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Home , Coccyx, Cystocele, Dyspareunia, Endometriosis, Pelvic organ prolapse, Pelvic pain

Women’s Institute A Woman’s Guide to Pelvic Health Conditions In women the is muscles, sexual abuse or pelvic fractures a group of muscles that form can result in a number of health problems a hammock-like support across the if not properly treated. opening of a woman’spelvis. These muscles, together with connective Women may experience: tissues, and nerves, keep all • Feeling a bulge and/or pressure of the pelvic organs, such as the bladder, of the , bladder, or uterus, vagina and rectum, in place and • Loss of bladder control, leakage help these pelvic organs function. of , • Sense of urgency to empty the bladder Sometimes the pelvic floor can be • The inability to hold a bowel movement compromised. , , • Pelvic scarring, chronic spasm of the pelvic

2 A Woman’s Guide to Pelvic Health Rectal : is differentiated from Pelvic in that with rectal prolapse the rectum actually protrudes out the anus rather than protruding into the vagina. prolapse (POP) Uterus or womb (): When a group of ligaments (uterosacral and cardinal ligaments) at the top of the vagina (POP) occurs weaken, causing the uterus to drop. when pelvic muscles and tissues become weakened, stretched or are injured. Some possible causes of injury include childbirth, chronically Stages of uterine prolapse: elevated intra-abdominal pressures (due to chronic , chronic and ) or surgery. Stage 1 Stage 2 Stage 3 When the pelvic floor tissues which hold pelvic organs in place become weakened or stretched, it can cause the pelvic organs to bulge (or prolapse) into the vagina. In some cases, the pelvic organs may prolapse past the vaginal opening.

The uterus descends The uterus descends The , located at Pelvic organ prolapse is a common, treatable into the upper portion to the opening the opening of the uterus, medical condition which affects an estimated of the vagina. of the vagina. sags past the vaginal opening and may protrude one-third of all women – and half of all women outside the body. ages 55 and older. While pelvic organ prolapse can affect women of all ages, the risk of developing Stage 4: The uterus is completely out of the body. This condition also is called POP increases with age. Post-menopausal women complete prolapse (procidentia). are at the highest risk for developing POP.

Pelvic organ prolapse may include one (or more) of (apical vaginal prolapse): Vaginal vault prolapse the following conditions, including prolapse of the: may occure following a surgery (removal of the uterus). About 10 percent of women who undergo Bladder (): When the wall of the vagina overlying the a hysterectomy develop some degree of vaginal vault prolapse, bladder weakens and the bladder pushes against the vagina, where the top of the vagina drops toward the vaginal opening. producing a bulge. Pelvic pressure or protrusion are common Just like uterine prolapse, vaginal vault prolapse is staged syptoms. , inability to fully empty the according to the severity of the prolapse. bladder or recurrent bladder may also be a symptom.

Rectocele: When the vaginal wall overlying the rectum weakens and the rectum pushes against the vagina, producing a bulge. Pelvic pressure, protrusion and difficulty with bowel movements may result.

Summa Health 3 Visit summahealth.org/pelvic for more information and a list of our specialists and locations.

Bladder Function • , such as sedatives may be caused or muscle relaxants by a variety of factors, including: Women of all ages may have • Urinary tract • bladder control issues and • Constipation • Constipation may experience: • Muscle damage or weakness Persistent UI: of the anal sphincter muscles Bladder urgency and frequency: • • Nerve damage of the anal Frequent urination means needing • Childbirth injury sphincter muscles to urinate more often than usual. • Advanced age • Loss of elasticity (stretch) in the rectum Urgent urination is a sudden, strong • • Childbirth injury urge to urinate, along with discomfort • Hysterectomy • or rectal prolapse in your bladder. • Obstruction • Rectocele • Neurological disorders • Inactivity Painful bladder syndrome: Causes recurring discomfort or pain in the bladder and the surrounding pelvic region. Bowel Function Many people take normal Pelvic pain refers to pain Urinary incontinence (UI): bowel function for granted. in the lowest part of the , A loss of bladder control resulting in the However, this is a delicate in the area below the leakage of urine from the body. This system with the potential and between the hipbones, or includes , which for issues to arise, such as: . The pain may be sharp is urine loss while laughing, sneezing, or similar to , and it can coughing, running or other physical (tailbone) pain: be steady or come and go. Pelvic activity or urge incontinence, which A rare condition that causes persistent pain differs from , is leaking urine with a sense of urgency pain in the bottom of the spine. which occurs higher in the torso. while unable to reach a bathroom in time. Constipation: Conditions include: Urinary incontinence, both temporary Bowel movements that are infrequent • Pelvic muscle spasm and persistent, may be caused by: or hard to pass. • • Temporary UI: Fecal incontinence: • (pain with sexual • Alcohol Fecal incontinence is the involuntary intercourse) • Dietary habits, including consumption loss of stool or mucous from the rectum, • Pregnancy and post-partum related pain of carbonated drinks, artificial including the inability to hold a bowel • Vaginal atrophy (dryness and pain sweeteners, corn syrup, citrus fruits movement until reaching a toilet and associated with aging tissues) and others passing stool into one’s underwear without being aware of it happening.

4 A Woman’s Guide to Pelvic Health Treatments

There are a wide range of both nonsurgical and surgical treatment options available to treat pelvic floor disorders.

Nonsurgical Options

Women of all ages may Pelvic Floor Physical Therapy beverages with caffeine, alcohol, have bladder control Patients learn techniques that help milk or carbonated beverages them regain pelvic floor control (fizzy) may help control urinary issues. Women may and function. urgency and incontinence. experience: Behavioral and/or Dietary Medications Modifications A small silicone device, similar Several medications can improve • Bowel training helps patients to a diaphragm, is inserted into the bladder or bowel control by blocking develop a regular bowel movement vagina to relieve symptoms of uterine the signals from the nervous system pattern. Over time, the body or vaginal prolapse. which cause urgency. becomes accustomed to a regular bowel movement schedule, Pelvic Exercises thus reducing constipation Electronic monitoring of a normally Kegels consist of repeatedly and fecal incontinence. automatic bodily function in order to contracting and relaxing the muscles improve bladder and bowel control. of the pelvic floor. Strengthening • Changes to diet such as eating these muscles is beneficial for the right amount of fiber can help Botox Injections bladder and bowel control. with diarrhea and constipation. Botox can be injected into the Increasing fluid intake can help bladder muscle for treatment prevent constipation. Avoiding of urge incontinence.

Summa Health 5 Pelvic Floor Physical Therapy

Summa Health offers pelvic Bowel Function • Sacroiliac treatment and bracing floor physical therapy to help • Bowel disorders • Soft and mobilization women regain pelvic floor • Coccyx (tailbone) pain • Therapeutic modalities such as control and function. • Constipation or electrical stimulation • Fecal incontinence • Vaginal dilator training The importance of maintaining a healthy pelvic floor can easily be Pelvic Pain Educational: overlooked. Surgery, natural aging, • Pelvic muscle spasm • Patient and partner education childbirth, scarring, sexual abuse, • Endometriosis • Patient education on topics such as pelvic fractures or tailbone injuries • Dyspareunia (pain with pelvic floor , bowel and bladder can result in a number of pelvic ) retaining and pelvic muscle function floor problems if not properly • Pregnancy and post-partum related pain • Post-operative recovery education treated. These situations can • Pre-operative pelvic floor cause excessive muscle tightness Depending on the cause, muscle education or weakness that may lead to treatment may include both muscle spasm, pain, incontinence physical and educational or constipation. techniques. Summa has specially trained physical therapists who work Restoring muscle balance through Physical: one-on-one with patients in physical therapy leads to less pain, • Anal rectal balloon retraining a comfortable, private setting. resolved incontinence issues and • Biofeedback A physician’s referral is required. an improvement in your overall • Bladder and bowel retraining Most major insurance plans quality of life. Nonsurgical, pelvic • Customized exercise program are accepted, including floor physical therapy techniques to achieve muscle balance Medicare and Workers’ may be used to successfully treat • Internal and external manual therapy Compensation. Talk to the following pelvic floor disorders: • Pelvic floor, trunk and musculature your doctor about getting strengthening exercises a referral for treatment. Bladder Function • Post-operative recovery exercises • Bladder urgency and frequency • Posture and gait assessment • Painful bladder syndrome • Pre-operative strengthening • Urinary incontinence exercises and education • Relaxation training

Take the Pelvic Floor Health Quiz Visit summahealth.org/pelvicquiz to take our 5 minute quiz to help determine if you have a pelvic floor disorder and the appropriate next steps. Your results will be emailed to you confidentially.

6 A Woman’s Guide to Pelvic Health Summa Health 7 Surgical Options

Surgical procedures used to treat pelvic The decision about which surgical organ prolapse and incontinence may technique is right for you is an important be performed using minimally invasive one. Your surgeon will take into account surgical techniques. These procedures many factors before choosing which often can be performed on an outpatient technique to use, including your past basis and often have a fairly short medical history, previous , recovery time. overall health status and anatomy.

No matter what type of surgery you Before having surgery, discuss all are considering, talk to your doctor treatment options carefully with your about your options. Minimally invasive physician. Understanding the benefits surgery techniques offer potential and risks of each treatment will help benefits over traditional abdominal you and your doctor decide which “open” surgery, including: option is best for you.

• Reduced blood loss • Less post-operative pain • Less risk of infectin • A shorter hospital stay • A faster recovery

8 A Woman’s Guide to Pelvic Health Colpopexy Injections of Urethral Bulking Agents Colpopexy is a surgical procedure used to elevate a prolapsed A procedure where a water-based gel containing particles made vagina back to its correct position within the . of calcium hydroxylapatite is injected around the to build During this procedure, a surgeon attaches the vagina to up the area and tighten the sphincter muscles near the opening surrounding tissue in the abdomen to hold it in place. There of the bladder. are two major types of colpopexy: Mid-Urethral Sling Procedure • Vaginal sacrospinous or uterosacral colpopexy: Surgery A procedure in which a surgeon makes a small incision in the is performed through the vagina, which allows repairs to be vagina and places a sling made of synthetic material under made in a minimally invasive fashion. The vagina is attached the urethra. The sling functions as a hammock for the urethra, to the sacrospinous or uterosacral ligaments to hold it in the providing support during activity and sudden increases correct position using either absorbable sutures or other in abdominal pressure (i.e., during coughing and sneezing). synthetic material. • Sacrocolpopexy: This is an approach where the surgeon Pubovaginal Slings makes a small incision in the abdominal wall or uses Similar to a mid-urethral sling procedure, but in this procedure, a laparoscope/robot to perform the surgery through tiny a biological tissue instead of a synthetic material is used to incisions. The vagina is attached to a support material made create a sling under the urethra. of either synthetic material or the patient’s own tissue (), depending on the surgeon’s preference, and then the support Electrical Stimulation material is attached to strong ligaments in the pelvis. Also called sacral nerve stimulation (SNS) or neuromodulation, this procedure involves placing a tiny wire connected to Uterine Suspension a battery near the tailbone under the . Electrical impulses Uterine suspension is the treatment of choice where preservation are then generated and travel along the sacral nerves to the of the uterus is desired. In this procedure, the surgeon returns pelvis. The sacral nerves control the function of the anus, the uterus to its position within the pelvis by reattaching the bladder and bowel. This device is used to treat both urinary uterus to the pelvic ligaments. Another technique uses synthetic and fecal incontinence. A small remote control device allows material to support the uterus. A uterine suspension may one to adjust the amount of stimulation to the optimal level be performed via the vagina using minimally invasive surgical depending on symptoms. The stimulator can be turned on techniques or laparoscopically, using very small incisions or off at any time. The procedure is performed in an outpatient on the abdominal wall. center using local .

Summa Health 9 Colostomy Treatment of Mesh-Related Complications A colostomy is a surgical procedure in which a pouch Summa urogynecologists and colorectal surgeons also treat is formed by drawing the healthy end of the patients with mesh-related complications from surgery. Some or colon through an incision in the abdominal wall and stitching of the complications which can result include: it into place. A plastic bag-like device is attached to the opening, • Vaginal and pelvic pain which provides an alternative way for to exit the body. • Pain in the abdomen, , leg or A colostomy may be temporary or permanent, depending • Painful sexual intercourse on the reason the procedure was performed. • Urinary tract issues, including the inability to void (urinate/pee) secondary to obstruction from mesh Rectal Prolapse Repair Rectal prolapse repair can be performed via an abdominal Additional complications also can develop years after the initial approach (either through an open incision or laparoscopic/ surgery. In menopausal women, the thinning of vaginal tissue robotic incisions) or a transperineal approach (no abdominal increases the risk for developing ulcerations. While uncommon, incisions). Surgery involves moving the rectum back into its ulceration can lead to exposure of the mesh through the vaginal correct anatomical position. wall. Mesh erosion can occur when mesh enters the urinary tract or bowel. Sphincteroplasty Sphincteroplasty involves repairing a damaged anal sphincter Some of the treatment options for meshrelated by rejoining the separated ends of a sphincter muscle torn complications include: by childbirth or injury. • Vaginal hormone replacement treatment (HRT) using • Excision (surgical removal) of the mesh Nonabsorable Bulking Agents • Physical therapy for pain Nonabsorbable bulking agents can be injected into the wall of the anus to build up the tissue around the anus. This narrows Treating mesh-related complications in a timely manner the opening so the sphincters are able to close more tightly. is important. Patients have a much better chance of resolving complications if they seek treatment as soon as they notice a problem. If you are experiencing symptoms, discuss them with a doctor.

REFERENCES: National Digestive Diseases Information Clearinghouse (NDDIC) website, last accessed on November 11, 2013, at http://digestive.niddk.nih.gov/ddiseases/pubs/fecalincontinence/#sup1

Pelvic Health Team

Pelvic Floor Physical Therapy /Gynecology

Kelly Holden, Amy Senn, PT, Bogdan Christopher Sevasti Erica Laipply PT MSPT, BCB-PMD Orasanu, M.D. Rooney, M.D. Yeropoli, M.D. M.D.

10 A Woman’s Guide to Pelvic Health Locations

Akron Green Richard M. and Summa Health Green Medical Center Yvonne Hamlin Pavilion Green Medical Center Summa Health Akron Campus 1835 Franks Parkway 95 Arch Street, Suite 220 Uniontown, OH 44685 Akron, OH 44304 Christopher M. Rooney, M.D. Christopher M. Rooney, M.D. Bogdan Orasanu, M.D. Medina Erica Laipply, M.D. Summa Health For an appointment Medina Medical Center Summa Health Medical Group 3780 Medina Road, Suite 200 with any of our 51 Park West Boulevard, Suite 200 Medina, OH 44256 Akron, OH 44320 Christopher M. Rooney, M.D. specialists, please Sevasti K. Yeropoli, M.D. call 800.237.8662 Summa Health Therapy at Kohl Wadsworth Family YMCA at University Park Summa Health 477 E Market Street, Suite 100 Wadsworth Community Center Akron, OH 44304 621 School Drive 330.375.7357 Wadsworth, OH 44281 Amy Senn, PT, MSPT, BCB-PMD 330.334.0705 Kelly Holden, PT Barberton Summa Health Barberton Campus 201 5th Street Northeast, Suite 6 Barberton, OH 44203 Bogdan Orasanu, M.D.

Summa Health 11 Talk to a Doctor Women who suffer from pelvic organ prolapse, fecal and urinary incontinence or pelvic floor issues often don’t report their symptoms due to embarrassment. As a result, patients are unaware of possible treatment options, many of which can be performed on an outpatient basis.

Call 800.237.8662 to make an appointment with a Summa pelvic health specialist.

summahealth.org/pelvic

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