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women's sexual anatomy problems

by Chris Steidle, MD

Symptomatic Pelvic Relaxation

While childbirth definitely has rewards, children do not arrive without lasting effects, both good and bad, on their mother. After childbirth, many women begin to have problems with loss of urine while coughing, sneezing, laughing or movement and a few even have difficulty maintaining rectal sphincter control. Childbirth or hard manual labor can also lead to prolapse of the uterus, bladder or rectum.

If a woman’s bladder begins to “drop” she may experience increased difficulty in both social and intimate situations. Fortunately, many women may experience only slight dropping of the bladder, called cystocele, without experiencing any loss of urine. When a woman’s urethra loses support, she will leak urine when the pressure on the bladder exceeds the capacity of the urethral sphincter to hold the urine back. This is often called stress incontinence. Many women notice this during coughing, sneezing or when they push or pull something heavy. Some women experience loss of urine while walking, especially when their bladder becomes full. Not only is the loss of urine a problem, but also the bladder can actually change its position enough so that it becomes somewhat of a barrier in the anterior portion of the vagina and makes penetration during intercourse more difficult.

In addition, women that experience loss of urine may suffer damage to their self-image and they may not feel that they can stay as clean as they would like to be. Both feelings can indirectly affect spontaneous intimacy. Women who lose urine during intercourse often begin to avoid the act entirely because of the embarrassment they feel.

Women with stress incontinence may benefit from a surgical repair if other such conservative measures as Kegel exercises, insuring that adequate estrogen levels are present, or biofeedback exercises do not work.

Urge incontinence, which may or may not be associated with an anatomical defect, is another indirect concern for many women in terms of their sexuality. Women who have detrusor muscle instability (urge incontinence) often may be getting up more than two times a night just to urinate. These women may lose urine even without an increase in anterior abdominal pressure and they become fearful of this happening in various situations. This condition can often be successfully treated with medication.

Uterine Prolapse

When symptomatic pelvic relaxation progresses until the uterus and cervix relax into the vagina or even sometimes outside the vagina, the potential for problems with intercourse become obvious. Often a patient complains about pressure when standing for long periods or that their partner is bumping something with deep penetration during intercourse. An examination may reveal that the cervix appears to be in a normal position when the woman is lying on the exam table. However, when she is asked to bear down, the cervix may progress to the vaginal opening and sometimes beyond. In this situation, a pessary (a rubber or vinyl-covered wire inserted into the vagina) can stabilize the patient until surgery can be performed. Once the cervix bulges beyond the vaginal opening, no training regimens are effective at bringing the organs back to their normal position.

In women that have had hysterectomies, the top of the vagina where the cervix once was may also be prone to bulge beyond the vaginal opening. This area is commonly referred to as the vaginal apex or vaginal cuff.

Women can have partial or complete inversion of the vagina to the point where the tissue bulges out beyond the vaginal opening and sometimes stays there. This is often the result of the small intestine pushing into the vagina to create a hernia called an enterocoele. These may occur by themselves or in combination with the bladder (cystocele) and or with the rectum (rectocele.) Many women can be effectively treated for these conditions with a pessary. Since women are living much longer and are more active in later stages of life, they may use a pessary initially and then later require more definitive surgical therapy. The repair of vaginal apex support can be performed either from a vaginal or abdominal approach. The vaginal approach is favored by many gynecologists because they can obtain good anatomical results and the patient does not have to endure the discomfort of an abdominal wall incision.

One method of repair is to use remnants of the utero-sacral ligaments, which are thickenings of connective tissue and not true ligaments. The utero-sacral ligaments extend from the base of the uterus and the cervix to the sacral area. Often these are plicated or brought together and shortened, and once the enterocoele or hernia sack is reduced, they can provide support to the vaginal apex.

Many women will benefit from having the top of the vagina attached directly to the right sacrospinalis ligament. This is a true ligament that extends from one bony process to another in the pelvis. The right side is most commonly used because using the left side often involves displacement of the sigmoid colon. Sacrospinalis ligament fixation of the vaginal apex is often done in conjunction with both an anterior (bladder) repair as well as posterior repair (rectocele).

When a woman has marked, genuine, stress incontinence many gynecologists see dramatic short term and long term improvement when a sling type procedure is used to support the urethra. This is either done by the gynecologist or in conjunction with a urologist that is familiar with women’s incontinence.

Rectocele is a herniation of the rectal bowel into the posterior side of the vagina, which also may present as tissue bulging outside the vaginal opening. For some patients, a rectocele bulging outside the vagina may be their only complaint and they have absolutely no difficulty expelling bowel movements. Other women may have much smaller rectoceles and yet they have many problems. Treatment of rectoceles involves a long term strategy including but not limited to avoiding constipation, possibly changing employment, and learning not to hold one’s breath when pushing, pulling or lifting. This may take many training sessions. Furthermore, women who smoke are advised to dramatically reduce or eliminate their smoking. Not only does smoking seem to weaken the tissue but also the accompanying “smoker’s cough” can be disastrous to surgical repairs. Many gynecologists prefer that the patient have her constipation evaluated and under control prior to any surgical repairs. In addition, patients that have experienced a progression of their pelvic relaxation condition should be counseled that their body is prone to this kind of problem and they must modify their life style at the same time as their surgical procedure to achieve the desired postoperative affect.

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Posted January 2000
Last Updated July 2008

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