In female anatomy, the pelvic diaphragm maintains the structural integrity of the uterus, bladder, vagina, and bowel and keeps them from dropping from their normal position into the vaginal canal. If the pelvic diaphragm weakens, that can lead to what is called pelvic organ prolapse, where the organs intrude into the lower region and cause incontinence, pain, and other health problems.
Surgery, usually involving the insertion of an artificial mesh barrier, was often recommended for pelvic organ prolapse, but recently, questions have surfaced about mesh surgery’s effectiveness due to long-term complications. In this episode of Kentucky Health, host Dr. Wayne Tuckson talks with a Louisville obstetrician/gynecologist about the current debate over pelvic surgery and how treatment of pelvic organ prolapse is being re-evaluated.
Dr. Kate Meriwether, M.D., is an assistant professor of obstetrics and gynecology at the University of Louisville, specializing in female pelvic medicine and reconstructive surgery. During the program, Dr. Meriwether presents a series of slides showing female anatomy and the pelvic region, and viewer discretion is advised.
Dr. Meriwether describes her professional responsibilities as “working like an engineer, but for the female organs.” She specializes in the group of organs that reside in the pelvic area: the vagina, uterus, fallopian tubes, and ovaries involved in reproduction; and the intestines, bladder and rectum, which process nutrients and excrete waste.
These are all supported by a complex, interconnected series of muscles and ligaments called the pelvic diaphragm or pelvic floor, which is shown in a slide along with the related organs.
The pelvic floor “is actually dynamic,” Meriwether says. “It can stretch, it can open when it needs to open, to let things out, like the waste that we give out every day… It can contract when it needs to hold things in…. and it can pertain to other functions, [such as] sexual activity, having babies, other things that go on in women’s lives.”
Causes and Symptoms of Pelvic Organ Prolapse
Meriwether compares the pelvic diaphragm to a hammock or suspension bridge, and notes that when one part of the diaphragm weakens, it puts additional strain on the other areas. Over time, the muscle patterns can stretch and deteriorate to the point where one of the organs located above the vagina (uterus, bladder, or rectum) can intrude into the vagina and push it down. The vaginal walls can themselves drop down as well.
Most women who visit Meriwether for a consultation complain of feeling, or even viewing, a bulge in their vagina. When an adjacent organ drops down into the vaginal area, the vagina will fold and turn inside out, which can make it actually protrude out of its opening.
“[Patients] can feel [the bulge] when they sit on it, or they’ll notice something protruding out,” Meriwether says, “or they’ll feel pressure or [feel like] something is trying to come out of them, and this causes a lot of anxiety or fear, understandably, because they’ll say, ‘Gosh, I’ve got a mass, or something that’s not normal.’ And that’s the most common way that women will present to me.”
Meriwether discusses terminology for specific types of pelvic organ prolapse: cystoceles (front part of vaginal muscle weakens and bladder falls down); rectoceles (back part of vaginal muscle weakens and rectum falls); and enterocele (muscle on vaginal “roof” weakens, small intestine falls). The uterus can also fall down into the vagina, and even if a patient has had the uterus removed via a hysterectomy, the remaining tissue area can still drop down if the structural diaphragm has weakened, she says.
This rearrangement of pelvic organs can cause difficulty in urinating (with cystocele) and defecating (rectocele). Conversely, if the pelvic diaphragm has repeatedly been subjected to sudden, rapid pressure that occurs in chronic coughing or sneezing, or even hearty laughter, a patient may eventually lose the ability to control their urination and/or defecation and develop incontinence.
“The thing that is most damaging to the pelvic floor is actually having an infant,” Meriwether says. “When a woman has a pregnancy and she is going to deliver a baby…[and]that’s stressful for the pelvic floor. A baby is a large, large item – sometimes up to ten pounds, as you know – and when women push out babies, that strains and damages all of the ligaments that are interconnected and hold the pelvic floor and the vagina up.”
Other causes of organ prolapse include aging, obesity, chronic constipation, and lung disease. And “smoking actually makes the connective tissue a little bit weaker, all throughout your body, as if you just needed one more reason to quit smoking,” Meriwether says. Any condition that injures nerves, such as diabetes or a spinal cord problem, can also cause the pelvic muscle to weaken.
Surgical Repair May Involve Complications
Meriwether shows a slide presenting a cross-section of lower female anatomy, to illustrate how close the vagina is to the bladder and rectum, with the uterus sitting above those organs. When pelvic organ prolapse becomes serious enough to cause chronic pain and/or incontinence, surgery is often recommended to repair the pelvic muscular wall. The success of the repair, Meriwether says, is primarily dependent on the experience and skill of the surgeon.
From the 1990s onward, most surgeries have involved either inserting a synthetic mesh framework to supplement natural tissue, or by suturing a woman’s existing pelvic muscle and ligaments to strengthen the weakened area.
The surgical procedure is called a sacrocolpopexy. “That is a big, long word, but all that means is that you’re going in through the belly, and nowadays in the modern era we’ll often do this through laparoscopic incisions,” Meriwether says. “We go in and we place mesh, or sort of an artificial, flexible material, that your tissue can grow in and around, in the front of the vagina, and in the back of the vagina, and then we attach them to strong ligaments in your pelvis – usually a strong ligament that runs down the front of your tailbone.”
Meriwether says that due to recent questions about mesh surgery, more patients have undergone graft procedures using their existing tissue. In 2008, the Food and Drug Administration issued a precautionary warning to patients of a sizable incidence of complications arising from mesh surgery. Meriwether says that by 2011, more research had been conducted, and a panel of experts announced that an estimated 10 percent of women who had undergone mesh surgery for pelvic organ prolapse had complications following surgery – “much higher than we thought it was.”
The most common complication, Meriwether says, is called erosion – where the mesh that is inserted in the muscle between the vagina and adjacent organ “erodes” into the vagina. “[Patients were] getting pain or scar tissue from the mesh,” she says, “or they were getting infections from mesh or other complications, vaginal bleeding, vaginal discharge, other things related to the mesh.”
Patients who develop erosion following mesh surgery have to either take medicine to encourage the growth of natural tissue around the mesh, or undergo surgery again to clip or resect the mesh – a very difficult procedure.
Meriwether says that it is important to note that no matter what sort of surgical procedure a patient has for pelvic organ prolapse, between 10 to 20 percent of those who undergo a first surgery will end up with a recurring prolapse. “Whenever I do a support procedure, I still have to counsel a woman that there’s a small chance that that bulge could come back again,” she says, “just because time and gravity still go to work.”
She also counsels that mesh surgery may still be the preferred procedure for women who have serious pelvic organ prolapse. They should make sure to schedule surgery with someone experienced in the procedure and who “knows the vagina very well, surgically.”
“Those women who are really at high risk for that bulge coming back, or for their native tissue failing, [they] probably do need mesh surgery, and they should have it in the hands of an experienced surgeon,” she concludes. “Folks that are just having a repair for the first time, and who are not very likely to fail [with] their own native tissue repair, mesh might not be the best choice for them, because it comes with a price tag of complications.”