Pelvic Relaxation Syndrome
I saw a patient today in the office who is a very healthy, fit, and highly intelligent 48 year old. One day a few months ago after a very vigorous workout, she noticed something bulging out of her vagina. She also felt some achy pelvic pressure and pulling sensations. She was uncomfortable. She has no urinary leaks or other complaints. She leads a highly stressed life. This vaginal bulge was really stressful. She wasn't in a panic, but she wanted some good advice.
When I examined her, she had pelvic relaxation syndrome. This means that the bladder, the uterus, the rectum, and the intestines push down into the vagina, and sometimes push through the vaginal opening to hang outside a bit. I have seen cases where the vagina everts. It can stick out sometimes six or seven inches, and look somewhat like a penis. Thankfully, this case wasn't nearly so bad.
Fortunately for her, she has a strong Levator Ani muscle, otherwise known as the pelvic floor muscle. She also has good control of this muscle. When she contracts it, the vagina goes back to it's normal configuration. Everything goes back to normal. Unfortunately, it doesn't stay in the contracted position. When she relaxes, the pelvic contents come down again. Especially when she strains.
I discussed with her the options and the expected future outcomes of this kind of condition. First of all, the very best option for her is to do Kegel exercises to get the structures back where they belong. This pathway is not super easy. It will take a dedication to do the Kegele exercises on a routine basis, on a regular schedule, and as needed in the future. Women can get this muscle so strong that it will have a resting tone, and a thickend bulk, that will hold everything inside in its proper location even when she does nothing at all. Plenty of women have a high resting tone of this muscle, and no longer have to think about it.
Another option is to put a pessary in. This is a device that will itself rest on the levator muscle in the vagina, and in turn it will hold the other anatomical structures up where they belong. The device is super comfortable, because it restores normal anatomy and doesn't press on anything badly. If it is properly fitted, and properly placed, it will not be a discomfort at all. It may not even be perceptable that it is there. It will have to be removed for intercourse, so she or her partner will have to be taught how to do that. That is kind of easy.
Pessaries can be a bridge to "Kegeling" the pelvic floor back into good shape. Or the pessary can be permanent. Many women want to keep it forever because it is so comfortable to have it in there.
I discussed with her the option of surgery. This is the option that many women want to pursue, as soon as the diagnosis is made. They want to get better instantly. Surgery is not the best answer by far. First of all, all surgeries have surgical risks of infection, bleeding, scarring, and damage to nearby structures. These risks are higher with vaginal surgeries because the vagina is not going to be sterile, and the ligaments all come together in complicated ways. Vaginal surgeries also have a failure rate that is much higher than, for instance, taking out the appendix. When the appendix is out, it is out. There is very little chance that it might recur, and get a new appendicitis. But, pelvic relaxation surgery has a failure rate of 20 to 50 percent. And even if it works, there is a chance that the problem can re-occur later.
Also, everyone by now, even this patient, has seen the ads by the lawyers targeting women who have had mesh implants go bad. Mesh implants can erode their way into valuable structures, such as the vagina, the bladder, the rectum, the pelvic ligaments, the pelvic blood vessels, and the nerves that are everywhere down there.
So I am not a big fan of the implants. When they work, they work great. But they are not dissolvable. They stay where they are put forever. And every structure that is supported by this mesh will eventually atrophy. What I mean by that is, for instance, the muscles that hold up the bladder are no longer required. Those muscles will atrophy and go away. This will be similar to the atrophy that we see when a broken arm comes out of a cast. The arm muscles will be shrunk to nearly nothing. Those muscles will need rehabbing to get their strength back. But the "cast" on the bladder support muscle never gets removed, so the atrophy never goes away.
Don't get me wrong, the implants have their place. They work as well as magic in some cases. And women's life can be completely normalized by them. But they, like all interventions, have some risks that I don't like.
I would much rather do a conventional surgical repair of the vaginal support problems. I would prefer to use dissolvable sutures for all of my repairs. That way, the natural structures that get left behind are in very good shape to heal themselves. We can always go back to repair more structures. But removing a mesh, even a bad one in the wrong place, is very difficult or impossible.
After these discussions this patient has wisely chosen to continue with very aggressive Kegel exercises. I will fit her for a pessary some day if I can convince her that it will help her with her Kegels and repairing the vaginal ligament damage.
If, in several months, she is unsatisfied with the progress, then we can discuss the different surgical options. I will be more than happy to repair the vaginal supports surgically. But the more natural ways are certainly better, and lead to a healthier outcome.
Finally, the patient told me that she is very sorry she didn't choose to have a Cesarean Section. It turns out that her first child was born by C-Section. When the second pregnancy was full term, the doctor advised her to have a repeat C-S. She refused and had a difficult traumatic birth, a VBAC. Her third child nearly fell out in labor. She tells me now that her mother had difficult births and had to wear diapers for years. This patient has daughters. She tells me that she will urge her daughters to have C-Sections every time. The few days of abdominal incision pain is nothing compared to the awful feeling of a fallen pelvic floor.
So my next post will be "Why Is The Cesarean Section Rate So High"? We do far more C-Sections than ever before in history. Are they necessary? What are the pro's and the con's?
I'll try to make some sense of it.
Thanks everyone for reading my blog. I hope you all have a great time reading it. Comments and criticism are welcome.
Sincerely,
John W Marcus MD FACOG
member of the Lifeline Medical Group at www.lma-llc.com
89 North Maple Ave
Ridgewood NJ 07450
201-447-0077
I discussed with her the options and the expected future outcomes of this kind of condition. First of all, the very best option for her is to do Kegel exercises to get the structures back where they belong. This pathway is not super easy. It will take a dedication to do the Kegele exercises on a routine basis, on a regular schedule, and as needed in the future. Women can get this muscle so strong that it will have a resting tone, and a thickend bulk, that will hold everything inside in its proper location even when she does nothing at all. Plenty of women have a high resting tone of this muscle, and no longer have to think about it.
Another option is to put a pessary in. This is a device that will itself rest on the levator muscle in the vagina, and in turn it will hold the other anatomical structures up where they belong. The device is super comfortable, because it restores normal anatomy and doesn't press on anything badly. If it is properly fitted, and properly placed, it will not be a discomfort at all. It may not even be perceptable that it is there. It will have to be removed for intercourse, so she or her partner will have to be taught how to do that. That is kind of easy.
Pessaries can be a bridge to "Kegeling" the pelvic floor back into good shape. Or the pessary can be permanent. Many women want to keep it forever because it is so comfortable to have it in there.
I discussed with her the option of surgery. This is the option that many women want to pursue, as soon as the diagnosis is made. They want to get better instantly. Surgery is not the best answer by far. First of all, all surgeries have surgical risks of infection, bleeding, scarring, and damage to nearby structures. These risks are higher with vaginal surgeries because the vagina is not going to be sterile, and the ligaments all come together in complicated ways. Vaginal surgeries also have a failure rate that is much higher than, for instance, taking out the appendix. When the appendix is out, it is out. There is very little chance that it might recur, and get a new appendicitis. But, pelvic relaxation surgery has a failure rate of 20 to 50 percent. And even if it works, there is a chance that the problem can re-occur later.
Also, everyone by now, even this patient, has seen the ads by the lawyers targeting women who have had mesh implants go bad. Mesh implants can erode their way into valuable structures, such as the vagina, the bladder, the rectum, the pelvic ligaments, the pelvic blood vessels, and the nerves that are everywhere down there.
So I am not a big fan of the implants. When they work, they work great. But they are not dissolvable. They stay where they are put forever. And every structure that is supported by this mesh will eventually atrophy. What I mean by that is, for instance, the muscles that hold up the bladder are no longer required. Those muscles will atrophy and go away. This will be similar to the atrophy that we see when a broken arm comes out of a cast. The arm muscles will be shrunk to nearly nothing. Those muscles will need rehabbing to get their strength back. But the "cast" on the bladder support muscle never gets removed, so the atrophy never goes away.
Don't get me wrong, the implants have their place. They work as well as magic in some cases. And women's life can be completely normalized by them. But they, like all interventions, have some risks that I don't like.
I would much rather do a conventional surgical repair of the vaginal support problems. I would prefer to use dissolvable sutures for all of my repairs. That way, the natural structures that get left behind are in very good shape to heal themselves. We can always go back to repair more structures. But removing a mesh, even a bad one in the wrong place, is very difficult or impossible.
After these discussions this patient has wisely chosen to continue with very aggressive Kegel exercises. I will fit her for a pessary some day if I can convince her that it will help her with her Kegels and repairing the vaginal ligament damage.
If, in several months, she is unsatisfied with the progress, then we can discuss the different surgical options. I will be more than happy to repair the vaginal supports surgically. But the more natural ways are certainly better, and lead to a healthier outcome.
Finally, the patient told me that she is very sorry she didn't choose to have a Cesarean Section. It turns out that her first child was born by C-Section. When the second pregnancy was full term, the doctor advised her to have a repeat C-S. She refused and had a difficult traumatic birth, a VBAC. Her third child nearly fell out in labor. She tells me now that her mother had difficult births and had to wear diapers for years. This patient has daughters. She tells me that she will urge her daughters to have C-Sections every time. The few days of abdominal incision pain is nothing compared to the awful feeling of a fallen pelvic floor.
So my next post will be "Why Is The Cesarean Section Rate So High"? We do far more C-Sections than ever before in history. Are they necessary? What are the pro's and the con's?
I'll try to make some sense of it.
Thanks everyone for reading my blog. I hope you all have a great time reading it. Comments and criticism are welcome.
Sincerely,
John W Marcus MD FACOG
member of the Lifeline Medical Group at www.lma-llc.com
89 North Maple Ave
Ridgewood NJ 07450
201-447-0077
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