Continence Coach: On the Alert for Pelvic Organ Prolapse

  Clinicians everywhere are involved in incontinence management. Non-specialists may focus on helping patients battle incontinence symptoms to safeguard skin from breakdown. Continence care practitioners may be occupied with assessment, diagnosis, and intervention for urinary incontinence — one in five of patients with stress urinary incontinence also presents with symptoms of fecal incontinence¹ and conversely, at least half of female patients with fecal incontinence will have stress urinary incontinence as well.² If you are the clinician, you are managing plenty of complex circumstances.

  In a relatively older, sedentary patient population, bladder and bowel control problems may be overlooked, compromising suspicion of pelvic organ prolapse. In fact, although at least half of all women who delivered vaginally represent cases mild enough to be considered asymptomatic, prevalence of prolapse is high.³ Unfortunately, one of the greatest obstacles to seeking treatment is the fact women are likely to accept and endure prolapse, even more so than incontinence, as a natural part of aging and a consequence of childbirth. As the condition advances, symptoms can become distressing, with uncomfortable perineal pressure, urinary retention and frequency, difficulty in defecating, lower back pain, chafing, bleeding of exposed tissue, and interference with intimate relations.

The Impact of Vaginal Delivery on the Pelvic Floor

  Using magnetic resonance imaging, researchers recently verified the link between levator ani muscle damage during childbirth to pelvic organ prolapse and fallen bladder.⁴ Women having forceps-assisted vaginal delivery were found to be twice as likely to have major levator ani defects with prolapse — vaginal birth confers a four to 11-fold increase in risk for prolapse among women,⁵ with episiotomy (surgical incision of the perineum) and forceps use major damage-causing culprits. Forceps-assisted deliveries are related to increased risk of sphincter tears and urinary and fecal incontinence; in addition, they have a negative impact on pelvic organ support.⁶ Of course, episiotomy is routine with forceps. Thankfully, we finally have moved beyond these non-evidence base-supported interventions. We’ve also ascertained the benefits of upright and lateral birth positions over the traditional lithotomy position⁷ and debunked the myth that strong pelvic floor muscles might obstruct labor.⁸ But an entire generation of women is still coping with the damage of misguided intervention — women 65 years and older are perhaps the most vulnerable to pelvic floor dysfunction leading to incontinence and prolapse.

Practice Changes

  Adopted as standard practice in the US as far back as 1920, performing an episiotomy during vaginal delivery is no longer recommended as liberally or routinely as it had been for decades. Median episiotomies (ie, a vertical incision into the midline of the perineum toward the anus), more commonly performed in the US than other parts of the world, are now strongly associated with anal sphincter laceration, post-partum pain, and other tears with no short- or long-term benefits.⁹ Until new guidelines were officially issued by the American College of Obstetricians and Gynecologists in 2006,¹⁰ episiotomy was considered the standard of care and performed in at least two thirds of all vaginal deliveries, leaving many women with numerous issues.

What Clinicians Can Do

  Practitioners need to be alert for risk factors for prolapse. When performing an assessment for incontinence, inquire about the possibilities for prolapse. Remember to check for rectoceles in connection with assessing bowel health and cystoceles when addressing urinary incontinence or incomplete bladder emptying. For older female patients especially, enhance your knowledge of pessaries as an option and obtain training in pessary fitting if you currently lack those skills in your continence care provider “toolbox.” We need to look after our mothers and grandmothers, providing them dignity and quality of life in their final decades.

The National Association For Continence is a national, private, non-profit organization dedicated to improving the quality of life of people with incontinence. The NAFC’s purpose is to be the leading source for public education and advocacy about the causes, prevention, diagnosis, treatments, and management alternatives for incontinence.

This article was not subject to the Ostomy Wound Management peer-review process.