REPROSAIT 4 U

The rectum is the temporary storage area for bowel motions, and makes up the last 20cm or so of the large bowel.

A rectocele occurs when the rectum pushes the back wall of the vagina forward, causing a prominent bulge into the vagina.

Risk factors include difficult childbirth and the use of forceps during delivery, but women who have never had children can also develop rectocele.

The degree of severity varies; for example, in mild cases the rectocele may be felt as a small bulge high inside the vagina while, in severe cases, the bulge may be hanging outside of the vagina. Milder cases can be treated by measures such as management of constipation, Kegel exercises to strengthen the pelvic floor and the insertion of a vaginal pessary to prop up the pelvic organs. Surgery may be needed in severe cases.

Symptoms

The symptoms of rectocele may be vaginal, rectal or both, and can include:

1. A sensation of pressure within the pelvis
2. The feeling that something is falling down or falling out within the pelvis
3. Symptoms are worsened by standing up and eased by lying down
4. Lower abdominal pain
5. Lower back pain
6. A bulging mass felt inside the vagina
7. Vaginal bleeding that’s not related to the menstrual cycle
8. Painful or impossible vaginal intercourse
9. Constipation
10. Problems with passing a bowel motion, since the stool becomes caught in the rectocele
11. The feeling that the bowel isn’t completely emptied after passing a motion
12. Faecal incontinence (sometimes).

Rectovaginal septum explained

The pelvic organs are supported by the pelvic floor muscles. Structures including ligaments and connective tissue help to keep the pelvic organs tethered in place. In women, the front wall of the rectum is situated behind the rear wall of the vagina.
The front wall of the rectum and rear wall of the vagina, and the thin layer of tissue between them, are together called the rectovaginal septum (or wall). This wall can become weak or stretched by pressure such as childbirth or straining while going to the toilet and by ageing. A weak or thinned rectovaginal septum allows the front wall of the rectum to bulge into the vagina.

A range of causes

Some of the events that may weaken or thin the rectovaginal septum and cause a rectocele include:

• Vaginal (normal) childbirth
• Giving birth to multiple babies
• A long and difficult labour
• Assisted delivery during childbirth, including the use of forceps
• Tearing during childbirth, particularly if the tear extended from the vagina to the anus
• Episiotomy (a surgical cut made to enlarge the vaginal opening during childbirth to avoid injury to mother and baby), particularly if the cut extends to the anus
• Hysterectomy
• Pelvic surgery
• Chronic constipation
• Straining to pass bowel motions
• Advancing age, as older women are more prone to rectocele.

Related problems

A rectocele sometimes occurs by itself. In other cases, it may present alongside other abnormalities including:

1. CYSTOCELE - the bladder protrudes into the vagina.
2. ENTEROCELE- the small intestines push down into the vagina.
3. UTERINE PROLAPSE - the cervix and uterus drop down into the vagina and may protrude out of the vaginal opening.
4. VAGINAL PROLAPSE - in cases of severe uterine prolapse, the vagina may slide out of the body too.
5. RECTAL PROLAPSE - the rectum protrudes through the anus.

Diagnosis methods

Rectocele is diagnosed using a number of tests including:

1. Pelvic examination
2. Special x-ray (proctogram or defaecagram).

Treatment options

Generally speaking, a rectocele with no obvious symptoms doesn’t need medical treatment, but it is wise to pay attention to diet and other lifestyle factors that contribute to constipation. Treatment options may include:

1. High fibre diet
2. Fibre supplements
3. At least six to eight glasses of water per day
4. Stool softeners (don’t use laxatives)
5. Instruction on how to help yourself to pass a bowel motion; for example, you may be advised to gently press a finger against the rear wall of the vagina while toileting
6. Don’t strain on the toilet
7. Hormone replacement therapy for postmenopausal women
8. Pelvic floor (‘Kegel’) exercises
9. The insertion of a pessary, which is a ring-like device worn high in the vagina that helps to support the pelvic organs.

Surgery

Surgery may be needed if the rectocele doesn’t respond to other treatments and is causing symptoms. Unfortunately, the rectocele will recur after operation in about 10 per cent of cases. Depending on individual factors, such as the severity of the rectocele and the presence of other prolapsed structures, the operation can be performed in a number of ways, including:

• Through the vagina
• Through the anus
• Through the area between the vagina and anus (perineum)
• Through the abdomen
• In some cases, a combination of surgical techniques may be necessary.

Things to remember

• Some of the causes of a rectocele include vaginal childbirth, hysterectomy, pelvic surgery and chronic constipation.
• A rectocele may occur by itself or present alongside other pelvic abnormalities, such as a prolapsed bladder (cystocele).
• Surgery may be needed if the rectocele doesn’t respond to simpler treatments.

A cystocele is when the bladder bulges into the vagina.

Risk factors include vaginal childbirth, regularly straining on the toilet to pass bowel motions, obesity, smoking and chronic lung diseases with coughing.

Postmenopausal women are more susceptible to cystocele. This is because the sex hormone, oestrogen, helps to keep the muscles of the vagina and bladder – the pelvic floor muscles – in good tone. Once oestrogen levels drop, these muscles become thinner, weaker and less elastic. The vaginal skin stretches, which may allow the bladder to bulge into the vagina.

A cystocele can occur by itself or it may happen along with other abnormalities such as a rectocele (when the rectum protrudes into the vagina) or a uterine prolapse (when the uterus and cervix drop down to the vaginal entrance).

Treatment options include pelvic floor exercises, oestrogen therapy, inserting a pessary into the vagina to hold up the pelvic organs, and surgery. Other names for cystocele include prolapse of the bladder and ‘fallen’ bladder.

Symptoms

The symptoms of cystocele depend on individual factors, such as the severity of the condition, but can include:

1. Stress incontinence – urine leaks when coughing, sneezing, laughing, standing up, running or walking
2. Inability to completely empty the bladder after going to the toilet
3. Recurring urinary tract infections (UTIs)
4. Urination problems, such as straining to get urine flow started or an unusually slow flow of urine that tends to stop and start
5. A sensation of fullness or pressure inside the vagina
6. A bulging mass felt on the front wall of the vagina
7. In severe cases, the vagina and the bladder protrude out of the vaginal entrance.

Grades of severity

A cystocele is graded on its degree of severity:

1. GRADE 1 – the bladder protrudes a little way into the vagina.
2. GRADE 2 – the bladder protrudes so far into the vagina that it is close to the vaginal opening.
3. GRADE 3 – the bladder protrudes out of the vagina.

A range of causes

The vagina and bladder are held apart by tissue known as the pubocervical fascia. Thinning, weakening or tearing of the pubocervical fascia, and poor tone of the supporting muscles and ligaments, allow the bladder to drop against the vaginal wall. Some of the events that may cause or contribute to the development of a cystocele include:

• Vaginal childbirth
• Repeated heavy lifting
• Habitually straining to pass bowel motions
• The drop in oestrogen levels that occurs at menopause.

Diagnosis

Cystocele is diagnosed using a number of tests including:

• MEDICAL HISTORY – to check for possible risk factors.
• PHYSICAL EXAMINATION– cases of grade 2 or 3 cystocele can be easily diagnosed by vaginal examination.
• VOIDING CYSTOURETHROGRAM – a rarely used special x-ray that is taken while the patient is urinating. This test reveals whether the flow of urine is affected by the cystocele and if there is significant urine left in the bladder after passing urine (residual urine).
• OTHER TESTS– such as a bladder or pelvic ultrasound, a urodynamics investigation or x-rays to exclude other possible causes of urinary problems.

Treatment

Treatment for cystocele depends on the severity of the condition, but can include:

• MILD CASES – when there are no symptoms, treatment may be unnecessary. Regular monitoring is needed to make sure the cystocele doesn’t worsen. The doctor may advise a few lifestyle changes to prevent the condition getting worse, including doing pelvic floor exercises to strengthen the pelvic floor muscles.
• MODERATE CASES – a pessary is a small ring-like device that’s inserted high in the vagina. This is used temporarily in younger women and helps to keep the bladder in place. Health risks of long-term pessary use include infection and ulceration. This is more likely to be used in elderly women who are considered unfit for surgery due to chronic medical conditions.
• SEVERE CASES where symptoms impair quality of life. There are many different surgical techniques now available.

Pelvic floor physiotherapy

Pelvic floor exercises help to increase the strength of the pelvic floor muscles. They may reduce the symptoms felt as the result of a moderate to large cystocele. These exercises may also reduce symptoms of stress incontinence, which is often associated with a cystocele. It is important to learn to do the exercises correctly to gain the most benefit. There are specially trained physiotherapists or other health professionals available to help teach the correct techniques.

Surgery

Surgery for cystocele repair is usually done under general anaesthesia but also may be done under spinal or epidural anaesthesia. There are now many different types of surgery available depending on the symptoms a woman has. Traditionally, the vaginal wall is cut, the bladder is pushed away from the vagina and the excess vaginal tissue is removed. The bladder is supported by sutures into the pubocervical fascia and then the vagina is closed.
Mesh, graft or tape may be used to hold the bladder and urethra in place. Some procedures may be performed laparoscopically. Other procedures performed during the operation depend on individual factors: for example, a vagina overstretched by childbirth may be tightened.
A urinary catheter may be worn for between one and six days following surgery depending on the type of operation performed. Full recovery takes around four to six weeks.

Self-care suggestions

Your doctor may advise that you make a few lifestyle changes to prevent the cystocele from worsening or recurring after surgery. These suggestions may include:

• Don’t lift heavy objects.
• Increase the amount of fibre in your diet to prevent constipation and straining.
• Drink between six and eight glasses of water each day. Not drinking enough water makes stools hard, dry and difficult to pass.
• Exercise daily to help keep you regular.
• Use stool softeners, which may help in the short term.
• Avoid straining on the toilet for either bowels or bladder; use the hissing or sighing technique.
• Perform pelvic floor exercises daily to strengthen the muscles supporting the pelvic organs. You may need instruction from your doctor or other health care professional, such as a pelvic floor rehabilitation physiotherapist.
• Always squeeze up your pelvic floor muscles before you lift, cough, laugh or sneeze.
• If you are postmenopausal, your doctor may recommend hormone therapy, usually in the form of local oestrogen preparations such as a cream or a vaginal tablet, to help tone the muscles supporting the vagina and bladder.
• Seek medical advice for any condition that causes coughing and sneezing such as asthma, chest infections and hay fever.
• Keep yourself within a healthy weight range.
• Avoid sit-ups. Learn how to strengthen your deep abdominal muscles, but avoid straining.

Point to remember

1. A cystocele is when the bladder bulges out into an overstretched vagina.
2. Risk factors include vaginal childbirth and regularly straining on the toilet to pass bowel motions.
3. Severe cases of cystocele need surgical repair.

Prolapse of the uterus

The uterus (womb) is an organ of the female reproductive system.

It is shaped like an upside down pear and is located inside the pelvis.

The uterus, bladder and bowel are supported by a tight hammock of muscles slung between the tailbone (coccyx) and the pubic bone. These muscles are known as the PELVIC FLOOR, or the LEVATOR ANI MUSCLES.

Ligaments and connective tissue also anchor the uterus in place. If these tissues are weakened or damaged, the uterus can slip down into the vagina.

Common causes of uterine prolapse include CHILDBIRTH – OBESITY – CHRONIC CONSTIPATION and POSTMENOPAUSE .

Other names for uterine prolapse include PUDENDAL HERNIA and PELVIC FLOOR HERNIA

Treatment options include special muscle strengthening exercises. Surgery may be needed in severe cases.

Symptoms

The symptoms of uterine prolapse include:

1. A sensation of heaviness in the vagina
2. A distinct lump or bulge in the vagina
3. Tissue protruding out of the vagina
4. Persistent aching in the lower back
5. Trouble passing urine
6. Frequent urinary tract infections
7. Greater than normal amounts of vaginal discharge
8. Painful sexual intercourse.

Degrees of prolapse

Uterine prolapse is categorised by the degree of tissue protruding into the vagina. In most cases, other pelvic organs (such as the bladder or bowel) are also prolapsed into the vagina, and the ovaries sit lower than normal inside the pelvis. The three categories of uterine prolapse are:

• FIRST DEGREE (mild) - the neck of the uterus (cervix) protrudes into the lowest third of the vagina.
• SECOND DEGREE (moderate) - the cervix protrudes to the opening of the vagina.
• THIRD DEGREE (severe) - the whole uterus protrudes out of the vagina.

A range of causes

The pelvic floor and associated supporting ligaments can be weakened or damaged in many ways including:

1. Pregnancy, especially in the case of multiple babies such as twins or triplets.
2. Vaginal childbirth, especially if the baby was large or delivered quickly, or if there was a prolonged pushing phase.
3. Obesity.
4. Chronic constipation and associated straining to pass motions.
5. Low levels of the sex hormone oestrogen after menopause.
6. Constant coughing associated with conditions such as chronic bronchitis or asthma.
7. Fibroids.
8. In rare cases, pelvic tumour.

Pelvic floor exercises

In mild to moderate cases, special exercises of the pelvic floor can correct uterine prolapse. Familiarising yourself with the muscles of each orifice gives you a better chance of performing the exercises correctly. To identify the muscles of your vagina, insert one or two fingers and squeeze them. For your urethra, halt the flow of urine in midstream, but do not do this on a regular basis. Finally, familiarise yourself with the muscles of your anus by pretending to stop yourself from breaking wind. Consult with your doctor, physiotherapist or health care professional to ensure correct performance. Basically, the pelvic floor exercises include:

• As a warm-up, direct your attention to your pelvic floor. Gradually squeeze all three sphincters and increase the tension until you have contracted the muscles as hard as you can. Release slowly and gently.
• Squeeze slowly and hold for five to 10 seconds. Release slowly. Repeat 10 times. Relax for 10 seconds in between each one.
• Perform quick, short strong squeezes. Repeat 10 times.
• Remember to squeeze your muscles whenever you sneeze or cough.

VAGINAL PESSARY
A device shaped like a doughnut may be inserted into the vagina and positioned to prop the cervix and uterus. Side effects include irritating discharge and an increased risk of ulceration. Vaginal pessaries are considered a short term solution, and pelvic floor exercises and perhaps surgery will still be needed in the longer term.

VAGINAL SURGERY
In moderate to severe cases, the prolapse may have to be surgically repaired. In laparoscopic surgery, slender instruments are inserted through the navel. The uterus is pulled back into its proper place and reattached to supporting ligaments using permanent stitches. Over time, scar tissue grows over these stitches and further strengthens the repair. The operation may be performed abdominally in some circumstances. In around nine out of 10 cases, corrective surgery is successful.

Prevention techniques

Some women are at increased risk of uterine prolapse. Simple preventive measures include:

• PREGNANCY - pelvic floor exercises throughout the duration of pregnancy.
• VAGINALCHILDBIRTH - a well-timed episiotomy (an intentional and controlled cut of the skin between the vagina and anus) to prevent tearing and trauma to the pelvic floor muscles caused by the baby’s emerging head, and post-partum pelvic floor exercises.
• POSTMENOPAUSE - oestrogen creams to boost flagging hormone levels, and pelvic floor exercises.
• OBESITY - loss of excess body fat with dietary modifications and regular exercise, and pelvic floor exercises.
• OTHER CONDITION - treat underlying disorders (such as asthma, chronic bronchitis or chronic constipation) in consultation with your doctor.
• CHRONIC CONSTIPATION - drink plenty of fluid, eat lots of fruit, vegetables and fibre, and relax your tummy muscles to avoid straining when using your bowels.

Point to remember

• Uterine prolapse occurs when weakened or damaged muscles and ligaments allow the uterus to slip into the vagina.
• Common causes include pregnancy, childbirth, hormonal changes after menopause, obesity and chronic constipation.
• Treatment options include pelvic floor exercises and vaginal surgery.

PELVIC FLOOR ~ pelvic diaphragm

The pelvic floor muscles are tightly slung between the tailbone (coccyx) and the pubic bone, and support the bowel, bladder, uterus and vagina.

Muscular bands (sphincters) encircle the urethra, vagina and anus as they pass through the pelvic floor.

When the pelvic floor muscles are contracted, the internal organs are lifted and the sphincters tighten the openings of the vagina, anus and urethra. Relaxing the pelvic floor allows passage of urine and faeces.
If the muscles are weakened, the internal organs are no longer fully supported and you may not be able to control your urine. Common causes of a weakened pelvic floor include childbirth, obesity and the associated straining of chronic constipation. Pelvic floor exercises are designed to improve muscle tone and prevent the need for corrective surgery.

Symptoms

The symptoms of a weakened pelvic floor include:

1. Leaking small amounts of urine when coughing, sneezing, laughing or running
2. Failing to reach the toilet in time
3. Uncontrollably breaking wind from either the anus or vagina when bending over or lifting
4. Reduced sensation in the vagina
5. Backache
6. Tampons that dislodge or fall out
7. A distinct swelling at the vaginal opening
8. A sensation of heaviness in the vagina.

Common causes

The pelvic floor can be weakened in many ways, including:

1. The weight of the uterus during pregnancy
2. Vaginal childbirth, which overstretches the muscles
3. The pressure of obesity
4. Chronic constipation and associated straining to pass motions
5. Constant coughing
6. Some forms of surgery that require cutting the muscles
7. Lower levels of oestrogen after menopause.

Complications of a weakened pelvic floor

LOSS OF BLADDER CONTROL a common symptom of a weakened pelvic floor ( URINE INCONTINENCE ) . Some people experience BOWEL INCONTINENCE , which means they can’t always control the passage of wind or faeces ( INCONTINECE ALVI ).

Weak pelvic floor muscles can also cause SEXUAL DIFFICULTIES such as reduced vaginal sensation.

In severe cases, the internal organs supported by the pelvic floor, including the bladder and uterus, can slide down into the vagina. This is called a PROLAPSE. A distinct bulge in the vagina and deep, persistent vaginal aching are common symptoms.

Familiarising yourself with the pelvic floor

Pelvic floor exercises are designed to strengthen the muscles. Each sphincter (vaginal, urethral, anal) should be exercised, so you need to familiarise yourself with these muscles in order to contract them at will. If the pelvic floor is especially weak, it may be difficult to detect any muscular contractions at first.
Suggestions on identifying your sphincters include:

1. VAGINAL - one or two fingers into your vagina and try to squeeze them.
2. URETHRAL - you urinating, try stopping the flow in midstream. This should only be done to identify the sphincters. Do not do it on a regular basis.
3. ANAL – pretend you are trying to stop yourself from breaking wind and squeeze tightly.

The exercises

You can perform these exercises lying down, sitting or standing. Ideally, aim for five or six sessions every day while you are learning the exercises. After you have a good understanding of how to do the exercises, three sessions each day is enough.

Before you start, direct your attention to your pelvic floor muscles. Try to relax your abdominal muscles. Don’t bear down or hold your breath. Gradually squeeze all three sphincters and increase the tension until you have contracted the muscles as hard as you can. Release gently and slowly. Then perform the exercises, which include:

1. Squeeze slowly and hold as strongly as you can for 5 to 10 seconds while breathing normally. Release slowly. Repeat 10 times. Relax for 5 to 10 seconds between each one.
2. Perform quick, short, strong squeezes. Repeat 10 times.
3. Remember to squeeze the muscles whenever you clear your throat or cough.

Professional help

It is important to perform these exercises correctly. You can consult with your doctor, physiotherapist or continence advisor to ensure proper performance. It may take weeks or months before you notice a substantial improvement. In severe cases, pelvic floor exercises aren’t enough to solve the problem and surgery may be needed. Be guided by your health care professional.

Other considerations

You can further improve the strength of your pelvic floor in many ways, including:

• Lose excess body fat
• Cure constipation by including more fruit, vegetables, fibre and water in your daily diet
• Seek medical attention for a chronic cough.

Key To Remember

• The pelvic floor muscles support the bladder, uterus and bowel.
• The pelvic floor can be weakened by pregnancy, childbirth, obesity and the straining of chronic constipation.
• Pelvic floor exercises are designed to improve muscle strength.