Genital Prolapse And Urinary Incontinence. Pelvic Floor Dysfunction.
The pelvic floor is a muscular and ligament structure whose function is to maintain the pelvic organs in their place. This structure is pierced by three orifices, such as the vagina, the anus and the urethra. When these muscular structures fail, pelvic floor dysfunctions occur which have significant repercussions on patients' quality of life.
The prevalence of this condition is high and it ranges in different studies between 20 and 50% of women, increasing with age, the number of children, the type of childbirth (vaginal vs caesarean section) and the status of being overweight. Race and the menopause are also risk factors. It is more common in white women. Having said this, the higher life expectancy of the population and the increasingly bigger demand for a good quality of life by women, means that this prevalence is growing, and that consultations for problems derived from pelvic floor dysfunction are a significant health problem in developed societies.
The most significant symptoms when a pelvic floor dysfunction occurs are:
The prolapse or drop of the pelvic organs, such as the uterus, the bladder, the urethra and the rectum, which tends to manifest with the appearance of a lump in the genitals, feeling of fullness, constipation and difficulty emptying the bladder.
- Urinary incontinence (stress, mixed or emergency).
- Alterations in the defaecating function (faecal or flatal incontinence, constipation or pain when defaecating).
- Alterations in sexual function.
In this way, and given the complexity of the structures that form the pelvic floor, different types of problems and symptoms are produced depending on which muscle-ligament structures are affected. The organs that may prolapse include the bladder (cystocele), the urethra (ureterocele), the uterus (uterine or ureterocele prolapse) and the rectum (rectocele). A deterioration of the retention function could also be produced whether it is of urine, or of faeces or gases, associated or not with the prolapse of the different pelvic structures. On the majority of occasions, a combination of several of these problems occurs, which are combined to a greater or lesser extent.
The diagnosis of this condition is made through carrying out a detailed and thorough medical history, the performance of tests or validated questionnaires on patients, which allow us to quantify the intensity of the symptoms, examination in a specialised pelvic floor unit, urodynamic testing and functional ultrasound scan of the pelvic floor. With all these tests, we try to classify in the most precise way possible the type of condition that our patient presents, in order to be able to apply the most effective and safest treatment.
Treatment should be started once the patient has been diagnosed in detail and it includes different types of professionals depending on the degree, the patient's symptoms and the organs affected in the pelvic floor dysfunction.
In the event of urinary incontinence without associated genital prolapse, there are medical treatments including anticholinergics and α-adrenergic agonists in cases of emergency urinary incontinence, associated with rehabilitation which should be carried out in a pelvic floor unit by expert physiotherapists, and selective serotonin receptor inhibitors and noradrenaline for mild or moderate stress urinary incontinence. Oestrogen therapy, whether it is in a local or systemic form, can improve these problems substantially.
Another type of minimally invasive treatment that is applied with very good outcomes is vaginal laser treatment, which improves some types of urinary incontinence substantially, improving the quality of the vaginal mucosa and the connective tissue, which may also help the improvement of sexual dysfunction that is associated in many cases with this problem.
Lastly, in certain patients, in whom non-invasive treatments are not applicable or efficient, or in whom there are associated problems such as symptomatic genital prolapse, surgery can be used, which will consist of the repositioning or removal, in the case of the uterus once the patient's reproductive desires have been fulfilled, of prolapsed organs and the reconstruction of the supportive pelvic structures, whether it is with the patient's own tissues, or with the placement of different types of mesh which replace the function of these. These techniques usually have a very satisfactory outcome.
We must not forget that, given the muscle-ligament nature of the pelvic floor, and the multifactorial origin of the problems of this, physiotherapy treatment must complement any other treatment that the patient is undergoing, since it improves the outcomes of this and it reduces relapses to a great extent, and that the combination of different treatments tends to be necessary on many occasions for the solution of these problems.