News Release

As reported by, April 2, 2008.

Problems In The Pelvis

By Abram Katz

Most men used to shy away from discussing impotence. Then ads for "erectile dysfunction" drugs made the subject slightly easier to talk about with their doctors.

However, many women still are hesitant to broach a fairly common problem they experience that can cause incontinence, discomfort and other intimate difficulties. While a new generation of women is more medically assertive, few of their husbands have heard of these conditions -- pelvic organ prolapse, or pelvic floor dysfunction.

Richard S. Bercik, M.D., newly appointed chief of urogynecology at Yale-New Haven Hospital and Yale School of Medicine, said women who have urological or gynecological problems are sometimes reluctant to seek help because problems of incontinence, pelvic organ prolapse, bladder inflammation or sexual dysfunction can be embarrassing to discuss, or they assume the symptoms are a normal part of aging.

Some estimates place the incidence of pelvic floor prolapse at 35 percent of women. The condition usually surfaces in women who have given birth, and is aggravated by coughing or straining that accompanies constipation. Susceptibility also apparently depends to a large extent on genetics.

Sometimes pelvic floor dysfunction can be successfully treated with exercises and other nonsurgical treatments.

Meanwhile, new surgical techniques that use synthetic and biological meshes are being employed, though some physicians continue to prefer the "older" operations.

Both men and women have a pelvic floor. However, men never give birth and are more prone to simpler hernias.

The floor is a complex structure of muscles and tendons anchored to the pelvis. The pelvic floor can be envisioned as a "hammock" of tissue that provides support for reproductive organs, and the structures that store and eliminate waste, said Dr. Antonio Asis, an obstetrician and gynecologist at Asis Medical Associates in New Haven, Conn. He is also on staff at the Hospital of Saint Raphael.

When this hammock is weakened by the pressure of childbirth, the positions of internal organs can shift, pushing against each other, even squeezed through the pelvic floor.

For example, the bladder may "drop," pressing against the uterus and vagina. In extreme cases, the uterus may bulge into the vagina. In milder cases, the drooping floor leads to undue pressure on the lower section of the large intestine.

A weakened pelvic floor can affect the sphincter that controls the release of urine, leading to occasional incontinence, Asis said.

"There are many procedures that make the symptoms better. Some are quick, others are complicated, depending on the patient's age and condition," Asis said.

Far too often, women experiencing such discomforts do not seek medical treatment because they may be embarrassed or fearful that their condition is caused by a serious medical issue, Bercik said.

"There are a number of surgical techniques that have been around for years to strengthen the pelvic floor," said Dr. Phillip Smith, head of the University of Connecticut Health Center's urodynamics program.

Smith said he prefers a more conventional approach that involves suturing the "dropped" organs to strong ligaments in the pelvic floor. This avoids the use of graft material, which has gained a large following among gynecological surgeons.

A new kind of procedure uses biological or synthetic mesh to reinforce the pelvic floor. The mesh attaches to the pelvic bones, creating a new "hammock."

Asis said the mesh is designed to act as a scaffold for muscle cells, which gradually grow into the material and incorporate it into the tissues of the lower abdomen.

Smith said potential complications with mesh repairs include hardening of the material, and erosion of muscle revealing the material.

Dr. Robert Samuelson, director of gynecology at St. Raphael's, said up to 50 percent of women who have given birth may experience some degree of pelvic floor weakening. About 30 to 50 percent of women in nursing homes have pelvic floor prolapse.

"Most ob/gyn doctors see several women a week with this condition. There is discomfort, pressure and incontinence," he said.

Exercises to strengthen the pelvic floor are sometimes effective. Otherwise, Samuelson said surgeons often insert meshes to add support to the weakened muscles. "Mesh is placed in places where normal supporting muscles used to be," he said.

"Mesh is gaining acceptance, but it's not indicated for all repairs. I prefer it in most repair cases. The advantages are structural," Samuelson said.

While the anatomy and musculature of the pelvic floor and associated organs are complex, patients usually have suffered with symptoms for a long time and understand the causes of their symptoms, he said.

A woman considering a surgical repair should ask her physician how many procedures he or she has performed. Doctors who have done many operations are preferable, Asis said.

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