Urogynaecological conditions: prolapse, bladder and pelvic floor problems

Urogynaecology is a sub-speciality of gynaecology which is a kind of women’s health medical speciality, and it focusses really on the pelvic floor or pelvic floor disorders, and the ‘uro’ bit is the bladder, and because a lot of these patients have bladder problems. That might be things like incontinence, overactive bladder, infections, but we’ve also cover things as I mentioned like vaginal prolapse, vaginal symptoms, birth trauma, and both the vaginal symptoms and bladder symptoms often involve bowel symptoms as well, things like anal incontinence, and obviously being female the reproductive tract, sexual dysfunction, sexual disorders. So urogynaecology encompasses managing all of those sorts of symptom and body systems that kind of surround anatomically the female genital tract.

One of the things that I really enjoy about being a pelvic floor specialist is I look at women through, look after women through all stages of the lifecycle. So that can be very young women having urinary tract infections, bladder pain, or period related problems, through to women in their reproductive years having pelvic floor problems during pregnancy or as a result of pregnancy and delivery. through to being older, post-menopausal, hormone related changes around the change of menopause, and then elderly population.

The pelvic floor is a sling of muscles that run from the pubic bone underneath to the tailbone. So it’s this sling of muscles underneath, and the muscles go around the urethra and the vagina, and around the back passage. And they sort of lift up underneath and help support the bladder, the uterus and the bowel. So they’re really important for maintaining our continence, so these muscles help sort of squeeze and close off around the urethra, and the vagina and the back passage, so they do help us control our bladder. So if you had a really full bladder and you felt that you were about to cough or sneeze, you might tighten your pelvic floor. They help control our bowels, so again if you felt that you were about to pass wind, you might tighten your pelvic floor and help control that. They provide support, they have a really important role in sexual function as well, so with sexual response. And so, a healthier pelvic, pelvic floor is important not only for control of bladder and bowel, so being able to hold on, but also emptying. So, when we go to the toilet to empty our bladder or to empty our bowels we need to be able to relax the pelvic floor as well. So really important roles in, in all of those areas.

So urinary incontinence, if you use the strict definition, is the involuntary loss of urine. And so that’s basically leakage of urine. We divide it because, into different types of incontinence, because the way we can manage urinary incontinence depends on the type of incontinence. So, some people might have to rush to the loo, and we call that urge incontinence, so they don’t make it in time, they have urgency. We talk about stress incontinence, which is leakage with coughing, sneezing and exertion. But many people have mixed, a bit of both, which makes managing that quite challenging. Some people just leak without awareness, so we call that involuntary incontinence, or insensible incontinence. And then urinary incontinence is tied into other types of bladder symptoms, so people will often hear about over-active bladder, or if you have an over-active bladder, over-active bladder syndrome, and that might be the kind of need to run to the loo, go really regularly, getting up at night, feeling like you have to rush, and that may or may not be associated with incontinence.

Generally when people talk about POP or pelvic organ prolapse we’re talking about vaginal prolapse. So, this is where the vaginal canal, which is part of the lower female genital tract, inverts on itself, or drops down, and that’s normally related to weaknesses in the supporting structures around it, which has lots of causes. And there are typically three structures or elements of pelvic organ prolapse or, and vaginal prolapse. So on the front of the vagina we’re talking about the bladder and that’s why a lot of these patients have bladder symptoms. On the back of the vagina it sits next to the lower part of the bowel, so we call that rectal prolapse, or rectocele or back wall vaginal prolapse. And that often will be related to bowel symptoms. And then really importantly the top of the vagina normally sits the womb, or the uterus, and the cervix, and a lot of women have hysterectomies so they can have what’s called a vault, and the top of the vagina can also drop down too. Generally we’re talking about three different areas of the vagina that are dropping down into the vaginal canal, and at its worst, forms coming towards the outside of the entrance to the vagina.

So urinary tract infections are a really complicated part of what we call LUTS, which are lower urinary tract symptoms. So that’s a really nice umbrella term for basically a bladder problem that causes you symptoms of, of bladder dysfunction. And some people will get recurrent or chronic or relapsing urinary tract infection. One of the difficulties is that ties very closely with something called cystitis, which is a very commonly used term but we don’t really know what that means when we’re talking about it. So, cystitis just means inflammation or irritation of the bladder. That might be because someone has a recurrent infection or chronic infection, or a relapsing infection. But there are lots of other causes of cystitis, and cystitis really, if you ask people and look in the medical literature what does cystitis mean it just means an unpleasant sensation within the bladder, often associated with bladder filling, but there are hormonal causes, infective causes, lots of other things can cause that unpleasant sensation of bladder filling that isn’t necessarily an infection.

Bladder pain syndrome is what we call in medicine a diagnosis of exclusion, so that means we’ve ruled out a cancer, a stone, an infection, something that we can easily identify and treat. But some patients will be left with an element of cystitis that is so unpleasant it’s painful, and that might be pain in the bladder on a day-to-day basis, or all the time, or that might be pain in the bladder just when the bladder fills. We don’t really understand why patients get bladder pain syndrome, so it’s a very poorly understood condition. We think some people develop bladder pain syndrome because they’ve got recurrent relapsing or chronic infections that maybe have settled and are not easily detected. It might be that they get it as part of a wider pain syndrome, so we know that patients with bladder pain syndrome share many of the same features with patients that for example have chronic back pain, or chronic pelvic pain or migraines. So sadly some people are just prone to being hypersensitive or feeling pain more easily than, you know, comparatively to someone else.