Prolapsed Bladder & Pessaries

What is a Dropped Bladder/Prolapse?

Dropped bladder is a general term used by doctors and patients to describe a condition known as Pelvic Organ Prolapse. Pelvic Organ Prolapse means that one of the pelvic organs – the bladder, the uterus, the intestines or the rectum has fallen down into the vagina. Prolapse ranges in severity from very mild (i.e. prolapse that can only be felt by your doctor on examination) to severe where one or more of the pelvic organs actually protrude through the vaginal opening. When the prolapse is severe you can actually see it; it looks like a red ball protruding from the vagina.

What causes prolapse?

Prolapse is caused by a weakening of the muscles that normally hold the pelvic organs in place. Childbirth (labor and delivery) is the most common cause of weakening of these muscles. The aging process itself, particularly in women who do a lot of heavy lifting, may be another cause.

Can anything be done to prevent prolapse?

Although no one knows for sure, it makes sense that if you do regular strengthening exercises called Kegel exercises, the muscles will maintain their strength and prolapse will be prevented. Many doctors believe that undergoing a cesarean section instead of natural childbirth will reduce the likelihood of subsequent prolapse. Beware, though, a cesarean section has its own complications and it might not be the best solution for you. Elective cesarean section is a controversial subject, which you should discuss in detail with your doctor if you are considering it.

What are the symptoms of prolapse?

The most common symptom of Prolapse is a feeling of pressure in the lower abdomen, vaginal or rectal area – a feeling like you are “sitting on a ball.” In severe cases you may actually see the prolapse protruding from the vagina and, if so, it may get irritated and cause a discharge or even bleeding. With more severe degrees of prolapse it may be difficult to urinate, causing you to have to push or strain. You may experience a weak urine stream and feel like you do not empty your bladder. You may (though it’s rare) be unable to urinate at all, in which case you would need to have a catheter (tube) passed into the bladder to empty the urine. Sometimes the prolapse can block the kidneys causing kidney failure. Fortunately, when the prolapse is repaired the kidneys usually return to normal, provided that the condition is caught early enough.

Prolapse may also cause constipation. If you push or strain, instead of the stool coming out, you may push the rectum down and the stool can get stuck in a “pocket.”

Does prolapse cause incontinence (loss of urine control)?

It sounds confusing, but prolapse can both cause and prevent incontinence. When the prolapse is mild, the part of the bladder and the urethra that drops downs actually causes incontinence. But when the prolapse is severe, it may actually block the urethra, preventing incontinence. This is very important to understand because if you elect to have surgery to fix the prolapse, unless the possibility of incontinence is evaluated beforehand, the surgery often makes the incontinence much worse or even brings on new incontinence. Fortunately though, with proper pre-operative evaluation this can be recognized and the incontinence repaired at the same time so that the surgery is successful.

How do I know if I need treatment?

For the overwhelming majority of patients with prolapse treatment is completely elective. That means you (not your doctor) decide if the symptoms are bad enough to warrant treatment. However, for some patients, treatment is medically necessary because your prolapse causes a blockage to the kidneys or such a severe blockage to the bladder that you are not able to urinate at all.

What are the treatment options?

There are only two. A pessary or surgery.

What is a pessary?

A pessary is a device that is usually made out of a plastic type substance and is usually in the shape of an “O,” a donut or ring. It is placed in the vagina, like a tampon, to hold organs in place. Pessaries come in many different sizes and shapes and need to be fitted by your doctor to your vagina. Pessaries are quite safe, although in some patients they seem to be associated with recurring bladder infections. If a pessary works for you, and it is comfortable, it can be a lifetime treatment. It can be left in place for several months at a time and may be changed by either your doctor or yourself (so long as you are properly instructed first). They are not, however, effective in all patients.

Many people with prolapse have bladder symptoms. Sometimes the dropped bladder actually causes a blockage and you’re either unable to urinate all, or you have difficulty urinating. If you push or strain, that only makes the prolapse worse and it becomes even harder to void. In other people, the prolapse causes a discomfort, aching or a constant feeling that you have to urinate. In some people, the bladder becomes hypersensitive or overactive and you have to urinate very frequently. If you have any of these symptoms and you have a dropped bladder, uterus, or rectum, a pessary may relieve all of your symptoms.

Unfortunately, there is no simple way to attain the proper fit or choose the best kind of pessary. It’s all trial and error. Your doctor will examine you and try a certain type or size. Then, if it feels comfortable, you should get up and walk around and see how it feels. Further, some pessaries are shaped so that they also hold the sphincter in place and can be used to treat stress incontinence. They do work in some people and they do not to our knowledge appear to do any serious harm. Of course any pessary or bladder neck prosthesis can cause inflammation, infection or even an erosion of the vaginal wall, so they need to be checked by your doctor periodically. If you do not have any particular infirmities, you probably will be able to insert and remove the pessary yourself. Many people use the pessary only when they are going out or exercising or whenever else they want. Even if you can’t put it in and take it out yourself, you can use a pessary if you want to. Your doctor can fit you, insert it, then remove at 3 month intervals, wash it off, inspect the vagina and put it back in, provided that there are no vaginal erosions or infections.

How do I know if a pessary would be a good idea for me?

The only way to know if a pessary is for you is to try it. Try it. You might like it…But follow the instructions carefully.

If the pessary is so good, why should I consider surgery?

If the pessary works for you, there is no need to ever consider surgery. However, it does not work well for everyone. In some women the pessary works well with respect to holding their organs in place, but it “unmasks” incontinence. This means that when you use the pessary you start to leak urine. When that happens the choice is to not use the pessary, live with the prolapse and remain dry or have surgery.

What kind of surgeries are there?

When it comes to prolapse there are almost as many different kinds of surgeries as there are surgeons. That means that it is very important for you to discuss the particulars of your case with a surgeon in whom you have great confidence. In very general terms there are operations that are done through the vagina and operations that are done through the abdomen.

In either case, though, the goals of the surgery are the same – to create a strong support to prevent the organs from falling down. Many surgeons use plastic material called mesh to support the tissue, but this may result in serious complications (the FDA has issued a warning about this). Dr. Blaivas and Dr. Purohit do not do these mesh surgeries – they use only your own natural tissue for the repair.

If the uterus is prolapsed it may be necessary to have a hysterectomy as well. In addition, it may be necessary to repair incontinence.

So if you are considering surgery, be sure that you do your homework and learn a lot about the different surgical possibilities, the potential risks and benefits, and most importantly, about how to select your doctor.

 

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