CLINTON — DEAR DR. MONA: My insides seem to be hanging out from my bottom. It is hard to sit and I feel a constant pulling sensation when I am standing. What can be done about this? I still have my uterus and it is very hard for my husband and me to be intimate because of the discomfort I experience. — Edith

DEAR EDITH: What you are describing is something called uterine prolapse, or loss of pelvic floor support. I am not sure what type specifically without examination or more information at this time.

Let me tell you what this could be. A women’s pelvis has three organs competing for a space in the vagina — the bladder, the uterus and the rectum. These organs are kept in place suspended by a hammock called the pelvic fascia. The pelvic fascia has an opening for the urethra (through which you urinate), the cervix, and the rectum  (the opening through which you have bowel movements.)

At certain times in a women’s life the pelvic fascia is subjected to stress or pressure. This occurs in pregnancy and delivery, with repeated coughing spells, or with weight gain which causes increased abdominal pressure. At these times, breaks in the pelvic fascia may develop, and organs may drop through (or herniate) into the vagina. Bladder herniation leads to a cystocele (cysto - bladder, cele - sac), a rectocele is when the rectum herniates, and it is called uterine prolapse if the uterus falls down. A combination of several of these may also occur.

Women with these problems may complain of pelvic pressure, back pain, a pulling sensation, difficulty with intercourse, or the sensation of sitting on a ball. In some extreme cases, women may have difficulty having a bowel movement, difficulty in urination, leaking urine with intercourse, vaginal dryness, ulcers or bleeding of the vagina due to dryness.

Why this happens to some women and not others is not clear at this point. Genetics seem to play a role.

However, we know for a fact that pregnancy in and of itself and trauma during childbirth, especially with large babies or difficult deliveries, can cause loss of pelvic support. Aging and loss of estrogen is also responsible for loss of tissue and muscle tone leading to prolapse.

Heavy lifting, chronic cough, chronic obstructive pulmonary disorder (COPD), constipation, and frequent straining are known to increase the risk of prolapse. Ethnicity may play a role in prolapse development since Asian and African women do not have this problem to the same extent as Northern European women.

You can do something to prevent prolapse development. Avoid activity or changes that will increase the pressure in the pelvic area.

For example, smoking destroys your tissues and causes chronic cough so refraining from smoking may make a difference. Maintain a good body weight, exercise regularly, avoid chronic constipation, and especially do kegel exercises, and avoid heavy lifting.

Pelvic floor support problems can be managed conservatively with kegel exercises and weight loss if there are no complications, since this is not a life threatening condition. However, prolapse does affect the quality of life and so many women may prefer intervention.

Treatment options include the use of a device called a “pessary” to elevate the fallen organs, or surgery to repair the defects (usually vaginally, and occasionally abdominally). Surgery is not a solution for every woman.

You can also get some benefit from hormone treatment of the vaginal area but as you are aware hormones have their own risks and you and your doctor should discuss this.

Vaginal surgery is preferred because there is rapid recovery and minimal discomfort. Abdominal surgery is reserved for extreme cases that cannot be accomplished vaginally. In addition, the robotic surgery had been successfully used to accomplish extensive repairs in a minimally invasive manner.

The goal of surgery is to restore the anatomy and retain the function of the vagina. This is accomplished by repairing the defect using the women’s own fascia or implants (meshes either biological or permanent) to support the prolapsed organs.

There are many new developments in management of pelvic support problems and it is indeed an exciting time for women with this type of problem due to the increasing options available.

So, Edith, make an appointment to talk to your doctor, and remember, you don’t have to live with this.



Dr. Mona Alqulali is a board certified OB-GYN.