Uterine Prolapse,Medical and Physical Therapy Treatment

Introduction

In this post I will be talking about the uterine prolapse /prolapse of the uterus,its symptoms treatment with both Medical / Surgical and Physical Therapy.

It is a common condition in women, statistically it is said that nearly half of the women b/w age 50 to 79 have some degree of uterine prolapse.This is not medically dangerous or an emergency condition.People can engage in sexual activity following the diagnosis of prolapse , intercourse may feel uncomfortable.

Anatomy :

The uterus is located in the pelvis supported by ligaments and pelvic floor muscles which form a hammock .When one or both the pelvic floor muscles and ligaments get weak the organs are no longer are held up in place and may sag to be out of place through the vagina.

Causes

Damage to the supporting structures of uterus can occur

During Childbirth ( usually the most significant cause )
Chronic constipation
Chronic coughing
Genetically weak connective tissue
Aging process.
More causes from my previous post

Diagnosis and Degree of Prolapse:

The degree of prolapse depends upon how far down the vagina the protrusion of uterus has occurred.Your Dr. will determine the degree of prolapse on pelvic exam. If you have symptoms of incomplete bladder emptying the Dr made do a Cystoscopy to look inside the bladder.

MRI may also be done to accurately assess the internal organs.

Uterine Prolapse and Infertility

Uterine prolapse can reduce the chance of a couple getting pregnant since the uterus is not positioned properly to receive and keep the sperm alive.Sperm dies when exposed to air.This can be corrected surgically by hysteropexy.

Uterus Prolapse and Pregnancy

Women with mild to moderate prolapse can get pregnancy .During the pregnancy progression of the prolapse can be minimized by adapting the lifestyle modifications mentioned below. Learning to relax the pelvic floor is very important to all for a smooth vaginal birth and not further increase the prolapse.Pelvic floor relaxation can be done through diaphragmatic breathing .Recommended to discuss with Dr. regarding the type of birth Vaginal vs C section keeping the prolapse in mind.

Uterus Prolapse and Running

Running is high impact activity which can put a lot of stain on a pelvic floor and the uterine prolapse has a potential of getting worse with running Somethings that can be done to prevent the prolapse from getting worse are as follows .

Decrease the speed of running
Decrease the running distance. Long distance running put prolonged pressure on the pelvic floor.
Run on a level surface , avoid running on concrete.
Avoid running uphill. The posture of leaning forward as one goes uphill can increase the intra abdominal pressure and in turn affect the pelvic floor.

Symptoms specific to Uterine Prolapse: It time to see a Dr, when you experience these symptoms

Heaviness or pulling feeling/pain in the vagina .My patient generally describes their symptoms as “I feel like something is falling out of my vagina.”
Progressively increased heaviness in the vagina as the day progresses.When the prolapse is of an advanced degree a pink bulge can be noticed at the vaginal entrance (with use of a mirror to look ), in standing or with coughing and straining.
Pain with sexual intercourse
Urine leakage during sex.
Difficulty or inability to have an orgasm.
Stress ( with coughing, sneezing and laughing ) urinary incontinence.
Difficulty with bowel movement
Patients may have to use the finger through the vagina to help empty the bladder or have a bowel movement.

Treatment :

Lifestyle Modifications:Control what you are able to control .

Proper Biomechanics of lifting/pushing or pulling : Do not hold your breath , but exhale with exertion and lift from the legs and not your back.
Sitting posture .Avoid slouching when sitting on a couch or at the desk working ,to decrease the pressure put on the pelvic floor.
Standing posture.Try to maintain a neutral spine to avoid slouching, this does not have the core muscles firing effectively and the pelvic floor and core muscles need to be working together in sync.
Wt.management

Most prolapses once they become symptomatic need some degree of intervention.

Mild to Moderate degrees of prolapse can be treated and some cases reversed with Physical therapy with Kegel exercises .This can adequately strengthen your muscles to prevent further progression of the prolapse.

Severe Degrees of prolapse will still benefit from skilled PT as a preoperative intervention to strengthen the muscles as I always tell my patient’s “You go into surgery stronger you come out stronger and the recovery is faster.”Once the prolapse is of a severe degree it will need surgery since that will continue to get worse .

Surgical Repair of prolapse – Vaginal Hysterectomy

Vgainal Hysterectomy is the common surgery done to address Uterine Prolapse.This is a procedure where the Uterus is removed via the vagina.This method has better recovery and has no abdominal or laparoscopic incisions.

The surgery is performed in a hospital setting under general or spinal anesthesia.

The surgeon makes an incision around the cervix, the bladder and rectum are carefully moved and all the major blood vessels clamped and then the uterus is removed and the top of the vagina is sutured and this is called the vaginal vault.

Success rate after Surgery

85 % of women who have a Vaginal Hysterectomy are cured of uterine prolapse.About 15% may develop a vaginal vault prolapse in the months or years later.

Complications of Surgery:

As with any surgery there are some possible complications.

Infection , Surgical site ,or urinary tract infection.
Blood clots
Urinary retention
Injury to any of the adjacent organs during surgery

Recovery after Surgery

Patients are usually recommended to “take it easy ” for about 6 weeks and avoid any heavy lifting.Sexual activity may be resumed after discussion with Dr. after 6 weeks.

Conclusion

Treatment of uterine prolapse depends on the degree of prolapse
Pelvic PT and lifestyle modification is an effective way to manage mild to moderate prolapse
Surgical option for the advanced stages of prolapse.

When there is a problem there is a solution it just needs to be found !

References

www.iuag.org

Pelvic Floor Function,Dysfunction and Treatment( Level 1) Herman and Wallace

www.acog.org

July 13, 2020July 13, 2020

All you need to know about Bladder Prolapse/Cystocele.

Introduction

Do you want answers to your questions of badder prolapse or cystocele ? I have answers to all your questions such as is bladder prolapse curable? If so how? and is it dangerous? What will happen if I do not get any treatment? Can it be fixed with Physical therapy? What is surgery like? Will I need surgery? These and many more will be answered as you read this blog post.

Prevalence

This is the most common of the 3 kinds of organ prolapse seen in associated with urinary incontinence seen in the older female population 60 years and older.

Anatomy

The 3 main functions of the pelvic floor are

The 2nd image is Bladder Prolapse .Image obtained from Google mages , no intention of copyright violation.

Bladder
Bowel
Sexual function

The associated organ systems of the above listed functions are located in the pelvic floor. The bladder, the rectum and the uterus are supported by tissues called the ligaments.Most of the time, these organs are held in place by a combination of strong ligament and pelvic floor muscles.When the supportive ligaments and muscles get weak the organs start slide from their places to bulge through the vagina.When there is a bladder prolapse the bladder starts to protrude through the front ( anterior ) vaginal opening.

Degrees of Bladder Prolapse : The degree of prolapse is measured in the extent of prolapse relative to the hymen.

1st degree
2nd degree
3rd degree

Symptoms of Bladder Prolapse:

Urinary Incontinence-
Stress Incontinence : urinary leakage with coughing sneezing and laughing
Urge Incontinence : Decreased ability to control and subside the urge to urinate is felt.
Incomplete bladder emptying
Recurrent urinary tract infections
Difficulty inserting a tampon and difficulty with keeping the tampon in during menstruation. Common patient statements are “ the tampon doesn’t stay inside for long or I have trouble inserting the tampon.“
Difficulty initiating the urine steam.
A feeling of bladder fullness which increases as the end of the day usually feels better when patient is laying down .
A bulge can be seen and felt at the vaginal opening. Can be seen during straining/ coughing in lying down and seen and felt in standing as well (in severe cases).
Pain and discomfort with intercourse.

Causes /Risk Factors of Bladder prolapse

Chronic coughing and sneezing can be a risk factor for bladder prolapse

Childbirth( Vaginal delivery , especially instrument assisted )
Constipation
Chronic coughing as in C.O.P.D.( lung diseases)
Repetitive heavy lifting and strenuous exercises such as crossfit
Postmenopausal. Estrogen is responsible to keep the vaginal tissues supple and in good tone hence post menopause the tissues (ligaments ) loose elasticity and are prone to bladder prolapse.
Any pelvic Surgery
Genetic factors
Caucasian Ethnicity

Diagnosis of Bladder Prolapse

A Through History and Physical Exam to assess the degree of prolapse

Test for Bladder prolapse :

Urodynamics : to know the type of incontinence.
Urine test to check for UTI ( urinary tract infection )

Treatment for Bladder prolapse

The treatment depends on the degree of prolapse.
No treatment may be required if it’s not interfering with your daily activities or causing urinary issues.
Prolapse can remain asymptomatic until the organ descent has reached a certain point and hence it may not be recognized until advanced. In some women the prolapse progresses rapidly and some it remains stable for years .Handa et al ( 2004 ) found that spontaneous regression was seen in cases of mild prolapse.
Miedel et al (2011) found that only small % of women with POP worsen over 5 years.
Bladder prolapse is not dangerous in mild cases. It’s an inconvenience interfering with daily activities and in most of the less severe degrees of prolapse can be treated effectively with a combination of lifestyle change, pelvic floor therapy and medications.The severe degree of prolapse may require surgery.

1. Lifestyle changes :

Wt. loss ( if overweight )
Treating Chronic Cough
Avoiding straining and managing constipation
Pelvic floor muscle exercises Kegel exercises
Pessary .May require some practice to insert the Pessary.May require regular follow up with Dr .

A. Pelvic Floor Exercises :

A,PFMT ( Pelvic floor muscle training ) has been concluded to have a positive effect on POP (pelvic organ prolapse ) due to the following hypothesized reasons (Bo, 2004)

Women learn to contract the pelvic floor before and with any increase in the intra abdominal pressure , such as bearing down when lifting heavy wts .
Regular strengthening exercises build up the strength of the Pelvic floor and the structural support overtime .

B. The Knack

The Knack is a technique that we pelvic PT’s call instruction to consciously contract the PFM before an activity that requires an increase in the intra abdominal pressure for eg lifting something heavy or before a cough or a sneeze (if you can predict it).
I instruct my patients “ Squeeze before you sneeze “.
This will take some practise but will prove to be effective, as reported by my patients about 3 to 4 weeks of regular pelvic floor exercises.

3. Medications:

Estrogen Replacement Therapy

4.Surgery

Surgical options may be considered as a means of treatment usually in severe degree of prolapse and when conservative management was not effective. Prolapse recurs in 70% of the women who had surgery.(Iglesia et al 2010) and 1/3rd of the operated women undergo one further surgical procedure for prolapse (Olsen et al 1997)

Types of Surgery

Reconstructive Surgery – restores organs to their original place.Normal activities can be resumed after recovery from surgery.
Obliterative Surgery -which narrows and closes off the vaginal to support the prolapse, sexual intercourse is not possible after this surgery.

This can be done in one of the following ways.

Open Surgery

Laparoscopic Surgery

Robotic assisted surgery

Recovery time : Depends on the type of Surgery but the Dr usually recommends no heavy lifting, straining , and sexual activity for 6 weeks post surgery.

Conclusion

Bladder prolapse is a treatable condition and patients can return to a good quality of life after the diagnosis of a bladder prolapse.
Mild degrees of Prolapse, can be treated effectively and successful most of the time with Physical therapy , Pessary and lifestyle modification .
Surgery is an option in advanced prolapse.

References :

1.www.urologyhealth.com

2.www.acog.org

3.Evidenced based Physical Therapy for Pelvic Floor 2nd edition

July 7, 2020July 14, 2020

Guide to Pudendal Neuralgia and Physical Therapy

Introduction

Are you suffering with pain in the butt( pudendal neurlagia ) or is it siatica? How do you know? Pudendal Neuralgia is chronic pain in the innervation of the pudendal nerve, which is in the perineum( genital area). This can be found in men and women but 2/3rd of the patients are women. Pudendal nerve is the main nerve of the pelvis. it is formed in the low back in the pelvis near the tailbone, its travel in the pelvis is tortuous as it weaves its way in and out of the pelvis giving branches of nerves on its way to different pelvic floor muscles.

It is particularly vulnerable for compression in 2 anatomical areas 1. the Alcock’s canal and 2. in the “clamp” the nerve course between sacrotuberous and sacrospinous ligament.The cure of pudendal neuralgia will depend on targeting the cause of the symptoms, this is discussed more in the physical therapy section of this post.

Other names for Pudendal Neuralgia:

Pudendal canal syndrome
Cyclist’s Syndrome
AlCock’s Syndrome

Causes of Pudendal neuralgia

Nerve compression as in ligamentous or fascial entrapment (cyclist, childbirth injury and scarring)
Change of bony alignment as in sports injury.
Increased pelvic muscle tone ( fear or due to pain ) can compress the nerve.
Decreased pelvic and hip flexibility.
Any surgeries and resulting scars in the pelvic area.
Chronic Constipation ( lots of repetitive small trauma)
Recent loss of wt,decreasing the cushioning and causing compression of the nerve.

When nerves get irritated chronically pain is perceived at a lower level and the pain response is greater.

Is it Pudendal Neuralgia? If your answer is yes to the following it might be PN.

Do you have pain with sitting but reduced when sitting on the toilet?
Did your problems begin after biking for a long time?
Did your problems begin after a fall on your tailbone (coccyx)
Do you have incontinence of stool, gas or urine ?
Did you have pain during intercourse ?
Do you have pain after ejaculation?
Do you suffer from sexual impotency ?

Symptoms:

Pain is the main symptom, pain which progressively gets worse as the day goes on and pain with sitting but relieved by sitting on the toilet.
Symptoms may also be experienced as bladder. bowel and sexual dysfunction.
Symptoms may start suddenly or be of a gradual progression.
Symptoms may be on one side or both sides of the perineum.
Skin of the perineum may be sensitive to touch.

Location of pain: Perineum sometimes can be the hip and pelvis as well.

In the labia
Vulva
Clitoris ( Penis and Scrotum in men)
Urethra
Rectum and Anus

Diagnosis:

Pudendal nerve neuralgia is rare and is difficult to diagnose, it usually coexists with Pelvic floor dysfunction and is hard to diagnose.The most common misdiagnosis in men of PN is nonbacterial prostatitis. The Dr. who treat PN are Neurologists pain management Drs.. Some of the tests used to diagnose Pudendal neuropathy are as follows

Pudendal nerve motor latency test (PNMLT)
EMG ( Electromygraphy )
3T MRI
MRN ( Magnetic resonance neurography may give clear enough images to see nerve entrapment )
Diagnostic nerve blocks (CT guided)

To summarise the Conclusive diagnosis depends on the following

Symptoms consistent with PN.
An abnormal test, ( any of the above listed )
Pain along the pathway of the nerve.
Ruled out all other possible causes and diseases, such as infection , prostatitis (in men). Vaginal infections or STD’s to name a few .

Treatment for Pudendal Neuralgia:

PN is more likely to respond well to treatment when caught early .

The treatment can be divided into

Conservative Treatment
Surgical Treatment

Conservative Treatment:

A through Physical exam and understanding the symptoms
Ruling out all other causes of the pain, such as coccyxdynia ,interstitial cystitis and prostatitis
Tests to rule in Pudendal neuralgia
Physical Therapy
Pudendal nerve block
Medications,( Antidepressants )
Lifestyle modifications – Avoiding the prolonged pressure on the buttocks by limiting sitting, avoiding strenuous exercises
Perennial suspension pads to help relieve pressure when sitting.

Surgical Treatment :

Surgery includes relasingthe entrapped pudendal nerve, which can be 3 approaches

Trans-perenial
Trans-rectal
Trans-ischiorectal

Physical therapy for Pudendal Neuralgia

Physical Therapy is a very important part of conservative treatment of the PN. Treatment is most effective in a team approach. PT, plan of care is going to depend on the findings during the Initial evaluation, after taking a thorough history and a physical exam, I prepare a custom tailored plan for the patient depending on the patients goals and the impairments I found.

When increased tone of the pelvic floor muscles and Trigger points are found (a trigger point is a hyperirritable spot in the muscle fibers which is painful with compression.)Trigger point release can be done manually when trigger points are identified. A more aggressive trigger point treatment would be trigger point injections ( injections are usually done by a Dr.)
When Pelvic floor dysfunction is noted, relaxing and lengthening the tight or shortened pelvic floor provides relief. Kegels is not appropriate to be done in this case.
Pudendal nerve gliding is done when abnormal neural tension is noted.
When Biomechanical and structural abnormalities are found in the SI joint, hips, low back, and joint hypermobility, exercises to improve stability and restore function are taught.

Dos	Don’ts
Do Stretching to lengthen the pelvic floor. Do seek myofascial release and trigger point release. Do Diaphragmatic breathing to coordinate relaxing the pelvic floor muscles	Don’t do pelvic floor strengthening exercises such as Kegels. Do not do Valsalva breathing

Conclusion:

1.Pudendal neuralgia is a rare peripheral nerve disorder, that can be very distressing .

2. Can be cured depending on the severity of nerve involvement

3.Most PN generally responds well to conservative treatment with Physical therapy.

References:

1. http://www.spuninfo.org

2. http://pudendalhope.org

3. http://www.tipna.org

4. http://www.pudendalhelp.com

5. http://www.pnfdn.org