8- DEFINING AND DIAGNOSING PROLAPSE
Sandy was 28-years old when her third daughter was born. As a
veteran of childbirth, she thought she knew what to expect. After this delivery though, things looked different down there. She felt a pressure at the opening of her vagina. When looking in a mirror to find out what was going on, she was shocked to see her cervix. It was as if I was turning inside out, Sandy said, what used to be inside was just right out there. Sandy told her best friend that it felt like a tampon that was way too low or starting to fall out. Now she often had an awkward, uncomfortable feeling. She felt lucky she and Ken hadnt started having sex since the delivery because she was worried about how it would work.
In a hurried visit to her obstetrician, Sandy learned she had a uterine prolapse. Since this baby was intended to be her last, the doctor recommended a vaginal hysterectomy. Her OB also told her that sex would be fine even now, especially if Sandy was in a horizontal position. Prolapse is a bit dependent on gravity, and during sex the uterus would slide back to a more normal position. Gee, you make it sound almost therapeutic, Sandy said. I wish having sex was the cure. I dont really want an operation.
On the drive home from the obstetricians office, Sandy began to think that perhaps the doctors recommendation was hasty and a bit radical. She also fretted about just what this operation would mean to her family. She had a one month old nursing infant, a 3 year old in preschool mornings only, and a 5- year old big girl who had started sucking her thumb and whining to sit in the infant carrier as soon as the new baby came home. Sandys husband Ken had used up
all his vacation days to help after the baby was born. Taking off more days from work without pay would not score any points with his boss and would mean lost income they werent counting on. There were no grandmothers available either; Sandys mom lived in Maine and had her own health problems, and Kens mom passed away years before.
Sandys doctor assured her that the prolapse was not dangerous, and she decided to put up with the annoying sensation until things had settled down a little at home. She said she knew there just werent all that many reasons to have a major surgery right now- whats the rush? After breast- feeding her baby for 6 months, Sandy realized that the feeling of pressure that alerted her to the prolapse had gone away. Her cervix was no longer visible unless she really pushed down hard. As far as sex was concerned, Sandy found that everything worked ok. Now 6 months after the delivery, time had helped her problem a bit.
She was actually able to ignore the prolapse for years and years, until her youngest child was ready to graduate from high school. When we saw Sandy in the office, she was 46 and had recently discovered that her cervix was once again right out there. Gravity, time, and a midlife change in hormones were causing the uterine prolapse to become a constant annoyance. Sandy came to us for a solution.
After a careful examination, we suggested Sandy have a vaginal hysterectomy and a bladder repair procedure to fix her prolapse permanently. The postpartum recovery and healing had really helped her prolapse the first time, but we knew shed need more medical intervention this time. Sandy felt very differently about having the surgery now than when it was first suggested 17 years ago. I know my baby-making days are long over, and now I have time to myself to recuperate in peace. I wasnt ready for a surgery then, but I have
no doubts about it now. Sandys surgery went well, and she felt very satisfied with the results. I have no regrets about waiting. My first doctor was a little bit too quick on the trigger for me. The timing now is much better, and it all worked out fine.
WHAT IS PELVIC RELAXATION?
Pelvic relaxation, also called prolapse, is the name for the dropping of the uterus or the bulging of the bladder or rectum into the vagina. You can think of this as a hernia, a weakening of tissues that normally hold things in place. Over the past few years, gynecologists and urologists have focused a great deal of attention on the causes and treatments for weakness in the supporting structures of the pelvis, which leads to prolapse. As the population ages and the number of women with prolapse and incontinence increases, doctors are searching for better ways to help women deal with these problems. And as we develop new methods to help diagnose and treat these conditions, new information will continue to emerge.
For example, magnetic resonance imaging (MRI) has recently been used in research studies to look for changes in the pelvic tissues of women with incontinence or prolapse. Weak muscles and torn connective tissue show up well on MRI, and it is a very accurate way of detecting any damage to the supporting tissues as a result of childbirth, trauma or aging. The MRI research results show that women with prolapse and incontinence generally have unsuspected damage to areas in the pelvis. A great deal has been learned in general from these MRI studies, and we are now better able to understand what needs to be done to correct these problems. At this point, MRI is very time consuming, cumbersome and expensive and is used primarily for research purposes, but the information from this research will help all women.
Inside of the pelvis, a group of muscles shaped like a hammock attach to the pelvic bones to form a broad area that holds all the abdominal organs in place. When you cough or sneeze or lift something heavy, the muscles in the pelvis automatically squeeze tight to resist the increase in pressure. Strong connective tissue envelops the uterus, bladder and rectum and suspends these organs from the bones in the pelvis. When you stand, gravity pulls the intestines and pelvic organs down, but the muscles and connective tissue resist this pull, and this well-designed architecture keeps the organs in the proper place. (see fig 1-1)
The vagina and rectum pass through gaps in the middle of the muscle hammock. These gaps create a naturally occurring structural weakness in the muscles. Injuries during childbirth further weaken these muscles and connective tissues, and sometimes result in hernias. Weakening near the bladder allows the bladder to bulge downward; weakening near the rectum allows the rectum to bulge upward; and weakening of the ligaments that support the uterus allows the uterus to slip down into the vagina. These changes are the components of pelvic prolapse.
WHAT DO YOU FEEL IF YOU HAVE PELVIC RELAXATION?
HOW DO WE MAKE THE DIAGNOSIS OF PROLAPSE?
WHAT IF YOU HAVE BULGING OF THE BLADDER?
WHAT IF YOU HAVE BULGING OF THE RECTUM?
WHAT IF THE INTESTINES CAUSE A BULGING OF THE VAGINA?
WHAT IF THE UTERUS IS DROPPING?
WHAT IS THE POP-Q?
DO YOU ALWAYS NEED TO BE TREATED FOR PROLAPSE?
Edited Excerpts from our book
The Incontinence Solution
By William H. Parker, MD, Amy E. Rosenman, MD, and Rachel Parker
||Order The Incontinence Solution directly from Amazon.com.
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