Posts Tagged ‘rectocele’

Rectoceles And Perineal Laxity: What You Need To Know

May 20, 2017

Andrew Siegel MD  5/20/17

recto copy

Image above: protrusion of the rectum into the floor of the vagina, a.k.a. rectocele (blue arrow); also note catheter in urethra (red arrow) and gaping vagina with scarring of tissues between vagina and anus, a.k.a. perineum (white arrow)

A rectocele is a specific type of pelvic organ prolapse in which the pelvic floor muscles and connective supporting tissue between the lower vaginal wall and rectum weaken, allowing protrusion of the rectum into the floor of the vagina and at times outside the vaginal opening. This not uncommonly follows vaginal childbirth, which places tremendous stresses on the tissues that provide to support of the pelvic organs. Other risk factors for the occurrence of a rectocele are chronic straining, menopause and weight gain.

Rectoceles are also known by the terms “dropped rectum,” “prolapsed rectum,” and “rectal hernia.” The most common symptom is an annoying vaginal bulge that worsens with assuming the upright position and being active and tends to improve with sitting, lying down and being sedentary. It is often quite noticeable when straining to move one’s bowels. It can give rise to bowel difficulties—most notably what is referred to as “obstructed defecation”—including constipation, incomplete bowel emptying, diarrhea and fecal incontinence. The prolapsed rectum often needs to be manipulated back into position in order to be able to effectively move one’s bowels. Rectoceles can also cause vaginal pressure, vaginal pain and painful sexual intercourse.

Relevant trivia: The word “rectum” derives from the Latin word meaning “straight,” because under normal circumstances the rectum is a straight chute, facilitating bowel movements. The presence of a rectocele causes kinking of the rectum to occur, destroying this anatomical arrangement and making bowel movements difficult without “splinting” the rectum (straightening it out) using one or more fingers placed in the vagina.

Often accompanying a rectocele is laxity of the perineal muscles, a condition in which the superficial pelvic floor muscles (those located in the region between the vagina and anus) become flabby. This causes a widened vaginal opening, decreased distance between the vagina and anus, and a change in the vaginal angle. Women who are sexually active may complain of a loose or gaping vagina. This may lead to difficulty keeping a tampon in position without it falling out, the vagina filling with water while bathing, vaginal flatulence (the embarrassing passage of air) and sexual issues including difficulty retaining the penis with vaginal intercourse and difficulty achieving orgasm. Perineal laxity may result in the vagina “surrounding” the penis rather than firmly “squeezing” it during sexual intercourse, with the end result diminished pleasurable sensation for both partners. The perception of having a loose vagina and altered anatomy can lead to self-esteem and other psychological issues.

Relevant trivia: Under normal circumstances, sexual intercourse results in indirect clitoral stimulation. The clitoral shaft moves rhythmically with penile thrusting by virtue of penile traction on the inner vaginal lips, which join together to form the hood of the clitoris. However, if the vaginal opening is too wide to permit the penis to put enough traction on the inner vaginal lips, there will be limited clitoral stimulation and less satisfaction in the bedroom.

Management of Rectoceles

Rectoceles can be managed conservatively with pelvic floor exercises, behavioral modifications and consideration for using a pessary. Alternatively, surgical treatment, a.k.a. pelvic reconstruction, is often necessary for more extensive rectoceles or for those that do not respond to conservative measures.

Pelvic floor muscle training (PFMT) is useful under the circumstances of mild-moderate rectocele, for those who cannot or do not want to have surgery and for those whose minimal symptoms do not warrant more aggressive options. The goal of PFMT is to increase the strength, tone and endurance of the muscles that play a key role in the support of the rectum and perineum. Weak pelvic muscles can undoubtedly be strengthened; however, if there is connective tissue damage, pelvic training will not remedy the injury, but does serve to strengthen the muscles that can help compensate for the connective tissue impairment. If not completely cured with PFMT, the rectocele and perineal laxity can still be improved, and that might be sufficient.  Chapter 5 in The Kegel Fix book  (www.TheKegelFix.com) is devoted to a specific PFMT regimen for rectoceles and other forms of pelvic organ prolapse.  Note that if the pelvic floor muscles are torn or widely separated, PFMT will not be productive until surgical repair is performed.

Another component of conservative management is modification of activities that promote the rectocele (heavy lifting and high impact exercises), management of constipation and other circumstances that increase abdominal pressure, weight loss, smoking cessation and consideration for estrogen hormone replacement, since estrogen replacement can increase tissue integrity and suppleness.

A pessary is a mechanical device that is available in a variety of sizes and shapes and is inserted into the vagina where it acts as a “strut” to help provide pelvic support and keep the rectum in proper position. Pessaries need to be removed periodically in order to clean them. Some are designed to permit sexual intercourse.

Surgery is often necessary in the case of a symptomatic moderate-severe rectocele, particularly when quality of life has been significantly impacted. This type of surgery is most often done vaginally, typically on an outpatient basis. Both the rectocele and the perineal laxity are addressed.  The goal of surgery is restoration of normal anatomy with preservation of vaginal dimensions and improvement in symptoms with optimization of bowel and sexual function.  With improvement of anatomy, function often significantly improves, since function often follows form. Difficulties with evacuation, constipation, straining, incomplete emptying and fecal incontinence should improve, if not resolve. There should no longer be a need to splint the rectum and sexual function (for both patient and partner) should dramatically improve with the rebuilding of the perineum.

Marietta S pre-PP

Pre-operative photo–note gaping vulva, exposed vagina, rectocele and perineal laxity; (c) Michael P Goodman, MD. Used with permission

 

Mariette S 6 wk p.o. PP

Post-operative photo–note closed vulva, unexposed vagina and restored perineum after levatorplasty, vaginoplasty, perineorrhaphy and aesthetic perineoplasty; (c) Michael P Goodman, MD. Used with permission

 

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.

Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health http://www.MalePelvicFitness.com

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health  http://www.TheKegelFix.com  

Much of the content of this entry was excerpted from Dr. Siegel’s The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health (Chapter 5. Pelvic Organ Prolapse)

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Even More About Pelvic Prolapse: Diagnosis & Treatment

October 29, 2016

Andrew Siegel MD 10/29/2016

Note: This is the final entry in a 3-part series about pelvic organ prolapse.

 How is POP diagnosed and evaluated?

The diagnosis of POP can usually be made by listening to the patient’s narrative: The typical complaint is “Doc, I’ve got a bulge coming out of my vagina when I stand up or strain and at times I need to push it back in.”

After listening to the patient’s history of the problem, the next step is a pelvic examination in stirrups.  However, the problem with an exam in this position is that this is NOT the position in which POP typically manifests itself, since POP is a problem that is provoked by standing and exertion. For this reason, the exam must be performed with the patient straining forcefully enough to demonstrate the POP at its fullest extent.

A pelvic examination involves observation, a speculum exam, passage of a small catheter into the bladder and a digital exam. Each region of potential prolapse through the vagina—roof, apex, and floor—must be examined independently.

box

A useful analogy is to think of the vagina as an open box (see above), with the vaginal lips represented by the open flaps of the box.  A cystocele (bladder prolapse) occurs when there is weakness of the roof of the box, a rectocele (rectal prolapse) when there is weakness of the floor of the box, and uterine prolapse or enterocele (intestinal prolapse) when there is weakness of the deep inner wall of the box.

Inspection will determine tissue health and the presence of a vaginal bulge with straining. After menopause, typical changes include thinning of the vaginal skin, redness, irritation, etc. The ridges and folds within the vagina that are typical in younger women tend to disappear after menopause.

Useful analogy: The normal vulva is shut like a closed clam. POP often causes the vaginal lips to gape like an open clam.

Since the vagina has top and bottom walls and since the bulge-like appearance of POP of the bladder or rectum look virtually identical—like a red rubber ball—it is imperative to use a speculum to sort out which organ is prolapsing and determine its extent. A one-bladed speculum is used to pull down the bottom wall of the vagina to observe the top wall for the presence of urethral hypermobility and cystocele, and likewise, to pull up the top wall to inspect for the presence of rectocele and perineal laxity. To examine for uterine prolapse and enterocele, both top and bottom walls must be pulled up and down, respectively, using two single-blade specula. Once the speculum is placed, the patient is asked to strain vigorously and comparisons are made between the extent of POP resting and straining, since prolapse is dynamic and will change with position and activity.

 

exam-relaxed

Image above shows vaginal exam at rest (mild prolapse)

exam-minor-strain

Image above shows vaginal exam with straining (moderate prolapse)

exam-full-streain

Image above shows vaginal exam with more straining (more severe prolapse)

After the patient has emptied her bladder, a small catheter (a narrow hollow tube) is passed into the bladder to determine how much urine remains in the bladder, to submit a urine culture in the event that urinalysis suggests a urinary infection and to determine urethral angulation. With the catheter in place, the angle that the urethra makes with the horizontal is measured. The catheter is typically parallel with the horizontal at rest. The patient is asked to strain and the angulation is again measured, recording the change in urethral angulation that occurs between resting and straining. Urethral angulation with straining (hypermobility) is a sign of loss of urethral support, which often causes stress urinary incontinence (leakage with cough, strain and exercise).

Finally, a digital examination is performed to assess vaginal tone and pelvic muscle strength. A bimanual exam (combined internal and external exam in which the pelvic organs are felt between vaginal and external examining fingers) is done to check for the presence of pelvic masses. On pelvic exam it is usually fairly obvious whether or not a woman has had vaginal deliveries. With exception, the pelvic support and tone of the vagina in a woman who has not delivered vaginally can usually be described as “high and tight,” whereas support in a woman who has had multiple vaginal deliveries is generally “lower and looser.”

Depending upon circumstances, tests to further evaluate POP may be used, including an endoscopic inspection of the lining of the bladder and urethra (cystoscopy), sophisticated functional tests of bladder storage and emptying (urodynamics) and, on occasion, imaging tests (bladder fluoroscopy or pelvic MRI).

cystogram-normal

Image above is x-ray of bladder showing oval-shaped well-supported normal bladder.

cd-cystocele

                    Image above is x-ray of bladder showing tennis-racquet shaped bladder,                          which is high-grade cystocele.

How is POP treated?

First off, it is important to know that POP is a common condition and does not always need to be treated, particularly when it is minor and not causing symptoms that affect one’s quality of life.

There are three general options of managing POP: conservative; pessary and surgery (pelvic reconstruction).

Conservative treatment options for POP include pelvic floor muscle training Kegel); modification of activities that promote the POP (heavy lifting and high impact exercises); management of constipation and other circumstances that increase abdominal pressure; weight loss; smoking cessation; and consideration for hormone replacement since estrogen replacement can increase tissue integrity and suppleness.

A pessary is a mechanical device available in a variety of sizes and shapes that is inserted into the vagina where it acts as “strut” to help provide pelvic support.

512px-pessaries

Image above is an assortment of pessaries (Thank you Wikipedia, public domain)

The side effects of a pessary are vaginal infection and discharge, the inability to retain the pessary in proper position and stress urinary incontinence caused by the “unmasking” of the incontinence that occurs when the prolapsed bladder is splinted back into position by the pessary. Pessaries need to be removed periodically in order to clean them. Some are designed to permit sexual intercourse.

Studies comparing the use of pessaries with pelvic floor training in managing women with advanced POP have shown that both can significantly improve symptoms; however, pelvic floor muscle training has been shown to be more effective, specifically for bladder POP.

PFM Training (PFMT)

PFMT is useful under the circumstances of mild-moderate POP, for those who cannot or do not want to have surgery and for those whose minimal symptoms do not warrant more aggressive options. The goal of PFMT is to increase the strength, tone and endurance of the pelvic muscles that play a key role in the support of the pelvic organs. Weak pelvic muscles can be strengthened; however, if POP is due to connective tissue damage, PFMT will not remedy the injury, but will strengthen the pelvic muscles that can help compensate for the connective tissue impairment. PFMT is most effective in women with lesser degrees of POP and chances are that if your POP is moderate-severe, PFMT will be less effective. However, if not cured, the POP can still be improved, and that might be sufficient for you.

Numerous scientific studies have demonstrated the benefits of PFMT for POP, including improved pelvic muscle strength, pelvic support and a reduction in the severity and symptoms of POP. Improvements in pelvic support via PFMT are most notable with bladder POP as opposed to rectal or uterine POP. PFMT is also capable of preventing POP from developing when applied to a healthy female population without POP.

In symptomatic advanced POP, surgery is often necessary, particularly when quality of life has been significantly impacted. There are a number of considerations that go into the decision-making process regarding the specifics of the surgical procedure (pelvic reconstruction) to improve/cure the problem. These factors include which organ or organs are prolapsed; the extent and severity of the POP; the desire to have children in the future; the desire to be sexually active; age; and, if the POP involves a cystocele, the specific type of cystocele (since there are different approaches depending on the type). Surgery to repair POP can be performed vaginally or abdominally (open, laparoscopic or robotic), and can be done with or without mesh (synthetic netting or other biological materials used to reinforce the repair). The goal of surgery is restoration of normal anatomy with preservation of vaginal length, width and axis and improvement in symptoms with optimization of bladder, bowel and sexual function.

More than 300,000 surgical procedures for repair of POP are performed annually in the United States. An estimated 10-20% of women will undergo an operation for POP over the course of their lifetime.

Dr. Arnold Kegel—the gynecologist responsible for popularizing pelvic floor exercises—believed that surgical procedures for female incontinence and pelvic relaxation are facilitated by pre-operative and post-operative pelvic floor exercises. Like cardiac rehabilitation after cardiac surgery and physical rehabilitation after orthopedic procedures, PFMT after pelvic reconstruction surgery can help minimize recurrences. Pre-operative PFMT—as advocated by Kegel—can sometimes improve pelvic support to an extent such that surgery will not be necessary. At the very least, proficiency of the PFM learned pre-operatively (before surgical incisions are made and pelvic anatomy is altered) will make the process of post-operative rehabilitation that much easier.

Useful resource: Sherrie Palm is an advocate, champion and crusader for women’s pelvic health who has made great strides with respect to POP awareness, guidance and support. She is founder and director of the Association for Pelvic Organ Prolapse Support and author of “Pelvic Organ Prolapse: The Silent Epidemic.” Visit PelvicOrganProlapseSupport.org.

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery. Much of the content of this entry was excerpted from his recently published book: The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health. For more info: http://www.TheKegelFix.com.

He has previously authored Male Pelvic Fitness: Optimizing Sexual & Urinary Health; Promiscuous Eating: Understanding And Ending Our Self-Destructive Relationship With Food; and Finding Your Own Fountain Of Youth: The Essential Guide For Maximizing Health, Wellness, Fitness & Longevity. Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro. Area and Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

The Kegel Fix is available in e-book format on the Amazon Kindle, iPad (Apple iBooks), Barnes & Noble Nook and Kobo and in paperback, all accessible via the following website: www.TheKegelFix.com. The e-book offers discretion, advantageous for books about personal issues, is less expensive, is delivered immediately, saves the trees, has adjustable fonts, as well as numerous hyperlinks—links to other sites activated by clicking—that access many helpful resources.  The book was written for educated and discerning women who care about health, well being, nutrition and exercise and enjoy feeling confident, sexy and strong.

 

More About Pelvic Organ Prolapse (POP)

October 22, 2016

Andrew Siegel MD 10/22/2016

This is the second entry in a three-part series about pelvic organ prolapse.  It is important to understand that the issue in POP is NOT with the pelvic organ per se, but with the support of that organ. POP is not the problem, but the result of the problem. The prolapsed organ is merely an “innocent passenger” in the POP process.

How Much Of A Vaginal Bulge Can POP Cause?

The extent of prolapse can vary from minimal to severe and can vary over the course of a day, depending on position and activity level.  POP is more pronounced with with standing (vs. sitting or lying down) and with physical activities (vs. sedentary).

The simplest system for grading POP severity uses a scale of 1-4:

grade 1 (slight POP); grade 2 (POP to vaginal opening with straining); grade 3 (POP beyond vaginal opening with straining); grade 4 (POP beyond vaginal opening at all times).

Which Organs Does POP Affect?

POP can involve one or more of the pelvic organs including the following: urethra (urethral hypermobility); bladder (cystocele); rectum (rectocele); uterus (uterine prolapse); intestines (enterocele); the vagina itself (vaginal vault prolapse); and the perineum (perineal laxity).

Urethra

The healthy, well-supported urethra has a “backboard” or “hammock” of support tissue that lies beneath it. With a sudden increase in abdominal pressure, the urethra is pushed downwards, but because of the backboard’s presence, the urethra gets pinched closed between the abdominal pressure above and the hammock below, allowing urinary control.

When the support structures of the urethra are weakened, a sudden increase in abdominal pressure (from a cough, sneeze, jump or other physical exertion) will push the urethra down and out of its normal position, a condition known as urethral hypermobility. With no effective “backboard” of support tissue under the urethra, stress urinary incontinence will often occur.

sui

Urethral hyper-mobility causing stress urinary incontinence (the gush of urine) when this patient was asked to cough.

Bladder

Descent of the bladder through a weakness in its supporting tissues gives rise to a cystocele, a.k.a. “dropped bladder,” “prolapsed bladder,” or “bladder hernia.”

A cystocele typically causes one or more of the following symptoms: a bulge or lump protruding into or even outside the vagina; the need for pushing the cystocele back in in order to urinate; obstructive urinary symptoms (a slow, weak stream that stops and starts and incomplete bladder emptying) due to the prolapsed bladder causing urethral kinking; urinary symptoms (frequent and urgent urinating); and vaginal pain and/or painful intercourse.

untitled

Cystocele

Rectum

Descent of the rectum through a weakness in its supporting tissues gives rise to a rectocele, a.k.a. “dropped rectum,” “prolapsed rectum,” or “rectal hernia.” The rectum protrudes into the floor of the vagina. A rectocele typically causes one or more of the following symptoms: a bulge or lump protruding into the vagina, especially noticeable during bowel movements; a kink of the normally straight rectum causing difficulty with bowel movements and the need for vaginal “splinting” (straightening the kink with one’s fingers) to empty the bowels; incomplete emptying of the rectum; fecal incontinence; and vaginal pain and/or painful intercourse.

rectocele

Rectocele with perineal laxity

Perineum

Often accompanying a rectocele is perineal muscle laxity, a condition in which the superficial pelvic floor muscles (those located in the region between the vagina and anus) become flabby. Weakness in these muscles can cause the following anatomical changes: a widened and loose vaginal opening, decreased distance between the vagina and anus, and a change in the vaginal orientation such that the vagina assumes a more upwards orientation as opposed to its normal downwards angulation towards the sacral bones.

Women with vaginal laxity who are sexually active may complain of a loose or gaping vagina, making intercourse less satisfying for themselves and their partners. This may lead to difficulty achieving orgasm, difficulty retaining tampons, difficulty accommodating and retaining the penis with vaginal intercourse, the vagina filling with water while bathing and vaginal flatulence (passing air through the vagina). The perception of having a loose vagina can often lead to low self-esteem.

Small Intestine

The peritoneum is a thin sac that contains the abdominal organs, including the small intestine. Descent of the peritoneal contents through a weakness in the supporting tissues at the innermost part of the vagina (the apex of the vagina) gives rise to an enterocele, a.k.a. “dropped small intestine,” “small intestine prolapse,” or “small intestine hernia.”

An enterocele typically causes one or more of the following symptoms: a bulge or lump protruding through the vagina, intestinal cramping due to small intestine trapped within the enterocele, and vaginal pressure/pain and/or painful intercourse.

enterocele

Enterocele

Uterus

Descent of the uterus and cervix because of weakness of their supporting structures results in uterine prolapse, a.k.a. “dropped uterus,” “prolapsed uterus,” or “uterine hernia.” Normally, the cervix is situated deeply in the vagina. As uterine prolapse progresses, the extent of descent into the vaginal canal will increase.

Uterine POP typically causes one or more of the following symptoms: a bulge or lump protruding from the vagina; difficulty urinating; the need to manually push back the uterus in order to urinate; urinary urgency and frequency; urinary incontinence; kidney obstruction because of the descent of the bladder and ureters (tubes that drain urine from the kidneys to the bladder) that are dragged down with the uterus, creating a kink of the ureters; vaginal pain with sitting and walking; painful intercourse; and spotting and/or bloody vaginal discharge from the externalized uterus, which becomes subject to trauma and abrasions from being out of position. The most extreme form of uterine POP is uterine “procidentia,” a situation in which the uterus is exteriorized at all times and, because of external exposure, has a tendency for ulceration and bleeding.

 

uterus

Uterine prolapse

ulcerated-procidentia

Severe uterine prolapse (procidentia) with ulcerative inflammation surrounding cervix

Vagina

The most advanced stage of POP occurs when the support structures of the vagina are weakened to such an extent that the vaginal canal itself turns inside out. Vault prolapse, a.k.a. “dropped vaginal vault,” “prolapsed vaginal vault,”or “vaginal vault hernia,” is rarely an isolated event, but often occurs coincident with other forms of POP and most often is a consequence of hysterectomy. If the vagina is likened to an internal “sock,” vaginal vault prolapse is a condition in which the sock is turned inside out. When I explain vaginal vault prolapse to patients, I demonstrate it by turning a front pocket of my pants inside out.

To be continued…

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery. Much of the content of this entry was excerpted from his recently published book: The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health. For more info: http://www.TheKegelFix.com.

He has previously authored Male Pelvic Fitness: Optimizing Sexual & Urinary Health; Promiscuous Eating: Understanding And Ending Our Self-Destructive Relationship With Food; and Finding Your Own Fountain Of Youth: The Essential Guide For Maximizing Health, Wellness, Fitness & Longevity. Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro. Area and Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

The Kegel Fix is available in e-book format on the Amazon Kindle, iPad (Apple iBooks), Barnes & Noble Nook and Kobo and in paperback, all accessible via the following website: www.TheKegelFix.com. The e-book offers discretion, advantageous for books about personal issues, is less expensive, is delivered immediately, saves the trees, has adjustable fonts, as well as numerous hyperlinks—links to other sites activated by clicking—that access many helpful resources.  The book was written for educated and discerning women who care about health, well being, nutrition and exercise and enjoy feeling confident, sexy and strong.