 30, and is expected to rise 46% to 4.9 million by 2050.

Management options 

Within the ~3.5 million USA women with POP who are considered to have symptomatic POP, there are 4 available management options:

  1. Expectant – women may consult regarding their problem, but will prefer to defer any management, due to various reasons.
  2. Reconstructive surgical management – various operations, by various routes. The purpose of surgery is to correct the anatomy as well as provide better bowel, bladder and vaginal function.
  3. Pelvic Floor Physiotherapy/Kegel exercises – considered acceptable for low stages of prolapse, perhaps a way for relieving some POP symptoms, but it is no longer considered a viable management option.

4. Vaginal pessaries

Vaginal pessaries are the only proven and well-studied noninvasive means of managing POP. A pessary is a device inserted into the vagina to support the walls and related pelvic organs. Modern pessaries are made of hypoallergenic silicone, rubber, or pliable plastic and are indicated for all pelvic prolapse stages. 77% of gynecologists in the US prescribe pessaries as first-line therapy for women with POP. Similarly in the UK, 86.7% of obstetricians and gynecologists surveyed prescribed pessaries in the management of POP. Pessaries are experiencing resurgence in popularity following the problems experienced with surgical solutions (high symptomatic recurrence rate while using native tissue and morbidity with the trans-vaginal mesh implants), and are now again viewed as a very viable option for the management of prolapse for women in any age group. Reports suggest that 76% of women can be successfully fitted at the follow-up visits. Success or failure will depend on appropriate pessary selection, patient characteristics, provider training and experience, thorough counselling, as well as the achievement of an adequate fit and patient satisfaction.

Vaginal ring pessaries are known to the medical literature for many centuries. Most of the prolapse cases which can be managed by pessaries, may be managed by ring pessaries, with or without internal support, and this is the most commonly used configuration.

Stress Urinary Incontinence

Stress Urinary Incontinence (SUI) is the most common type of urinary incontinence in women. It involves the involuntary leakage of urine due to damage and loss of support to the urethra, leading to urethral hypermobility and inadequate intra-urethral pressure. SUI is characterized by loss of urine from increased abdominal pressure caused by activities such as coughing, laughing, sneezing, running, lifting, and walking. This condition may be caused by direct damage to the urethra; however, it is more commonly caused by damage to structures that support the urethra and hold the bladder neck in position along the back of the pubic bone, resulting in hypermobility of the bladder neck and the urethra. Such damage is usually the result of events such as childbirth, constipation with straining, and pelvic surgery. Urinary incontinence is a very prevalent condition in women, reaching as high as 53.2%. The risk of incontinence increases with age.

The most prevalent type of urinary incontinence in women is SUI, which accounts for 40-50% of total incontinence cases. Urge Urinary Incontinence (UUI) (where incontinence occurs following a strong desire to void, and the sufferer does not make it on time to the bathroom) contributes about 25% of the incontinence cases. A mixture of both Stress & Urge incontinence is called Mixed Urinary Incontinence (MUI), and this happens in about 20% of the cases. There are also other types of incontinence, which happen less frequently.

In many cases (up to 80%), women are reluctant to discuss incontinence with their health provider and try and manage themselves by using absorbents, small towels, and avoidance from social events.

Invasive surgical procedures are usually reserved for the more severe forms of SUI, where women leak very often (usually with large amounts of urine) and have a substantial reduction in Quality of Life (QoL). Surgical treatment has a relatively high success rate, but it is an invasive procedure with considerable adverse events and complications. Most SUI sufferers will not require invasive procedures, and may benefit from Pelvic Floor Physiotherapy (PFP) and specific vaginal pessaries. The Poise® Impressa Device (Kimberly-Clark Worldwide Inc.) is a rather new device in this market, where a disposable small size device is inserted within an applicator into the vagina. The device provides sub-urethral support hence reducing or eliminating SUI.

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