Pelvic Organ Prolapse (POP) and Stress Urinary Incontinence (SUI) affects many New Zealand women. I recently had a chance meeting with a courageous young lady Jacqueline Alesich. Her life has been greatly affected by POP. Just like me, Jacqueline had just shared her intimate health story with the world. She did so in the hope that other women would be helped by her story.
As we talked I discovered that we had so much in common. Jacqueline had suffered for a long time with a debilitating intimate health issue. One that had put an enormous strain on her emotional and physical well-being. The story is so familiar. I felt an instant connection with Jacqueline and her suffering.
After talking to Jacqueline and reading her story I felt compelled to write this blog. Because as I discovered this is not an uncommon condition. There are many women in New Zealand suffering from Pelvic Organ Prolapse and Stress Urinary Incontinence. Worse still, some are suffering from terrible complications after surgery with surgical mesh.
So what is Pelvic Organ Prolapse?
It is complicated because it can be called many different things. It depends on the organ that is causing the problem. But simply put a prolapse is when an organ drops down to where it should not be. Caused by a weakness of the supporting structures of the bladder, uterus, vagina, small bowel, or rectum. Or unfortunately a combination of these.
These organs are said to prolapse if they descend into or outside of the vaginal wall or anus. All of these are intimate areas for women which means it can cause a lot of distress. Pelvic floor disorders such as pelvic organ prolapse are distressing and can seriously disrupt your quality of life. It can be called POP (short for pelvic organ prolapse) or depending on which organ has dropped it could be called one of the following.
- Cystocele. The bladder drops into the vagina
- The small intestine bulges into the vagina
- The rectum bulges into the vagina
- Descensus or Procidentia. The uterus bulges into the vagina or beyond the hymen.
- Vaginal vault prolapse.Prolapse of the vaginal vault which remains after removal of the cervix during a hysterectomy.
The degree of prolapse is measured using a system known as the POP score.
So what is Stress Urinary Incontinence?
Stress urinary incontinence (SUI) is the accidental or involuntary leakage of urine when there is pressure on the bladder. This may be caused by coughing, sneezing, running, jumping, and POP. Many women experience issues with this at some stage of their lives. However, it is more common during pregnancy, childbirth, weight gain, chronic straining, coughing and as you age. The extra pressure put on the pelvic floor muscles weakens this support allowing small amounts of urine to leak out.
It is a more common problem than you think. One in three women experiences SUI whether is it during pregnancy, during hormonal changes, or whilst playing sport. If you are experiencing hormonal changes due to perimenopause or menopause the drop in Oestrogen levels can affect the elasticity of your pelvic floor muscles. Lower levels of Oestrogen also impact the tissues supporting the bladder and lining of your urethra.
Many women who have POP also suffer from stress urinary incontinence which is why we will look at the two issues together. SUI can be embarrassing or distressing, and what treatment you opt for will depend on how much it is impacting on your life.
So what causes Pelvic Organ Prolapse and Stress Urinary Incontinence?
In short, anything that puts increased pressure in the abdomen can lead to pelvic organ prolapse. The most common cause of POP is pregnancy and childbirth. However, it can also be caused by obesity, constipation, pelvic organ cancer, hysterectomy, and a chronic long-term cough. For some women, the pelvic floor may be genetically predisposition to weaker muscle structures placing them more at risk.
What are the common symptoms of Pelvic Organ Prolapse?
Many women suffer from a variety of minor symptoms which at the time they do not realise are related. That is until the symptoms increase and they start to impact their quality of life. Common symptoms women report are painful intercourse, constipation, urinary incontinence, frequent UTI’s, a feeling of pressure or fullness in the pelvic area. Also low backache, spotting, period issues and a feeling that something is falling out of the vagina. Which symptom is experienced may depend on which organ or organs have prolapsed. Pelvic Organ Prolapse and Stress Urinary Incontinence often are diagnosed together.
Do Pelvic Organ Prolapses get worse if left?
For most, unfortunately, yes. For the majority of women, their prolapse gets worse over time as the muscles weaken under the strain and with age. A few women find that their prolapse will stay the same or improve with conservative treatment methods. To be diagnosed you need to visit your doctor who will ask you a lot of questions. Questions about your symptoms and about any pregnancies or health issues you are experiencing. They will also do a pelvic exam. If they want further information they may send you for the following tests.
- Cystoscopy: Helps the doctor see the interior lining of the bladder and urethra.
- Urodynamic tests: Shows how your body stores and expels urine.
- Computed tomography (CT) scan: Uses x-rays to take detailed pictures of pelvic organs.
- Intravenous pyelogram (IVP): X-ray test that shows the position, size, and shape of certain pelvic organs.
What treatment options are available?
The severity of your Pelvic Organ Prolapse and Stress Urinary Incontinence and how bothersome it is for you will determine what treatment options are available. In all cases, conservative treatments should be explored first.
Conservative treatments and management of POP and SUI
- Pelvic floor physiotherapy, Pilates and Kegel exercises will all strengthen the pelvic muscles. Read my blog post on how to Prevent Pelvic Floor issues with Pilates and Yoga.
- Lose weight if needed and avoid lifting heavy things
- Oestrogen replacement. This can be in the form of a cream that is inserted in the vagina.
- A ring pessary. Your doctor can have you fitted with a device called a pessary to help with the pain and pressure of pelvic organ prolapse. It is a removable device that helps hold the pelvic organs in place.
- A good healthy diet to avoid constipation
- Wearing light bladder leakage underwear for mild urinary incontinence
- If you are prone to UTI’s because of the prolapse taking a good vaginal probiotic and using a product like Uqora Target after sex should help.
- The Face Place in Auckland offers two treatments for women who are having minor issues with urinary incontinence. Both the O-Shot and ThermiVa help to support and strengthen the tissues around the urethra, in many cases stopping or significantly reducing bladder leakage. Because they improve both vaginal and urethral tissue, a nice side effect of the treatments is often an improvement in sensation, lubrication, and orgasm with sexual activity.
If you have explored all non-surgical treatment options and have had limited success with these you need to talk to your doctor about surgical options.
Surgery for Pelvic Organ Prolapse and Stress Urinary Incontinence
Surgery is the most common treatment for serious symptoms of POP and for SUI symptoms that are affecting your quality of life. If you are planning on having more children you may want to wait until after your last pregnancy to have the surgery. Another pregnancy could cause it to reoccur. Surgery may be done through the vagina or abdomen. Surgery often involves repairing the tissue that supports the prolapsed organ or providing support around the weakened pelvic floor muscles.
For a full recovery and to prevent a prolapse from coming back, it is important to follow an aftercare program. Follow the advice of your doctor and pelvic floor physiotherapist. Keep your weight at a healthy level and avoid constipation and straining your pelvic floor by heavy lifting. In the past, there were very few options in what type of surgery you had and most surgery involved mesh. However, with recent concerns around the use of mesh, there are many more options available now.
So What is Transvaginal Mesh?
Mesh sheets are being inserted under the bladder or in front of the bowel to prevent organs from falling into the vagina. Or mesh tape can be placed under the urethra like a sling. This then supports the bladder and prevents bladder leakage that occurs during coughing and exercise. The TVT sling is a medical device made of net-like material (usually made of synthetic polypropylene). It is surgically implanted to provide extra support when repairing weakened or damaged tissue.
Controversy has arisen from growing concern about women who have been experiencing complications. These can range from frequent urinary tract infections, erosion of the mesh, and pain, as a result of mesh complications. There is even a class action lawsuit currently happening in Australia that concerns the use of mesh for incontinence and POP in women, and there have been several in the USA too. The use of vaginal Mesh is banned in several countries as it is deemed too unsafe to use.
When done correctly, the majority of women (about 75%) will enjoy a vastly improved quality of life and independence. Unfortunately, as many as 25% of women undergoing SUI mesh surgery will experience some complications. Sometimes these complications extremely impact on their lives. If you prefer not to have mesh surgery, some surgeons in New Zealand do offer mesh-free surgery for incontinence.
Is Transvaginal Mesh safe or not?
Mesh surgery has had successful results for hundreds of thousands of women around the world, but as with any surgery, there have been some women affected horribly by complications. Many of these women are suffering from crippling pain with very little support being given to them. While I was researching this topic I was quite horrified at how much some of these women have been suffering and how much they have to fight to get the issues fixed. Some women have been left with permanent disabilities.
When you are considering surgery with the mesh you must ensure you have an excellent surgeon. One who has experience in this procedure. For women like Jacqueline, it appears that the complications arose because the mesh was not inserted correctly. She knew straight away that things did not feel right but it took 7 years for this mistake to be corrected.
Complications can arise from mesh surgery and can include bowel and urinary incontinence, chronic pain, and autoimmune disorders. Some people develop Autoimmune conditions because of FBR. Using biocompatible mesh (porcine, bovine) polypropylene or the foam can trigger this. I would highly recommend you read the Ministry of Health’s brochure on Considering Surgical Mesh to Treat Stress Urinary Incontinence?
Are their alternatives to Trans-vaginal Mesh?
There are alternatives to trans-vaginal mesh. Surgical treatment options are available that do not involve the use of mesh. By using your natural body tissue to create the sling you avoid the need for something synthetic. This surgery has a slightly longer recovery time, however. But, it completely avoids the risks of mesh infection, erosion, and pain that can sometimes accompany mesh surgery.
Surgical options available in New Zealand that do not involve mesh are as follows.
Colposuspension – Is an abdominal operation. It can be performed using either open or keyhole surgery to lift your vagina underneath your urethra using permanent
Natural tissue sling – Is an abdominal operation using open surgery to lift your urethra using a natural sling from your abdominal wall.
Biological tissue sling- Uses biological material of animal origin to lift your urethra.
Urethral bulking agents – A vaginal operation where a synthetic ‘bulking’ material is injected in or around your urethra to improve the seal. This material may be permanent or absorbed by your body
Research the facts before you go ahead with any surgery
“The Loss of a Life Well Lived” is a qualitative study. It looks at the impact of surgical mesh implants on the lives of a group of New Zealand women. This is an excellent read and was only published in June 2019. “Mesh down under support group” has excellent resources for people who have SUI or POP. Including a comprehensive list of questions to ask your surgeon if you are considering your options. I would highly recommend joining the group if you are after up to date support and guidance. Thank you to Carmel Berry for her advice and help when writing this blog.
For more information
For Support and Information in New Zealand please contact – Mesh Down Under
Ministry of Health Brochure – Considering a surgical mesh
“The loss of a life well lived” is a study of the impact that surgical mesh implants have had on the lives of a group of New Zealand women. “The Loss of a Life Well Lived”
Another excellent link for more information- resources and patient user guides