Prolapse and incontinence

In short

  • Prolapse and incontinence happen when the pelvic floor — the muscles and connective tissue at the bottom of the pelvis — is not working properly.
  • Common symptoms: losing urine, bowel problems, a dragging feeling or a bulge at the vaginal entrance, and pain during sex.
  • Causes include pregnancy and childbirth, age, heavy physical work and inherited weak connective tissue.
  • Treatments include pelvic floor physiotherapy, a pessary (vaginal ring), medicines and — for severe symptoms — surgery.
  • Pelvic floor problems are common and nothing to be ashamed of. You can discuss everything at Gynaecologie Amsterdam.

What are prolapse and incontinence?

Prolapse and incontinence happen when the pelvic floor is not working properly. The pelvic floor — muscles and connective tissue around the urethra, the vagina and the anus — is shaped like a funnel and absorbs the pressure that builds up in your belly when you cough, sneeze, laugh or move. Many people have pelvic floor problems, such as trouble passing urine, bowel problems or pain during sex, but they are rarely talked about. Some people feel ashamed, or think that little can be done — there is no need for that.

The pelvic floor is the bottom of the pelvis. It consists of muscles and connective tissue that are connected to the organs. The pelvic floor has several functions:

  • it closes off the pelvis
  • it gives the pelvis stability
  • it keeps the organs in place
  • it has openings for the urethra, vagina and anus
  • it holds in urine and stool
  • it makes it possible for you to pass urine and stool
  • it makes sex possible
  • and it makes giving birth possible

The pelvic floor muscles are normally always slightly tensed. This tension keeps the urethra and bowel closed, so you can hold in urine and stool. The pelvic floor muscles are not only important for passing urine and stool, but also, for example, for having sex.

What causes prolapse and incontinence?

Most prolapse and incontinence problems come from pelvic floor muscles that are too weak or too tense. Weak muscles and connective tissue cannot close off the bladder and bowel properly or hold the organs in place, which can lead to urine and/or stool incontinence and to a prolapse of the bladder, uterus (womb) or rectum — often felt as a dragging feeling in the lower belly or back, or a bulge at the vaginal entrance, worse later in the day and after standing, walking or lifting. Overly tense muscles can cause belly pain, difficulty passing urine, bowel problems and pain during sex. Many women have several symptoms at once — and sometimes the cause lies elsewhere. The gynaecologist can assess whether a pelvic floor problem is the cause.

There are several possible causes of weak pelvic floor muscles.

Pregnancy and childbirth. Women can have problems with weak pelvic floor muscles during and after pregnancy. Under the influence of hormones, the connective tissue becomes more lax, and the pressure from the belly on the pelvic floor is higher during pregnancy. During childbirth, the pelvic floor muscles stretch to make the birth possible. This can damage the muscles, the connective tissue and the nerve tissue of the pelvic floor.

Age. Like other muscles, the pelvic floor muscles become weaker as you get older. After the menopause, the body produces fewer female hormones. Many women also use their pelvic floor muscles less intensively as they get older.

Heavy physical work, being overweight, frequent coughing and straining. Heavy physical work (such as lifting, carrying and standing for long periods), being overweight, and frequent coughing or straining increase the pressure on the pelvic floor. The high pressure stretches the muscles, which makes them weaker.

Inherited weakness of connective tissue. You may have a natural tendency towards weak connective tissue. Women with this tendency are also more likely to have varicose veins and groin hernias.

An overly tense pelvic floor can also cause symptoms in the hips or lower back, or pain radiating into the thigh. It is most common in young and middle-aged women. Girls and women who have negative feelings about their lower body may unconsciously tense their pelvic floor muscles too much. This is called overactivity. Overactivity of the pelvic floor muscles is more common in women who have had distressing sexual experiences. It can also develop as a reaction to pain — for example after a complication from an operation, or after a vaginal infection. But women without any of this history can have overactive pelvic floor muscles too. Quite often, the cause of the overactivity remains unclear.

Pain or other symptoms low in the pelvis and back are not always caused by pelvic floor muscles that are too tense or too weak. Other common causes are:

  • problems with muscles and/or joints (such as complaints of the back, hips or tailbone)
  • bowel problems
  • bladder problems
  • abnormalities of the uterus or ovaries
  • psychological trauma and stress

Which bladder problems can incontinence and pelvic floor problems cause?

Pelvic floor problems can cause many urinary symptoms: losing urine when you cough, jump or stand up; not being able to hold urine in (incontinence); not emptying the bladder properly; a constant or very frequent urge; and bladder infections (cystitis). The most common forms are described below.

You may lose urine when, for example, you sneeze, lift something, exercise or stand up quickly. This is called stress incontinence (or exertion incontinence). Sneezing, lifting or standing up quickly causes a sudden rise in pressure in the belly, and so on the bladder. If the pelvic floor muscles are not doing their job properly, this sudden pressure can make you lose urine without wanting to.

Several treatments are possible. You can train the pelvic floor muscles with pelvic floor physiotherapy, or you can have an operation to repair the pelvic floor support. A decision aid for stress incontinence can help you prepare the conversation with your doctor, so that together you choose the treatment that suits you best.

Urgency incontinence (also called urge incontinence) means that you very suddenly get the urge to pass urine. This urge comes on so suddenly and so strongly that you may not reach a toilet in time. The urge can be triggered by, for example, hearing running water or opening the front door — you associate these with passing urine and can no longer hold it in.

If you have this, pelvic floor physiotherapy can help you train the pelvic floor muscles. You can also take medicines that keep this urge under control, for example Vesicare or Betmiga. These medicines calm the bladder muscle, so that you can postpone passing urine and empty the bladder more completely. How well they work varies from person to person: for some people they work very well, for others not at all. You need to take the medicine for at least six weeks to know whether it works for you. The most common side effect is a dry mouth.

With mixed incontinence you have both stress incontinence and urgency incontinence. For this combination, too, pelvic floor physiotherapy or medication can help. The same medicines are used as for urgency incontinence (for example Vesicare or Betmiga), with the same six-week trial period and the same possible side effect of a dry mouth.

If you very often feel the urge to pass urine, you may have an overactive bladder. With an overactive bladder, the bladder signals too early that you need to go, even though it is not yet full. This can mean you pass small amounts of urine very often. An overactive bladder can go together with unwanted urine loss, but not always.

An overactive bladder can be treated with bladder training, in which you are given exercises to postpone passing urine. Medicines that slightly relax the overstimulated bladder are also possible — the same medicines as for urgency incontinence (for example Vesicare or Betmiga), again with a trial of at least six weeks and a dry mouth as the most common side effect.

Passing urine is also called “emptying the bladder”. It can happen that you do not pass all the urine and some stays behind in the bladder. This is called a bladder-emptying (voiding) problem. If you have this, you may lose urine when, for example, you stand up from the toilet after passing urine. In other cases it may become impossible to pass urine at all.

A voiding problem can have several causes:

  • a pelvic floor that is too tense
  • an incorrect voiding technique

A pelvic floor physiotherapist can help. They can teach you to pass urine in a relaxed way and to truly empty the bladder. A prolapse of the front vaginal wall can also cause a voiding problem; in that case a pessary (vaginal ring) or an operation for the prolapse can help.

When there are problems with the closing muscle (sphincter) and the bladder muscle, you can develop an overflow bladder. This means the bladder is overfull. With an overflow bladder you can also lose urine without wanting to.

Pelvic floor physiotherapy can help: you learn in which position(s) to pass urine, and the physiotherapist can help you pass urine at fixed times to prevent an overflow bladder. If a large prolapse is the cause, a pessary or an operation can help.

If the bladder muscle and sphincter no longer work properly and the bladder gets too full, a catheter may be needed. This is a thin plastic tube that is passed into the bladder through the urethra. An indwelling catheter stays in the bladder for a longer period (days to weeks) and has a bag attached to collect the urine, which you can empty regularly. The doctor may also advise you to empty the bladder yourself with a catheter several times a day. This is called intermittent catheterisation, and a nurse teaches you how to do it.

Can pelvic floor problems cause bowel and sexual problems?

Yes. Bowel symptoms include unwanted loss of stool or wind, a strong urge you cannot postpone, a false urge, constipation, and not being able to pass all the stool. Sexual problems include less sensation during sex, losing urine during sex or at orgasm, and pain during sex.

You are constipated if you open your bowels fewer than three times a week, or if the stool is hard and pellet-like.

Constipation can be caused by:

  • a diet with too little fibre or too little fluid
  • holding in stool too long, so that it thickens and hardens
  • a side effect of medicines

There are several things you can do yourself against constipation:

  • get enough exercise
  • eat plenty of fibre and raw vegetables
  • drink enough: 1.5-2 litres a day

If this does not help, a doctor can prescribe laxatives. These make the stool thinner and softer, so it is easier to pass. It is sometimes said that laxatives make the bowel “lazy”, but that is a myth: laxatives do not cause dependence and the bowels do not become lazy from them.

Opening your bowels is also called “emptying the bowels”. With an emptying problem, you cannot pass all the stool, so stool stays behind in the bowel. This causes constipation, with symptoms such as:

  • belly pain
  • days without a bowel movement
  • hard pellets
  • small amounts of thin stool getting past a blockage

The cause can be a prolapse of the back vaginal wall (rectocele): the connective tissue between the vagina and the bowel is weakened, so stool passes less easily out of the last part of the bowel and you constantly feel that you need to go. Some women can open their bowels but still lose a little stool when they stand up from the toilet, or shortly afterwards.

Several treatments are possible. Treatment can consist of dietary advice, toilet advice and learning to relax the pelvic floor. You can also be given medicines to soften the stool, making it easier to empty the bowels completely when you go to the toilet.

Loss of stool is a collective name for all kinds of problems with controlling the bowels. It can range from not being able to hold in wind to losing liquid or solid stool. It may happen without you noticing it, or you may feel a very sudden urge and not reach a toilet in time. Further investigation can show where the problem lies (the bowel, the pelvic floor muscles or the connective tissue) and point to a possible treatment.

You can have a very strong feeling that you need to open your bowels, but when you sit on the toilet nothing comes. This is called a false urge. It can be caused by the small bowel dropping down into the pelvis: the small bowel presses against the last part of the bowel, which gives the feeling that you need to go even when there is no stool. This type of prolapse is called an enterocele. An operation can correct it.

Pelvic floor problems can lead to sexual problems, such as less sensation during sex, losing urine during sex or at orgasm, pain when the penis enters the vagina, and pain during sex.

These problems have several possible causes. Pelvic floor muscles that are too tightly tensed can make sex painful. It can also be that the vagina does not get enough blood flow and stays too dry — women in or after the menopause have this more often. Sex with a vagina that is too dry can hurt, and the pleasure in sex can fade as a result.

Several treatments are possible:

  • If the vagina is dry because the lining has become thin (during and after the menopause), the doctor can prescribe oestrogens. These are hormones applied in the vagina as a cream or pessary (vaginal tablet), and they strengthen the lining.
  • A pelvic floor physiotherapist can teach you how to relax the pelvic floor muscles and make you aware of how they work.
  • A sexologist can help you learn to deal with sexual problems. Some women find a way to cope with the symptoms together with their partner; sometimes it is hard to talk about it together. Women often have sex less often than they would like, while others have sex despite the pain because they feel they owe it to their partner. A sexologist can give advice that can increase the pleasure in sex for you and your partner.
  • If sexual problems go together with more serious psychological problems, you can also see a psychologist.

What types of prolapse are there?

With a prolapse, the pelvic floor muscles and/or connective tissue no longer work properly and the organs sink down into the pelvis. A larger prolapse can be visible as a small bulge between the labia, often easier to see when you bear down a little. A GP, gynaecologist or pelvic floor physiotherapist can confirm a prolapse with an internal examination; treatment depends on how severe the symptoms are.

The front of the vagina has dropped down into the pelvis. The front wall is the tissue between the urethra/bladder and the vagina, so the bladder can drop down with it. The medical term is a cystocele.

The back of the vagina has dropped down into the pelvis. This is the tissue between the vagina and the last part of the bowel; often that last part of the bowel has dropped with it. The medical term is a rectocele.

This is a type of back wall prolapse. The small bowel drops down from the belly between the back of the vagina and the last part of the bowel. From the outside it looks the same as a back wall prolapse. The medical term is an enterocele.

The uterus has dropped down into the vagina. If the prolapse is severe, the cervix can be visible between the labia at the entrance of the vagina, or the uterus (or cervix) can come outside.

If the uterus has been removed, the top of the vagina (the vaginal vault) can still prolapse.

The rectum is the last part of the bowel, just above the anus. It can prolapse in two ways: through the vagina or through the anus. With a prolapse through the vagina, a small bulge is visible at the back of the vagina. With a prolapse through the anus, part of the bowel comes out a little when you strain to open your bowels.

When should you see a gynaecologist about prolapse or incontinence?

Pelvic floor problems are not dangerous, but they can be a real nuisance in daily life. Many women do not dare to talk about them and feel alone with them. That is exactly why it matters to discuss them: your GP can refer you, and the gynaecologist can give you support or refer you to a specialised nurse, sexologist, pelvic floor physiotherapist or psychologist.

How much your symptoms affect you depends on the type of symptoms, how severe they are, whether they stop you doing things, and how you cope with them — this is different for everyone. Your GP can refer you either to a regular gynaecology clinic or to a specialised pelvic floor clinic.

Adjusting your lifestyle. Many women who lose urine plan their daily life around it: taking spare clothes with them, keeping track of where the nearest toilet is, or deliberately drinking less on days when they are out a lot. On top of the physical problems, stress and shame can cause psychological problems. The symptoms can be so severe that some women stop certain activities altogether, such as travelling, visiting family and other outings.

Problems at work. The possibility of something going wrong in company can make you very insecure. An accident at home is unpleasant, but at work it can feel even worse. This can lead some women to stop working or change jobs.

Problems with sex. Losing urine during sex can be very unpleasant and embarrassing. It can hold you back, and your pleasure in sex can fade. Sometimes women do not actually lose urine during sex, but the fear that it might happen is enough to stop enjoying sex or stop having it. Pain during sex caused by pelvic floor problems can also take away the pleasure.

If you notice you are going through an emotionally difficult time, discuss it with the GP, gynaecologist, pelvic floor physiotherapist, sexologist or nurse. They can give you extra support or refer you to a psychologist.

How are prolapse and incontinence examined and treated?

In the first consultation you describe your symptoms, and the gynaecologist asks about your wishes and expectations. Usually an internal examination is done, sometimes with a vaginal ultrasound. For prolapse symptoms you can usually choose between watchful waiting, a pessary (vaginal ring) and an operation; a decision aid can help you weigh the pros and cons with your doctor. Pelvic floor physiotherapy helps with many bladder, bowel and prolapse symptoms, and for urgency symptoms medicines are possible.

In the first consultation the gynaecologist asks questions to understand your symptoms better. Important topics are whether you have other gynaecological symptoms, have had illnesses or medical procedures in the past, have problems passing urine, have bowel problems, or have sexual problems.

If you have never had sexual contact, or have had distressing sexual experiences, it is good to tell the gynaecologist. The gynaecologist will take this into account during the physical examination, or may decide not to do a physical examination at the first visit.

Questionnaires and a bladder diary. To get more insight into your problems, the gynaecologist may ask you to fill in a special questionnaire. If you lose urine, the specialist may also ask you to keep a bladder diary.

Gynaecological examination. You are asked to lie in the gynaecological chair, with your legs apart in the supports. This gives the gynaecologist a view of the vagina to see whether a prolapse is visible. The gynaecologist feels in the vagina and anus for a prolapse, then inserts a speculum and asks you to bear down. This shows where a possible prolapse is coming from and how large it is. The gynaecologist or pelvic floor physiotherapist can then assess the pelvic floor muscles by feeling with two fingers in the vagina: you are asked to tense and relax the pelvic floor muscles, and also to cough and bear down. When needed, the function of the anal sphincter can also be assessed, by inserting a finger into the anus and asking you to tense and relax the anus.

Vaginal ultrasound. Sometimes a vaginal ultrasound is done at the first visit. This uses an ultrasound probe: a thin, elongated wand that is covered with lubricant and inserted through the vagina. It lets the gynaecologist see inside the pelvis and rule out a growth in the belly as the cause of your symptoms. The gynaecologist may also choose to do an external ultrasound over the lower belly: gel is applied to the skin and the probe is moved over the belly to look at the uterus and ovaries.

The gynaecologist can also refer you to another doctor — for example a urologist for urinary or bladder symptoms, or a gastroenterologist or bowel surgeon for bowel symptoms. If further tests are needed — for example a uroflow test, a cystoscopy or a defecogram — or if an operation is needed, Gynaecologie Amsterdam refers you on.

For further assessment and treatment you can be referred to a pelvic floor physiotherapist, who does a more extensive examination to judge whether pelvic floor physiotherapy can help.

  • External examination. The pelvis, back and hips are examined to see whether the pelvic floor problems are related to the joints around the pelvic floor muscles.
  • Internal examination. With one or two fingers in the vagina, the physiotherapist feels whether the pelvic floor muscles work well, assessing their strength and stamina. You are asked to tense the muscles and to bear down, to pretend you are holding in urine, and to cough. This lets the physiotherapist feel whether the pelvic floor closes off the urethra properly.

During the external and internal examination, the physiotherapist also checks for painful points in the pelvic area. Together, these examinations give a complete picture of whether the pelvic floor muscles are too tense or too weak. Afterwards, the gynaecologist and pelvic floor physiotherapist at Gynaecologie Amsterdam discuss the findings together.

For a front or back wall prolapse, it is possible to place a ring that keeps the uterus in place. The ring is made of a flexible material (silicone). Pessaries come in different types and sizes for different kinds of prolapse. With the ring in place, the uterus and bladder stay in position better and the prolapse symptoms are relieved. A ring is not suitable for everyone.

Whether a ring is an option for you depends on:

  • the type of prolapse
  • how firm the pelvic floor is
  • your individual anatomy
  • your personal preference between the different treatments

After a pessary is placed, the vaginal wall can become irritated by the pressure of the ring. This can cause discharge, bleeding and/or pain. If the ring bothers you, there are several solutions: a different type or size of ring may fit better, or the gynaecologist can prescribe oestrogens (female hormones) as a cream or vaginal tablet to make the vaginal wall firmer.

A pelvic floor physiotherapist explains the position and function of the pelvic floor muscles and the organs in the pelvis, and gives a range of advice, such as:

  • the right toilet postures
  • advice on drinking and diet
  • advice on training the pelvic floor muscles
  • exercises to tense and relax the pelvic floor for sexual problems

The physiotherapist can feel internally whether you are using the right muscles, or use equipment such as myofeedback. Myofeedback measures the strength and duration of the muscle contraction, so you can feel and see better what you are doing with your pelvic floor. This helps, because for many people it is difficult to consciously feel what is happening in the pelvic floor.

For severe symptoms caused by prolapse and/or urinary incontinence, an operation can be the answer. Gynaecologie Amsterdam will then refer you. You can read up in advance on the pros and cons of each treatment; a prolapse decision aid can help you with this.

Frequently asked questions

How do I know if I have a prolapse?

A prolapse can give a dragging feeling in the lower belly or back, or a small bulge between the labia, often worse later in the day and after standing, walking or lifting. A GP, gynaecologist or pelvic floor physiotherapist can confirm it with an internal examination.

Can urinary incontinence be treated without surgery?

Yes, often. Pelvic floor physiotherapy trains the muscles, medicines such as Vesicare or Betmiga calm an overactive bladder, and a pessary (vaginal ring) relieves prolapse symptoms. Surgery is an option for severe symptoms.

Is a pessary (vaginal ring) suitable for everyone?

No. It depends on the type of prolapse, how firm the pelvic floor is, your anatomy and your personal preference. If a ring irritates the vaginal wall, a different type or size may fit better, or oestrogens can make the vaginal wall firmer.

Related care

Ask your GP for a referral, then make an appointment.

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