ANSWER: For many women, pelvic problems begin with a feeling that something "down there" has fallen out of place. And that's exactly what may be occurring. Once identified, milder pelvic floor weakness can sometimes be managed with exercises. However, surgery may be required to secure organs back in place.
Pelvic floor prolapse may affect one or more pelvic organs. When the uterus sags part way or all of the way down the vaginal canal, the condition is called uterine prolapse. Prolapse may also occur with the bladder (cystocele), rectum (rectocele) and small intestine (enterocele). These organs may bulge into the vaginal canal or even down farther and extend out beyond the vaginal opening.
Pelvic floor problems can include discomfort, pressure or pulling in the pelvic area, groin or lower back when standing or when you lift or strain; incontinence of urine or stool with coughing or sneezing; difficulty emptying your bladder or moving your bowels; and a bulge of tissue at the vaginal opening.
Most women can benefit from physical therapy that is designed to strengthen the pelvic floor muscles. For milder cases of pelvic floor weakness, such therapy can improve symptoms - or at least keep them from getting worse - and possibly delay or avoid the need for surgery. For women past menopause, using estrogen applied to the vagina may also help.
Even women who will need surgery can benefit from physical therapy before surgery and after recovery. Exercises won't put a prolapsed organ back in place, but they may help improve symptoms and urinary or fecal incontinence.
Kegel exercises are the main way to strengthen pelvic floor muscles. These involve a daily routine of contracting the muscles that you'd use to stop the flow of urine. However, many women who think they're doing Kegel exercises correctly aren't exercising the proper muscles. Your care provider or a physical therapist specializing in pelvic floor exercises can help you identify the proper muscles.
Also of help may be techniques such as biofeedback and electrical stimulation. A physical therapist can help come up with a plan to address your muscle weaknesses, which may include Kegel exercises or bladder or bowel training.
For many women, surgery is an option if conservative therapy doesn't improve their symptoms. Surgery generally involves moving shifted organs back to their original locations, and then tightening muscles and ligaments to hold the organs in place. Often, removal of the uterus (hysterectomy) is done to facilitate this goal. If urinary incontinence is an issue -- or occurs after surgery -- additional surgical intervention can help the leakage problem.
There are many procedures to accomplish these goals, each with pros and cons. Choosing the best surgical procedure for you depends on the nature of your problem, the results you hope to achieve and the experience of your surgeon.
Some procedures are best done through open incisions in the abdomen, and others may best be done through the vagina. Some abdominal procedures may be done using minimally invasive techniques that involve inserting thin surgical instruments through several small incisions. Use of robotic methods is becoming more common with certain abdominal procedures. Minimally invasive procedures generally result in less pain and shorter hospital stays.
Finally, correcting the problem may not always be necessary for women who aren't sexually active or who don't have symptoms. In women who aren't candidates for surgery - or for those who want to avoid or delay surgery - a removable intravaginal device called a pessary can be fitted to help hold your pelvic organs in place. - Christopher Klingele, M.D., Gynecologic Surgery, Mayo Clinic, Rochester, Minn.
(Medical Edge from Mayo Clinic is an educational resource and doesn't replace regular medical care. E-mail a question to firstname.lastname@example.org , or write: Medical Edge from Mayo Clinic, c/o TMS, 2225 Kenmore Ave., Suite 114, Buffalo, N.Y., 14207. For more information, visit www.mayoclinic.org.)