Pelvic floor disorders seem to refer to a range of conditions and experiences. What can you tell us about the cases you see?
The term refers to urinary incontinence, fecal incontinence, such as accidental loss of urine or stool, pelvic organ prolapse — where the uterus, bladder, vagina, rectum can fall out of place and result in incontinence or other symptoms, such as urinary retention or incomplete bowel evacuation — sexual dysfunction, and pelvic floor dysfunction, where people have either muscles that are too tight or weak that can cause pain or incontinence.
As you can see, many of these symptoms tend to go together, so somebody may experience more than one of these symptoms.
What are some of the most common symptoms of pelvic floor disorders?
Commonly in the first year after birth, people can see stress incontinence — when they laugh, cough, or sneeze — because those tissues are recovering and remodeling, particularly the pelvic floor muscles, and that’s when pelvic physical therapy can be helpful.
Sometimes people may feel a bulge in the vagina. They may see it or feel it like particularly when they're in the shower, or if they've been on their feet all day, or lifting a lot of heavy things. Any kind of pressure that pushes down the Valsalva maneuver can make a bulge more pronounced.
In more severe cases of prolapse or when people get older, if it's been more chronic, sometimes they have urinary retention, or they may have trouble emptying the rectum with bowel movements. This tends to happen in more advanced cases.
Are there risk factors associated with these disorders?
The number one risk factor is vaginal delivery during birth — and that's further compounded if the person has had an instrumented delivery, such as forceps or vacuum delivery. The thought is that they sustain birth trauma, and while it does heal and recover people often are left with mild prolapse to start, and often stress urinary incontinence, like leakage, with coughing laughing, or sneezing, can get worse over time. These symptoms tend to progress around the menopausal transition.
What’s the state of research in this field? Has there been an evolution of treatment?
There is a lot of exciting research happening nationally and internationally right now: research on the types of meshes that we use in surgery, how the infrastructure of the mesh is laid out so the body can heal properly, tissue engineering to better regenerate tissue, and more.
In our lab, we look at uterosacral ligaments, which stabilize the uterus. We have a tissue biobank with 600 specimens, 400 of which are biopsies of the ligaments from women with prolapse and 200 without. We’re looking at and classifying the different changes that happen in the tissue because it’s not the same in every person. We want to understand how these changes lead to alterations in the biomechanical properties of the ligaments, causing them to fail and the pelvic organs to descend out of their proper position Understanding these specific factors can help us create better strategies to prevent and treat pelvic organ prolapse by targeting specific causes in individuals using personalized medicine.
What does treatment look like for these different conditions?
There’s a lot of talk around pelvic floor physical therapy, which can be helpful for many people. Weak pelvic muscles are common in pelvic floor disorders.
In cases of prolapse, we can offer patients a pessary, a ring that goes inside the vagina to support the pelvic organs, but this is not a permanent fix, as it just holds the prolapse in place. We can do corrective surgery reinforcing the patients’ own tissues, but these procedures have high failure rates since the tissues are already weak.
Alternatively, we can augment the strength of the repair using mesh for more durable results. However, there can be complications when using mesh.
Overall, we haven’t really changed our failure rates or mesh complications in decades since we do not understand the underlying biological mechanisms of how the pelvic tissues repair themselves after childbirth, and how they are maintained with menopause and aging. This is why that research piece is so important, so that we can improve outcomes for our patients.
There is a level of shame for many patients with these disorders. What’s your advice to them and what would you want them to know about seeking treatment?
We sometimes refer to pelvic floor disorders as one of those silent epidemics because if doctors don’t ask about incontinence, or prolapse, or sexual dysfunction, people won’t always come forward and ask about it.
Pregnancy can be a crucial time to focus on a woman’s health, especially in terms of conditions like diabetes or hypertension, but pelvic floor disorders are still more stigmatized. The good news is that treatment options are growing. Pelvic floor physical therapy is gaining popularity. In Europe, they send everyone for pelvic floor therapy after birth, and it should be a standard of care everywhere.
Pelvic floor disorders are not always an easy topic for people to talk about, even with their doctor. Many people think it’s only them who has this problem, but they’re not alone. These disorders may not be normal, but they also aren’t uncommon and there is help. There are people who are dedicated to having the patient’s best interest at heart – and just knowing that can be a big relief.
Finally, promoting awareness is crucial. There’s a lot that can be done to help people with these disorders. Sharing this information and creating a safe space for discussions reduces the stigma surrounding pelvic floor disorders and opens opportunities for prevention, treatment and improved quality of life for the millions of people suffering from these conditions. Promoting awareness also sheds light on the importance of research needed to advance the field.
