Pelvic floor relaxation and urinary incontinence are related but different problems that are frequently encountered by women in the reproductive and menopausal years. Almost all women that have delivered one or more babies vaginally will have some degree of pelvic floor relaxation. Thirty percent of women with one delivery will have stress incontinence in the first six months following delivery. Forty-four percent will have it following their second delivery. Urge incontinence is a multifactoral problem that frequently complicates the diagnosis and treatment of pelvic floor relaxation and stress incontinence.

DEFINITIONS

Pelvic floor relaxation is the dropping of the muscular wall that holds the abdominal contents above the vagina. Women frequently describe it as "it feels like my insides are going to fall out". Other complaints are of the sensation of sitting on a tennis ball; of having to push the vagina, bladder or uterus back in; of having to press back on the vagina to assist in moving the bowels. Stretching, tearing or loosening of the muscular attachments of the pelvic floor causes these symptoms. There are four main places that this can happen, either alone or in combination with the others. The bladder can fall down either from midline damage to the supporting tissues in the middle of the anterior vaginal wall or more commonly by detachment of the lateral walls of the vagina. This may or may not result in stress incontinence and less commonly in urge incontinence.

The second place that falling can occur is in the posterior wall of the vagina between the vagina and the rectum. This almost always results from childbirth and studies have shown that episiotomy is no protection. In this defect, the rectal wall bulges through the vaginal opening when straining occurs, such as when one tries to move the bowels. At times, it is necessary to reinforce or hold in the rectal wall by pressing on the posterior vagina. Not infrequently in this type of defect, it is found that the muscular valve in the rectum, the rectal sphincter, has been damaged.

The third type of defect is an enterocele and it is frequently mistaken for one of the other conditions. Here the tissue prolapsing is the small bowel pushing down between the rectum and the vagina. It commonly follows a hysterectomy, often by many years.

The last type of relaxation or defect is the vaginal cuff or uterine prolapse. In this condition the uterus or, after hysterectomy, the vaginal cuff comes down and tries to turn the vagina inside out, just like pulling the toe of a sock down through the cuff of the sock.

INCONTINENCE

Stress incontinence means that the bladder leaks urine when it is stressed by a sudden increase in abdominal pressure, such as a laugh, cough, sneeze or even running are common causes. Usually there is a squirt of urine, not a complete emptying of the bladder. In general this defect results from the bladder neck and tube dropping down below the "squeezer" muscles. In the normal person, the first response to a cough is to squeeze the levator muscle in the pelvic floor and bottom. Then, the upper muscle contracts and completes the cough or laugh. When that happens, the abdominal pressure is transmitted to the bladder neck and has the effect of closing the bladder and preventing leaking. If the bladder and its tube have dropped below the squeezer the abdominal pressure just serves to push urine out, like from an icing bag.

Urge incontinence is when the bladder is easily irritated and contracts with little or no provocation and the resistance muscles are not strong enough to prevent emptying. It is caused by many things including infection, irritation from certain foods, bruising with intercourse, stretching or poor support as in cases of anterior wall weakness. This condition can frequently be treated with medicines and is sometimes improved by surgery done for stress incontinence. Unfortunately, it is sometimes caused or may appear after surgery done for incontinence.

DIAGNOSIS

The first method of diagnosis is a good history, sometimes supplemented by a standardized questionnaire. This should contain a record of the time span of the condition and the severity. The factors that cause leakage and the usual time of day should be inquired after. Sometimes a diary with a record of voiding times and amounts, as well as the occurrence of leakage, is helpful. Other medical conditions that may affect the patient's general condition or treatment should be sought.

We sometimes use a "pad test" where pre-weighed sanitary pads are worn for a specified time and then weighed again. The increase in weight is presumed to be leaked urine. A physical examination is done to measure carefully the location and dimensions of defects in the vaginal support and to look for disease or abnormalities of other gynecological organs. Tumors in the ovaries or uterus may put pressure on the bladder. A general physical exam will help the doctor to understand other factors that may help the person to be a better candidate for some types of treatment than another.

Cystometrograms are frequently done to quantify the bladder pressures during filling and emptying of the bladder. This is done by putting small tubes into the bladder through the urethra and into the rectum or vagina. The bladder is then filled with sterile water and as this is done the pressures are measured and the presence of bladder spasms or contractions is looked for. Voiding studies may be done at this time. I frequently do a cystoscopy to inspect the inside of the bladder after the cystometrogram is finished.

TREATMENT

Like any other condition, there are generally three choices of treatment:

• Developing the patient's coping skills and exercising muscles and conditioned reflex to prevent or minimize the effects of the incontinence.

• Second is medical therapy, using drugs to modify the bladder's contractions and improve the strength of resisting mechanisms.

• The third choice is surgery, to either correct the abnormality or to cause a compensatory abnormality that will render the patient dry.

The physical treatments may consist of exercises to strengthen the squeezer muscles. This may be helped by the use of weights or even electrical stimulation. A physical therapist may help the patient to identify the correct muscles and also accessory muscles that can assist. Biofeedback and relaxation techniques are sometimes helpful. The Neocontrol is a new type of device that uses a magnetic field to stimulate and strengthen the pelvic floor muscles. 

Sometimes a pessary or "brace" made of plastic or rubber is used. These come in a myriad of shapes and sizes to accommodate almost anyone. In general they may be used for diagnosis to see if replacing the anterior vaginal wall will relieve symptoms, or for treatment in someone that is not physically eligible for surgery or has decided against surgery. Pessaries frequently cause some discharge and have to be removed, cleaned and replaced regularly. They may fall out on occasions and are rarely completely successful. Pessaries do, however, have an important niche in the complete scope of treatments for pelvic relaxation.

Medicines are generally of three groups. Anesthetics like Azo-dyes (orange) numb the bladder to irritant stimulus. Blue dye (Methylene blue) has much the same effect. These dyes are annoying because they stain the underclothes but have been used for many years with good effect. Antibiotics are used to treat urinary tract infections that may either be a cause or an effect of bladder malfunction. Other drugs like hyoscyamine; ProBanthine, amitriptyline, imipramine, or anti-cholinergics are used to modify the bladder's contractility, usually to make it less contractile or less prone to spasm. Some improve the contraction of the muscular sphincter in the bladder-tube or urethra. The anti-cholinergic medicines are a tremendous growth opportunity for the  pharmaceutical industry. There are now about 6 different drugs available. All are very similar, have similar effectiveness and similar side effects. Some people find one more effective than another, and we frequently will try several before finding one to stick with. All of them may take a couple of weeks to reach full effectiveness, so patience is necessary when starting.

Surgery has been done to improve incontinence for over 100 years and there are easily more than 100 operations designed to help incontinence. This in itself would indicate that no one operation is completely successful. However, with careful selection of the patient and the operation, success rates of 80 to 95 percent are usual. In general, pelvic floor repair involves reinforcing or reattaching the torn tissues to their original home. In anterior and posterior repair, the torn material under the vaginal skin is sewn back in the midline of the vagina and redundant tissue is removed. I usually use a graft of tissue similar to that used to make heart valves to support the bladder; synthetic mesh is also available.. After all, the normal tissues are already weakened and have  failed already. This is very likely to help a gaping vagina or one where the bladder is bulging down or hanging out but it infrequently helps the symptom of incontinence unless a sling operation is done as well. 

Repair of the lateral vaginal wall support is a less common operation but is much more effective for reducing a prolapsing bladder and has some effect on incontinence. When combined with the Burch repair, it may be the procedure of choice if it is necessary to open the abdomen for some other reason. In this operation, the vagina is approached from the abdominal side just above the pubic bone. The vaginal walls are sewn from the outside back to their normal fastening on the pelvic sidewall. This may also be done through the vagina.In most cases I feel that it is best to use a patch material. The materials available are still in a state of constant change.   A similar procedure is used to reinforce the rectal side of the vagina. This helps to avoid the problem of the repair collapsing several years later that people worry about. 

Enterocele is repaired from the vaginal side either by over-sewing the defect or from the abdominal side by reinforcing the pelvic floor with sutures.

Prolapse of the vagina, when it tries to turn inside out, is repaired by sewing the end of the vagina either to the sacrum with a mesh reinforcement or with a stitch to a ligament on the sidewall, done through the vagina. Both repairs are somewhat technically difficult, but work well. 

Formerly the most common incontinence operation was one of the many modifications of the Burch or Marshall-Marchetti-Kranz operation. In this operation, stitches supporting the bladder neck and or urethra are taken from above and sewn to the tissues on the back side of the pubic bone or just over it. The operation may be done by an open technique with a normal 5 or 6 inch surgical incision or it may be done laparoscopically through "band-aid" incisions. Some modifications of this type of operation use a minimal incision and place the stitches with an instrument like a knitting needle. Since the tension free slings have become available the Burch is rapidly becoming obsolete.

Sling operations use a strip of either natural material (formerly harvested from the patient herself, but now usually from an animal) or a synthetic material passed under the bladder neck to support it. The strip may be screwed into the bone on the upper or lower surfaces of the pubis or it may be sewn to the inside of the abdominal wall. Recent modifications leave the strip free in the abdominal or pelvic tissues,  held by friction and eventually scar tissue. The more obese a person is and the more severe the stress incontinence is, the more likely it is that a sling operation will be necessary to effect a cure. Most slings now are being done by one of the variations on the TVT. In this procedure the sling is placed in much the usual way under the urethra, but he upper ends of the "U" are not sewn down.  The ends are left "tension free". In an alternative procedure the "trans obturator sling, the ends are brough out in the crease of the leg.  The support is provided by the rough surface of the material that is used.  In Most cases the patient goes home directly after surgery.   The success rate is as good as the best of the other operations.  The advantage is in the lack of pain and rapid return to normal activity.  Less than three percent of people have enough difficulty voiding to need a catheter more than overnight, compared to almost 100% of the other procedures.  The operation is done with a single overnight or as an outpatient procedure. Complications are rare and usually minor. There are now at least 5 different versions of this operation put out by different companies.  A newer technique is similar to the TVT but the tape is passed through the obturator fossa, the hole in the front of the pubic bone on each side. This is on either side of the vagina in the crease of the groin. This is a very safe area with few nerves or blood vessels. It is well away from the abdominal cavity and the angle makes it very unlikely to damage the bladder. It is too soon to have any long term results but the early data suggests that the results are about the same as the TVT and SPARC. The new sling is called the Trans-obturator and is marketed as the MONARC and several others.

A last type of procedure is the injection of material such as collagen, fat or carbon spheres or plastic into the tissues around the bladder neck.  These "plump-up" the sphincter area and reduce leaking-often very dramatically.  This is done in the operating room under light anesthesia. There are several new materials just introduced and there is still controversy about their relative advantages.  

The complications of the procedures are chiefly either not working,  failing eventually or sometimes working too well so that the patient cannot void at all. In some cases the tissues may be eroded or worn through by synthetic materials. When the material is fastened to bone, a rare but crippling infection in the bone may occur. The skill of the operator is of greatest importance though because it sometimes takes a fine degree of judgment to know just how tight to make a stitch or a sling and that can be the difference between success and failure of the operation.

These operations all grew from the work of the late Professor Ulf Ulmsten of Upsaala Sweden and his collaborator Peter Petros, now of Perth Australia. 

The main organizations that sponsor and encourage research and teaching in the fields of pelvic floor repair and stress incontinence in women are the International Continence Society, Society of Laparoendoscopic Surgeons, American Association of Gynecological Laparoscopy, American College of Obstetricians and Gynecologists, Society of Vaginal Surgeons, the Society for Urodynamics and Female Urology  and  the American Urological Association. The American Board of Obstetrics and Gynecology is working to define a subspecialty of gynecologists doing this sort of work as Urogynecology.

I have been interested in pelvic floor repair since my days as a Family Practitioner before I did my residency in Ob-Gyn. Gyn residencies in the early 80's had less information about pelvic floor repairs so I have had to supplement my training with conferences and courses over the years, taught by some of the finest urologists, gynecologists, pelvic surgeons and anatomists in the world. I have spent time teaching and learning pelvic anatomy with the medical students at UNC and I participate in programs and surgery with the divisions of Gynecology and Urogynecology where I am privileged to be an Associate Clinical Professor. Since giving up obstetrics in January 1998, Urogynecology has been the branch of gynecology that has interested me most and has occupied most of my studies and research. I believe that here in Burlington we have excellent facilities, staffed by physicians, physical therapists and nurses that allow the diagnosis and treatment of most of the people who suffer from urinary incontinence and pelvic floor defects.