Online Health Chat with Matthew D. Barber, MD, MHS
September 9, 2013
Pelvic organ prolapse is a downward descent of female pelvic organs, including the bladder, uterus and the small or large bowel. This drop results in the protrusion (sticking out) of the vagina, uterus, or both. Prolapse development can be caused by several factors, including vaginal child birth, advancing age, and obesity. It occurs when weakened muscles cause one of the pelvic organs, most commonly the bladder, to drop.
Nearly 50 percent of women who have had children are affected by pelvic organ prolapse. Many women are embarrassed to talk about this problem—even to their doctors. It is important to discuss your concerns with your doctor as there are many different treatment options available—both surgical and non-surgical methods.
About the Speaker
Matthew D. Barber, MD, MHS, is Professor of Surgery at the Cleveland Clinic Lerner College of Medicine at Case Western Reserve University and Vice-Chair of Clinical Research in the Ob/Gyn and Women's Health Institute. He is a board-certified staff physician in the Section of Urogynecology and Pelvic Reconstructive Surgery in the Department of Ob/Gyn and the Glickman Urological Institute at Cleveland Clinic.
Dr. Barber's specialty interests include pelvic organ prolapse, urinary incontinence, fecal incontinence, vesicovaginal, rectovaginal fistulas and management of pelvic mesh complications.
Dr. Barber completed his fellowship in female pelvic medicine and reconstruction and his Masters of Health Sciences degree in clinical research at Duke University Medical Center, in Durham, NC. Dr. Barber also completed his residency in obstetrics and gynecology at Duke University Medical Center. He received his medical degree from Thomas Jefferson Medical College, in Philadelphia.
Let’s Chat About What to Do About Dropped Bladder
Matthew_D._Barber,_MD,_MHS: Good afternoon and welcome to this webchat on pelvic organ prolapse and urogynecology. Thank you for joining us today. It is a very common problem that many women have, but are too embarrassed to talk about. I look forward to your questions, and I hope to be able to provide some direction in regards to your concerns.
Some degree of relaxation or dropping of the bladder and vagina is common in women who have had vaginal childbirth. In fact, over one third of women who have had vaginal childbirth have stage 2 pelvic organ prolapse. Stage 2 is when the uterus or vagina protrudes to within 1 cm of the vaginal opening when they strain hard. Most women have no symptoms and do not require treatment. In essence, stage 2 could be considered normal in many women. We typically recommend treatment when a woman complains that they can feel or see a bulge coming through the vagina. Other related symptoms might be urine leakage or difficulty emptying the bladder or bowels. If you do not have these symptoms, then it is likely that you do not need treatment. If you are having these symptoms and they bother you, then your options for treatment are insertion of a pessary or surgery. Typically, we recommend surgery to women who have Stage 3 or 4 prolapse (i.e., prolapse that protrudes more than 1 cm beyond the vaginal opening with straining) or women with stage 2 prolapse who have bothersome symptoms. I would not recommend surgery to someone with stage 2 prolapse who did not have bothersome symptoms.
Causes of Pelvic Organ Prolapse
Redsnake: I was told that I have a prolapsed uterus by two different doctors. One said that I needed surgery right away, and the second said I am only at stage 2. When should I take action? I am very confused by these different opinions.
Matthew_D._Barber,_MD,_MHS: Vaginal childbirth commonly results in some degree of relaxation or dropping of the bladder. Although over one-third of women who have vaginal childbirth will experience stage 2 pelvic organ prolapse, most women have no symptoms and require no treatment.
LucyintheSkies: I have never had children. Does this give me a better chance of not having a dropped bladder or uterus? Or are there other factors besides vaginal birth that can lead to pelvic organ prolapse?
Matthew_D._Barber,_MD,_MHS: Yes, women who have not had vaginal childbirth have a lower risk of developing pelvic organ prolapse than those who do. Other clear risk factors are increasing age and being overweight. Some studies suggest that having a hysterectomy, smoking and having a job that includes heaving lifting also increase your risk. There is certainly a genetic risk as well.
shoeluvr: Can numerous fibroids and an enlarged uterus cause bladder prolapse? Why does my gynecologist think my bladder bulging into my vaginal canal is a fibroid even after I was sent to a urologist for stress incontinence issues?
Matthew_D._Barber,_MD,_MHS: Typically, uterine fibroids would not cause bladder prolapse. However, they can certainly make the symptoms and/or the degree of prolapse worse, depending upon the size and location of the fibroid. It is also possible that a fibroid in the right location could actually cause the front wall of the vagina—where the bladder is—to protrude. An ob/gyn can often figure this out with a pelvic examination, but sometimes an ultrasound or MRI is needed.
Association of Prolapsed Bladder and Rectocele
laura628: Can a prolapsed bladder contribute to a rectocele?
Matthew_D._Barber,_MD,_MHS: The often occur together, but it is unlikely that one caused the other.
Prolapsed Bladder and UTIs
gogetter: I have frequent urinary tract infections (UTIs) and I have prolapse of the bladder. I shower twice a day and drink lots of water and do everything I can to prevent UTIs. Is there any surgery to hold the bladder up away from the urethra?
Matthew_D._Barber,_MD,_MHS: In addition to drinking lots of water, other options for recurrent UTIs include using a vaginal estrogen cream (if you are postmenopausal) and/or taking a protective (‘prophylactic’) antibiotic every day. Sometimes when the UTIs appear to be related to sexual intercourse, you can take a low dose of antibiotics right before or right after intercourse to prevent them as well. In someone with prolapse, having surgery to correct the prolapse may also help.
Asymptomatic Bacteriuria vs. UTI
dcmna3: In the elderly, bladder infections seem to occur so frequently to the point my mother's doctor has told me he doesn't treat them. Then she developed a severe infection with blood loss that landed her in the hospital. Any suggestions on additional preventive medicine? Any special considerations for the elderly patient?
Matthew_D._Barber,_MD,_MHS: Many elderly patients have what doctors call ‘asymptomatic bacteriuria’ where the bladder becomes permanently colonized with bacteria, much like our mouths have bacteria that live in them. It is important to distinguish between a real UTI and asymptomatic bacteriuria in older patients. Asymptomatic bacteriuria should generally not be treated while a true UTI, which would often be associated with burning with urination and urinary frequency and urgency, should be treated. I would suggest your mother see a urologist, urogynecologist or infectious disease specialist if she has not already.
Staging Pelvic Organ Prolapse
grahama2: I have heard that there are stages of prolapse. How are these stages determined, and does the stage then indicate a specific treatment pathway?
Matthew_D._Barber,_MD,_MHS: Yes, urogynecologists stage prolapse by determining how far different portions of the vagina or uterus descend when a women strains during a pelvic exam.
- Stage 0 is perfect support of the uterus and vagina
- Stage 1 is mild descent of the vagina or uterus but no descent beyond 1 centimeter above the vaginal opening
- Stage 2 is descent to within 1 cm above or beyond the vaginal opening
- Stage 3 is prolapse more than 1 cm beyond the vaginal opening
- Stage 4 is complete prolapse of the vagina and/or uterus
Most women who have stage 0 or 1 and many who have stage 2 can be considered normal. Almost a third of women who have had children have stage 2 prolapse and many don't have symptoms and may never develop them. We offer treatment to women with Stage 3 or 4 prolapse and women who have stage 2 who have bothersome symptoms.
bbo: What exercises will help?
Matthew_D._Barber,_MD,_MHS: Pelvic muscle exercises, often called Kegel exercises, can be effective in improving vaginal support and slowing down prolapse. The pelvic floor muscles are the muscles around the vagina and bladder that you squeeze when you ‘hold’ your urine. We typically recommend 15 pelvic muscle contractions performed three times per day. It is also important to contract your pelvic floor muscles when you are lifting heaving objects and doing other activities that put pressure on your pelvis.
misslottie: What can you do if it is just beginning to drop? Is there anything besides surgery?
Matthew_D._Barber,_MD,_MHS: Pelvic muscle exercises, often called Kegel exercises, can be effective in improving vaginal support and slowing down prolapse. The pelvic floor muscles are the muscles around the vagina and bladder that you squeeze when you ‘hold’ your urine. We typically recommend 15 pelvic muscle contractions performed 3 times per day. It is also important to contract your pelvic floor muscles when you are lifting heaving objects and doing other activities that put pressure on your pelvis.
Magic: I am 72 years old and been diagnosed with mild to moderate bladder prolapse. Will Kegel exercises help me enough to avoid surgery in the future?
Matthew_D._Barber,_MD,_MHS: They might. Kegel exercises can be helpful in improving mild to moderate prolapse and urinary leakage. If you begin to notice bulging from the vagina, then you can consider a pessary or surgery. If urine leakage is your biggest issue, then sometimes surgery is appropriate, but often behavioral treatments and/or medications can be helpful depending upon the cause of the urine leakage.
Congor: Will doing Kegel exercises while wearing a pessary cause erosion of the vagina walls?
Matthew_D._Barber,_MD,_MHS: No, I would think not. Erosions are caused by a pessary that is too large or in the wrong place that constantly compresses the vaginal wall. They can typically be prevented by making sure you have the appropriate fit for your pessary, using estrogen cream in the vagina if you are past menopause, and undergoing regular examinations by your physician.
eileena: What are the advantages and disadvantages of using a pessary? Can it permanently damage the vagina?
Matthew_D._Barber,_MD,_MHS: Pessaries, which are like diaphragms inserted into the vagina to correct pelvic organ prolapse, are really the only non-surgical treatment for prolapse. They are very safe as long as you are seen and examined by your ob/gyn (obstetrician-gynecologist) or urogynecologist every few months. Some of my patients love them and have used pessaries for decades without any issues. Other patients of mine don't like how they feel and don't use them for very long. The only way to know for sure is to be fitted for one and try it for a while. About 50 percent of women who try a diaphragm, and can be successfully fitted will be happy, and still using them a year later. The major side effects of a pessary are an increase in vaginal discharge and, in some cases, an odor. Also, sometimes it can cause erosions or abrasions of the vagina that will require either treatment with an estrogen cream or temporary or permanent removal of the pessary. That is why it is important that anyone who uses a pessary have regular pelvic examinations by her physician.
Congor: I have been wearing a pessary successfully for five years for cystocele with uterine prolapse that was diagnosed when I was 77 years old. My gynecologist said that 90 percent of what was outside my body was my bladder. The rest was the tip of the uterus. He also said that my vaginal walls are thin and weak and that the pessary will help support the walls. I do have occasional urge incontinence, which I assume is related to the cystocele. When my gynecologist retired I went to another one who put hormone cream on the pessary after cleaning it and before reinserting it. He prescribed Estrace® (estradiol) vaginal cream and advised me to use a full plunger of the cream once a week.
Does Estrace® strengthen the walls of the vagina, and if so, do the risks of Estrace® outweigh the benefits for an 82-year-old woman? Another doctor advised me to use the gel of a vitamin E capsule and apply it to about an inch inside the vagina instead of Estrace®. Would that have a beneficial effect?
Matthew_D._Barber,_MD,_MHS: Estrogen creams, like Estrace®, are often recommended in women who are using pessaries in order to decrease the risk of developing an erosion or abrasion of the vaginal wall that can result from the pessary. Estrogen does appear to strengthen the vaginal wall and decrease the risk of these erosions. It also decreases the vaginal discharge and odor that some women get with pessary use. At the dose and frequency you describe, estrogen cream is safe. In fact, estrogen cream placed into the vagina typically does not affect organs outside of the genital tract so you don't have to worry about the same side effects that you might when you take estrogen by pill.
Delaying Treatment for Pelvic Organ Prolapse
eileena: If you decide to live with pelvic organ prolapse and not correct it through surgery or other means, is there a health danger? Are there consequences to just leaving the prolapse alone?
Matthew_D._Barber,_MD,_MHS: We offer treatment to women for pelvic organ prolapse when they develop bothersome symptoms such as seeing or feeling a vaginal bulge through the vaginal opening, urinary incontinence, or difficulty emptying the bowels or bladder. In women without these symptoms, particularly if they are not bothersome, treatment is rarely needed. Even in women with symptomatic prolapse, it is perfectly safe for many to just ‘live with it’ as long as they are seen regularly by their ob/gyn or urogynecologist and do not have vaginal bleeding or difficulty emptying their bladder. It is important to remember that pelvic organ prolapse is not life threatening. While pelvic organ prolapse can often cause distressing symptoms and significantly affect a women’s quality of life, sometimes it does not. In cases where the symptoms are minimal, regular observation by a physician without other treatment is just fine. The most common consequence of leaving prolapse untreated is that it will eventually get worse and symptoms develop. However, in many women with mild prolapse it may never get worse. I have some patients with severe prolapse who have chosen no treatment and done just fine, some for many years. If these patients ever proceed to where they develop difficulty emptying their bladder, erosions of the vagina that did not go away or if they developed symptoms that bothered them enough to request surgery, then I would suggest treatment.
dcmna3: Is it inevitable that a prolapsed uterus and collapsed bladder will require surgery? If the patient isn't experiencing any discomfort, are there any disadvantages in waiting for the corrective surgery?
Matthew_D._Barber,_MD,_MHS: No, it is not inevitable. Many women have mild prolapse that does not require treatment and may not ever progress to the point where treatment is required. If you are not experiencing any discomfort or other related symptoms, then waiting is exactly the right course.
Treatment for Urinary Incontinence and Pelvic Organ Prolapse
dcmna3: Who do I trust to repair a prolapsed bladder and uterus? Should I see my ob/gyn (obstetrician-gynecologist) or do I seek a different type of surgeon?
Matthew_D._Barber,_MD,_MHS: Anytime you have surgery, it is important to make sure that your surgeon has a lot of experience performing the proposed surgery. Some general ob/gyns are quite experienced with prolapse surgery and would be good choices to do this type of surgery. However, many general ob/gyns do not regularly perform prolapse surgery or only do a few operations per year, so it is important to ask. Urogynecologists are ob/gyn or urology specialists who have had additional training in advanced techniques of prolapse surgery and other pelvic reconstructive techniques. They typically perform many prolapse surgeries every month or even every week. The official name of the urogynecology’ specialty is female pelvic medicine and reconstructive surgery.
HoosierBuckeye: I have been diagnosed has having a prolapsed bladder and was instructed to do ‘floor’ exercises, as well as Kegel exercises to strengthen the muscles. Other than that, the only other options are to wear protective liners—or if the situation warrants, ‘diapers.’ I have been advised that the surgery to fix the situation only has a lifetime of approximately 10 years and cannot be re-done. Thus, I should wait until I am at least 70 years old to consider this route. Is this true? I don't have a serious issue at the moment, but I'm sure that the force of gravity will have a profound effect on this as time marches on!
Matthew_D._Barber,_MD,_MHS: From your description, it sounds like your main issue is urine leakage. Is this correct? Urine leakage (i.e., urinary incontinence) is often related to pelvic organ prolapse, but not necessarily. The treatments for urinary incontinence depend upon the type of urine leakage that you have. If you have leaking related to coughing, sneezing and physical activity, which doctors call ‘stress urinary incontinence,’ then the primary treatments are Kegel exercises and surgery. The most commonly performed surgery is a sling procedure. This surgery has a high success rate with approximately 85 percent of women becoming either dry or significantly improved. These procedures are intended to be permanent, and current data suggests that this surgery remains effective for at least 15 years. They likely last longer, but we just haven't been able to study them that long yet.
lightning#: I've been told that my pelvic floor is relaxed because of Ehlers-Danlos syndrome. Can Kegel exercises take care of this or is surgery necessary? I suppose it has to do with the severity of symptoms. The incontinence is annoying. I have seen a physical therapist who gave me exercises that caused spasms in my back.
Matthew_D._Barber,_MD,_MHS: Kegel exercises can be helpful in improving mild to moderate prolapse and urinary leakage. If you begin to notice bulging from the vagina, then you can consider a pessary or surgery. If urine leakage is your biggest issue, then sometimes surgery is appropriate, but often behavioral treatments and/or medications can be helpful depending upon the cause of the urine leakage.
janiceasad: Is the sling procedure safe? Will the tissue cause problems later in life? How are the outcomes of this procedure so far?
Matthew_D._Barber,_MD,_MHS: Sling procedures are the most commonly performed surgery for stress urinary incontinence (i.e., leaking when you cough, sneeze or do physical activity). They are generally quite safe and effective. In fact, it can be argued that they are the best studied surgery in all of gynecology. After a sling procedure, approximately 85 percent of women can expect to be dry or significantly improved. The surgery is usually performed as an outpatient (i.e., same day surgery). Sling procedures have risks that are much the same as any similar procedure, including a small risk of bleeding, infection, risk of anesthesia, etc. The best studied and most commonly used sling procedures use a synthetic mesh called polypropylene. Permanent mesh is used with the intent of making the surgeries last a long time—hopefully, the entire lifetime. The use of this mesh does add an additional risk of erosion of the mesh into the vagina or surrounding tissues, which occurs in less than one to two percent of women who have the procedure.
Mesh Repair of Pelvic Organ Prolapse
mflower: In 1999 my doctor used a mesh to repair my pelvic organ prolapse. My bladder did not fully empty after the surgery and even today the bladder leaks. My question is should I have a CT Scan to see if everything is ok? Was there any problem with the mesh that was used in 1999?
Matthew_D._Barber,_MD,_MHS: Do you know what kind of mesh? Was it a sling for urinary incontinence or a prolapse mesh to suspend your vagina and bladder? A CT scan will typically not reveal anything with most implanted meshes even if there is something wrong. I would suggest you see your gynecologist or urogynecologist for an pelvic examination. They may also want to do a test called urodynamics to further evaluate your bladder symptoms.
Repeat Surgery for Bladder Prolapse
sylvester: I have had bladder surgery and a sling inserted, several years ago. Is it possible for the bladder to prolapse again? I'm having symptoms like the first time, including the need to urinate twice, some burning or irritation, and the need to urinate urgently sometimes. I take diuretics, but also medications for the urgency.
Matthew_D._Barber,_MD,_MHS: Yes, it is possible for bladder prolapse to recur. Fortunately, this is not common, but five to 10 percent of women will require a second operation at some point in their life. If you are having symptoms again, I would suggest you make an appointment to be examined by a gynecologist or urogynecologist.
Recurrent UTIs After Pelvic Floor Reconstruction
eileena: If you had a previous pelvic floor reconstruction over 10 years ago and now suffer from chronic bladder and urinary tract infections (UTIs), could the bladder have shifted closer to the rectum so bacteria is crossing over through the tissues? If so, is there a repair possible to correct this? Or are there other suggestions to prevent UTIs?
Matthew_D._Barber,_MD,_MHS: Doctors define recurrent urinary tract infections as more than three infections over a 12-month period. There are a number of causes of recurrent UTIs, including vaginal atrophy (inflammation and thinning of the vagina in women who have gone through menopause) and changes in the anatomy of the urethra, bladder and/or vagina. In someone who has had previous pelvic reconstruction, it would be important to make sure that there is not obstruction or blockage of the urethra from the previous surgery. Another concern would be the possibility of a stitch or mesh from the previous surgery in the urethra or bladder. This is uncommon, but could certainly cause recurrent UTIs. I would recommend that you see a urogynecologist or urologist for further evaluation. After this doctor takes your medical history and examines you, it is likely that he or she may want to do further testing such as a cystoscopy or urodynamic evaluation to rule out these issues. Common treatments for recurrent UTIs include use of vaginal estrogen cream in postmenopausal women and use of preventative or prophylactic antibiotics on a daily basis.
Urinary Retention After Gall Bladder Surgery
Delayne: What is the most likely cause of urinary retention after gall bladder surgery?
Matthew_D._Barber,_MD,_MHS: How long ago was your surgery? Have you started any new medications?
Prior Rectocele Repair and Rectal Bleeding
liesel: I am a 74-year-old female. I am dealing with a lot of lower abdominal pain, mainly on my lower left side. I also have rectal bleeding issues about three or four times per week when I go to the bathroom. I did have a sigmoidoscopy in 2008 and a colonoscopy in September 2011. The gastroenterologist said nothing was wrong, but there was possibly a fistula that I would have to live with. I had a rectocele repair in 2001. A pelvic examination by my gynecologist two weeks ago did not reveal any problems. Should I worry about the constant rectal bleeding and the lower abdominal pain? What should my next step be since I already had the colonoscopy?
Matthew_D._Barber,_MD,_MHS: Rectal bleeding should always be taken seriously. The symptoms that you describe, chronic left sided lower abdominal pain and rectal bleeding, may indicate that you have a condition called diverticulosis or diverticulitis—or even something more serious. Even though your colonoscopy was normal in 2011, the fact that your symptoms have continued suggest that you have an ongoing problem that should be evaluated. I would suggest you return to the gastroenterologist and let them know you are still having the symptoms. Alternatively, you could seek a second opinion from another gastroenterologist. I do not think the rectocele repair you had in 2001 is in any way related to your current complaints.
Activity Restrictions with Prolapsed Bladder
HoosierBuckeye: Knowing that I do have prolapsed bladder, do I have to refrain from any heavy lifting? If so, would it aggravate the situation if I do not refrain? Also, what is the recommended minimum weight we should lift, if this is a risk?
Matthew_D._Barber,_MD,_MHS: You do not necessarily need to refrain. You should only refrain if doing heavy lifting causes the prolapse to protrude or causes you discomfort.
Moderator: I'm sorry to say that our time is now over. Thank you, Dr. Barber, for taking the time to answer our questions today pelvic organ prolapse.
Matthew_D._Barber,_MD,_MHS: Thank you again for joining me today to discuss pelvic organ prolapse and urogynecology. I have enjoyed our time today and all of your questions were great!
To make an appointment with a urogynecologists in Cleveland Clinic’s Women’s Health Institute, please call 216.444.6601, toll-free at 800.223.2273 (extension 46601) or visit us at clevelandclinic.org/obgyn for more information. You can also download our treatment guide at clevelandclinic.org/prolapseguide.
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On Cleveland Clinic
In the Section of Urogynecology and Reconstructive Pelvic Surgery in Ob/Gyn & Women’s Health Institute and the Glickman Urological Institute at Cleveland Clinic, our physicians have been performing a number of innovative urogynecology techniques for the diagnosis and pelvic floor disorders and treatment of urinary and fecal incontinence.
Both basic and advanced urodynamic testing, including video urodynamic testing, is available to evaluate women with urinary symptoms, disorders, and pelvic floor disorders. There are many different urogynecology treatments available for pelvic organ prolapse, urogynecologic disorders and incontinence. For other types of pelvic floor disorders and incontinence, outpatient or inpatient surgical procedures can be performed, including reconstructive pelvic surgery. To treat pelvic organ prolapse, ‘short-stay’ procedures include laparoscopic and robotic-assisted sacral colpopexy and vaginal reconstruction with and without mesh implantation. For urinary incontinence different types of outpatient procedures include tension free vaginal tape (TVT) procedure, transobturator tapes, mini-slings and sacral neuromodulation.
Cleveland Clinic gynecology care is ranked third in the nation by U.S. News & World Report, and has top ranking in Ohio. We offer care at convenient locations throughout Northeast Ohio.
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