Functional Constipation: Types and Diagnosis

Constipation

Surgery for Diastasis Rectus Abdominis

What if exercise alone isn't enough to heal DRA?

What makes you more likely to have DRA?

What are the best exercises for postpartum diastasis rectus abdominis (DRA)?

What is Diastasis Rectus Abdominis? Aka DR/DRA/Di-recti?

Prolapse Surgeries, Part II This article is a follow-up to a Part 1 article I wrote on prolapse surgeries, where I covered a lot of FAQs about who needs surgery and why. In this article, we'll cover the nitty gritty of surgeries, including the different types of surgeries and recovery times, etc. We won't rehash what I mentioned last time, so if you have questions about who might need surgery, and how successful surgery generally is or isn't, please revisit the past article! What types of prolapse surgeries are there? There are two types of surgeries. For most people who are patients at Pelvic Love and who are reading this article, they will have a type of surgery that preserves the ability to have vaginal intercourse. There is another type of surgery that closes off the vagina, but then of course after that, you are no longer able to have intercourse. So that is typically reserved for elderly people with vaginas, as this type of surgery has the highest cure rate for prolapse. But of the types of surgeries that leave the vaginal canal open, there are many options depending upon the type of prolapse. Does surgery vary based on the type of prolapse? Yes! For bladder prolapse, the most common type of surgery is called anterior colporrhaphy . In this procedure, the front wall of the vagina underneath the bladder has sutures placed in it to help reinforce the original position of the bladder. For rectocele (rectal prolapse into the vagina), the most common type of surgery is a posterior colporrhaphy . This also involves placing sutures on the backside of the vaginal wall to help keep the rectum in place. Sometimes this is also done in combination with a repair of the perineal body (the area between the vagina and anus), aka perineorrhaphy. What about uterine/cervical prolapse? This gets a little tricky. Many times, if you are done having children and your prolapse is more advanced, you may be advised to have a hysterectomy . However, there are other options that will allow you to keep your uterus. These surgeries are a little more complicated to explain, but if you click this link , you'll find them explained well. Basically they all involve some method of re-suspending the uterus and the cervix by using either stitches or mesh (NOT the mesh that is involved in so many lawsuits!). If you do opt to have a hysterectomy, then as you may imagine, this can place you at a higher risk of bladder and/or bowel prolapsing (if they have not already done so). The uterus takes up a fair amount of space inside the pelvis, so if you remove it, that leaves empty space for other organs to fall into. If I do have a hysterectomy, what are my options to avoid future issues with prolapse? This is the one topic for which I will drag out my soapbox. If you do have a hysterectomy, and it is an option for you, I would HIGHLY recommend your surgeon re-suspends the vaginal vault as part of your surgery . The vaginal vault is the apex of the vagina, and where the vagina is sewn shut after the uterus/cervix is removed. Many surgeons will just stop here and allow the top of the vagina to essentially scar in place. However, as you can imagine, when you remove a major internal organ, then you are also removing (or slackening) a lot of ligaments & fascia that support that organ and others! So this places the top of the vagina at a much higher risk from prolapsing in the future, and/or the bladder and bowel falling into the vagina. Please note, these "extra" steps to support the top of the vagina during a hysterectomy are not available to everyone . They do require more time under anesthesia, potentially greater skill from your surgeon, and the structures the vaginal vault is being sutured to are still intact. For example, I had a friend that had severe endometriosis and had a hysterectomy at 40 years old as a result. Her endometriosis was so advanced, and so many lesions had to be removed from inside the pelvis, that this didn't leave her surgeon with an option for a good place to suspend her vaginal vault. So even though I would recommend you discuss this with your surgeon, it's not an option for everyone. What are the options for suspending the vaginal vault after hysterectomy? There are many places from which the vaginal vault can be suspended after the uterus/cervix are removed. There are too many to go into detail in this format, but all have their pluses and minuses. The main options are the uterosacral ligament , sacrospinous ligament , and the sacrum itself . More general information can be found in this handout . What is recovery like after these types of surgeries? Every surgeon is different, but here are some general guidelines for recovering from a hysterectomy or prolapse repair. And YES, many times there is more than one repair being done at a time! Or a hysterectomy may be combined with an anterior and/or posterior vaginal wall repair, for example. Most often, you will have a catheter in place for anywhere from 8-24 hours after surgery (potentially longer for a bladder repair). And generally, your hospital stay is very short. Typically you need to take anywhere from 2-6 weeks off work. Around 2-3 weeks you can resume driving and taking short walks. And no sex (vaginal penetration) is allowed for 6 weeks. It's also important to remember that because these are very delicate tissues, they are not fully healed for THREE MONTHS. So, for quite some time you will likely have restrictions on heavy lifting. Have even more questions about your pelvic floor in general, or prolapse specifically? Here are two great websites for more info on all kinds of pelvic floor-related issues, not just prolapse: International Urogynecological Association handouts American Urogynecologic Society fact sheets References: All information contained in this post is aggregated from the handouts linked throughout the text.

Prolapse Surgeries, Part I Whew, surgery for prolapse is a big topic. So much so that I'm splitting it into two articles to avoid overloading your eyeballs and brains! Today we'll spend time discussing the whys and who's surrounding surgery. Then next time we'll get into the details of types of surgeries, recovery times, etc. If I have prolapse, do I definitely need surgery? In a word, no. Or at least, most likely not. I wanted to get this question out of the way first, because I think prolapse can be a very scary diagnosis when you are first told you have it. Then, your brain (or at least mine!) jumps to the most extreme outcome, which would be surgery. As we discussed in a past article about the best exercises for prolapse, pelvic floor muscle training and core strengthening can be a really effective treatment for prolapse. It can relieve your symptoms, delay/prevent the need for surgery, and potentially even reduce the grade of your prolapse. Plus, pessaries are another great non-surgical option that can prevent or delay the need for surgery too (if the idea of a pessary is new to you, check out my past article on pessaries). So, especially if you are newly diagnosed with prolapse, don't jump to the thought that you will have to have surgery someday! Who does need surgery for prolapse? Indications for prolapse surgery are the following: Significant "bother" of symptoms (vaginal heaviness/pressure, associated bowel/bladder symptoms, difficulty/pain with intercourse, etc) "Failed" a good trial of conservative treatment - PT/pelvic floor muscle training, pessaries, etc. that does not satisfactorily resolve symptoms Completed childbearing Typically more-advanced prolapse grades (3-4), unless with lesser grades the symptoms are severe and not responding to conservative treatment If your prolapse is mild (grade 1-2), you are going to have more children, or have other medical conditions that would make surgery difficult, then you can/should avoid it! Typically the biggest differentiator regarding the need for surgery is if the prolapse extends beyond the hymen, or external to the vagina. Conservative treatment is less likely to be successful (but not always, of course!) in cases where the prolapse is external to the vaginal opening. More often than not, surgery will eventually be needed to resolve symptoms. But, that doesn’t mean a good trial of conservative treatment isn’t a good idea! How common is prolapse surgery? It is pretty common, at least with age. If you have a uterus/vagina, you have a lifetime risk of 11-20% of undergoing surgery for prolapse or stress incontinence. By age 80 the risk is 20%. How successful is prolapse surgery? It is very successful, especially in the short term! Success rates are generally around 80-90%, especially within the first 2 years following surgery. However, it is true generally that the further away you get from surgery, the more likely your prolapse may return. And we don't have a lot of high-quality studies that follow people after prolapse surgeries beyond 2 years (many stop around 6-12 months). The other caveat here is how we define "success." There is a BIG difference between restoring your anatomy (i.e., reducing the organ back to its original position, and having it stay there) and improving your symptoms. Around 5 years post-op, the majority of repairs will have "failed" in terms of anatomy. Meaning that if someone did a vaginal examination, the prolapse will have returned (although potentially not to the same degree that it was present before). However, even in these cases, the symptoms are still reported to be much better, and happiness with surgery outcomes is still high. So this is further proof that the degree of prolapse isn’t always equal to the severity of symptoms and that more research is definitely needed. Why do prolapse surgeries fail? There are a lot of reasons. The biggest one is that the tissues surgeons are trying to repair are very delicate. There's a really fine line between suspending an organ via it's own ligaments, or using mesh, with just enough tension vs. using too much tension. So it's always a balance between fixing the original problem without causing further complications. The other is that many times, the original cause of the prolapse has not been corrected. As I discussed at length in my intra-abdominal pressure article, prolapse really is a top-down problem more than a bottom-up problem. In fact, one recent study that looked at outcomes 5 years after prolapse surgery found no difference between those who did and did not do post-operative pelvic floor muscle training (Jelovsek 2018). Essentially, pelvic floor muscle training did not stop the prolapse from returning. So if you still are doing a lot of heavy lifting, have continued constipation, or are just genetically predisposed to having prolapse, there is a high likelihood it will return because there is still a lot of top-down pressure on your internal organs. It's important to note though, as I stated above, generally, your symptoms still remain improved even if the prolapse itself returns post-operatively. Although of course, some people will need to have a second surgery. This is also why it's best to delay surgery for as long as possible. Should I have prolapse surgery? This is obviously a very personal decision, and depends upon a lot of factors! I think the biggest takeaways here are that you should try PT, pelvic floor & core exercises, and/or pessaries first. Pelvic Love also fits in well with these exercise recommendations, and has some specific videos for prolapse! All of these things are recommended to be the first-line interventions for prolapse and can help the majority of people who are living with prolapse. If that doesn't work for you, or for whatever reason your surgeon determines surgery is the best route right away, then definitely consider it.  It can be very successful, especially for symptom improvement! As with any surgery though, I would always recommend getting at least 2 opinions before deciding to move forward. And I would highly recommend at least one of those opinions come from a urogynecologist or colorectal surgeon depending upon your needs. The next article will discuss different options for prolapse surgeries, so be sure to check that one out! References: Bureau, M., & Carlson, K. V. (2017). Pelvic organ prolapse: A primer for urologists. Canadian Urological Association journal = Journal de l'Association des urologues du Canada , 11 (6Suppl2), S125–S130. https://doi.org/10.5489/cuaj.4634 Dumoulin, C., Hunter, K. F., Moore, K., Bradley, C. S., Burgio, K. L., Hagen, S., Imamura, M., Thakar, R., Williams, K., & Chambers, T. (2016). Conservative management for female urinary incontinence and pelvic organ prolapse review 2013: Summary of the 5th International Consultation on Incontinence. Neurourology and urodynamics , 35 (1), 15–20. https://doi.org/10.1002/nau.22677 Jelovsek, J. E., Barber, M. D., Brubaker, L., Norton, P., Gantz, M., Richter, H. E., Weidner, A., Menefee, S., Schaffer, J., Pugh, N., Meikle, S., & NICHD Pelvic Floor Disorders Network (2018). Effect of Uterosacral Ligament Suspension vs Sacrospinous Ligament Fixation With or Without Perioperative Behavioral Therapy for Pelvic Organ Vaginal Prolapse on Surgical Outcomes and Prolapse Symptoms at 5 Years in the OPTIMAL Randomized Clinical Trial. JAMA , 319 (15), 1554–1565. https://doi.org/10.1001/jama.2018.2827 Weintraub, A. Y., Glinter, H., & Marcus-Braun, N. (2020). Narrative review of the epidemiology, diagnosis and pathophysiology of pelvic organ prolapse. International braz j urol : official journal of the Brazilian Society of Urology , 46 (1), 5–14. https://doi.org/10.1590/S1677-5538.IBJU.2018.0581

What are Pessaries, and How Do They Work? Pessaries can be awesome, and they can also be really frustrating. But for many people with prolapse, they can be real game-changers! They can improve your symptoms immediately, delay/prevent the need for surgery, and allow you to get back to activities that would normally cause leakage or discomfort. But like any treatment there are upsides and downsides, so let's dive in. What are pessaries? Pessaries are prosthetic devices (like orthotics) that are placed inside the vagina to support the internal organs. They come in MANY shapes and sizes depending upon which organ(s) need(s) support, and what symptoms need improving. They are generally made of silicone but can be made of other medical-grade materials too. My favorite analogy about pessaries is that they are like a sports bra for your internal organs! So there is no shame in needing to use one, especially for higher-impact activities. And just like a sports bra, they don't make the surrounding muscles weaker, they just provide you a little lift right where you need it. Fun fact, pessaries have been around since at least 400 BC. People used to put ALL kinds of things inside vaginas to support the internal organs...my favorite is half a pomegranate soaked in wine as described by Hippocrates! What can pessaries help with? Pessaries help lift organs back toward their original position when they have started to shift due to pelvic organ prolapse. But, pessaries also help control symptoms typically associated with prolapse, like urinary incontinence and pelvic pressure. One of the number one indications for a pessary also is stress urinary incontinence, which most people don't know! So even if you only have stress incontinence with exercise, but don't necessarily have a prolapse, a pessary can still help you. Most of the time we think that pessaries are just helping to decrease symptoms while the pessary is in place. But, there is some emerging evidence to show that regular pessary use can actually improve the grade of the prolapse. This is because the pessary can reduce the strain on the prolapsed organ's ligaments, and then over time those ligaments may shorten and provide better support to the organ. Do they really work? Yes!! Pessaries have a high acceptance rate of over 70% (Vasconcelos 2020). And it's been established in multiple studies that pessaries in combination with pelvic floor muscle training is very effective, more so than either alone (Bugge 2020). Plus, once they are fit well, pessaries generally are a good long-term option. 60% of people are still using their pessaries after 2 years from the initial fitting (Mao 2019). The combo of pessaries and pelvic floor exercises can really make sense when you think about the pressure that a prolapsed organ can place on the pelvic floor. If you always have something pushing down against a muscle you are trying to work, it will be much harder for you to engage/activate that muscle. So, with a pessary in place, your pelvic floor can engage much better and get stronger more easily than without it! Are pessaries helpful for all types of prolapse? Not necessarily - this is the big bummer about pessaries. Pessaries can be incredibly effective for bladder and uterine prolapse. However, for rectoceles (rectum falling into the vagina), pessaries are very hard to fit and much less effective. This is because most pessaries for the bladder and uterus will pop in place by sitting behind the pubic bone. The pubic bone and pelvic floor will act like a little "shelf" to help hold it in place. But, for the backside of the vagina (the rectum), there isn't anything for the pessary to rest against. It doesn't mean that if you have a rectocele you can't find a pessary that works for you, but just remember that it might be a longer and more frustrating process than average. And in the end, you may decide you are better off without a pessary than with one. Who might need a pessary? A pessary can be helpful for you if you: have pelvic organ prolapse have stress incontinence do not need or do not want to have surgery need surgery but are unable to undergo surgery for medical reasons, or because you aren't done having children yet (and yes you can use pessaries while pregnant!) Who may not do well with a pessary? If you fit any of these criteria, a pessary may not be for you: are a smoker have a shortened vaginal length from radiation or any other medical procedures have had prior vaginal surgery have had a pelvic floor avulsion during childbirth (not a typical tear, but where the pelvic floor muscle is pulled off the pubic bone) have fragile vulvar tissues or are otherwise prone to skin breakdown Aren't pessaries just for old ladies? Absolutely not! Anyone can use a pessary at any age and at any stage of prolapse. As we've discussed before, the stage/severity of prolapse and the symptoms of prolapse don't necessarily match. So some people have very minimal prolapse with very severe symptoms, while others can have advanced prolapse with little to no symptoms. So, especially if you've already worked on your pelvic floor, go to PT, etc etc ,and are still struggling with prolapse and/or stress incontinence symptoms, a pessary may be really helpful for you. The bonus to being younger and using a pessary is that it typically means you’ll have an easier time inserting and removing the pessary on your own. Some older people, or generally people with arthritis or limited mobility, can’t reach their vagina well. Or, they may have trouble with the finger dexterity needed to put the pessary in or take it out. So if you don’t live with arthritis or limited mobility and only have symptoms with exercise, you can put the pessary in for exercise and take it out when you are done. Or you can remove it for intercourse and put it back in afterward without a big hassle. And some pessaries you can even leave in for intercourse depending upon their shape and size. How do I insert them, and what do they feel like? Pessaries are really similar to menstrual cups and discs in this manner as most of them are very flexible. You typically squeeze them between your fingers, slide them in vertically, and then they pop into place behind the pubic bone. Once they are inserted, you shouldn't feel them. Other types of pessaries that are called "space-filling" pessaries (like cube pessaries) rely on suction to stay in place. These do not compress in your hand. So those you push up into the vaginal canal like a tampon, and then they will stay in place on their own. What about cleaning? This is a great question and you may get different advice depending upon your sources! The difference here really relies upon whether or not you can insert and remove your pessary on your own. If you are able to do so, then it's recommended you take it out and clean it with soap and water about 1-2x/week. However, I've also heard the argument that if you are only doing it 1-2x/week you are likely to forget! So every day may be best. And if you do have sex with it in, you need to take it out and clean it afterward. If you cannot remove it on your own (especially if you have arthritis in your hands, or otherwise have some limitation with upper extremity mobility), then you do need to visit your doctor once every 3 months to have it removed, cleaned, and re-inserted. Where and how do I get a pessary? Most gynecologists (GYNs) have the ability to fit pessaries. However, depending upon their individual experience they may not feel comfortable fitting all types of pessaries, or may not have a lot of options for you to choose from. So, as I've said in previous posts you may want to see a urogynecologist if you have trouble fitting your pessary, or don't do well with the one your GYN gave you. The good news is that PTs can now fit pessaries too! However, this is very new to the PT scope of practice (at least in the US), so not many PTs are offering this service yet. But if you think about it, it makes sense for PTs to fit pessaries. We have the luxury of spending more time with patients, so we can make sure to get the exact right fit. Plus since we have more space we can usually have you stand up, walk around, even jump or run, etc to make sure it stays in and is comfortable. And we already have experience with things like foot orthotics, so this is just like a foot orthotic for your vagina! I'm excited to see more and more PTs be able to offer this service to their patients. Most of the time pessaries are covered by insurance, but like most things in women's health care, this can be variable. So if you have questions about coverage, make sure to discuss it with your provider, or even better call your insurance company ahead of time. Bottom line Pessaries often get a bad rap or are not thought of for most of us who are younger with prolapse and/or incontinence. But they can be SO helpful, and really should be the first line intervention after pelvic floor exercise/PT for prolapse and stress incontinence! They are pretty cost-effective (certainly less than surgery and PT), don't limit your future options (unlike surgery), and can always be removed and/or changed in size if they become uncomfortable. In fact, it's pretty normal to have to change sizes over time if you use a pessary long-term.  Want even more info? Check out some great handouts on pessaries by different urogynecological professional organizations here and here . References: Bugge, C., Adams, E. J., Gopinath, D., Stewart, F., Dembinsky, M., Sobiesuo, P., & Kearney, R. (2020). Pessaries (mechanical devices) for managing pelvic organ prolapse in women. The Cochrane database of systematic reviews , 11 (11), CD004010. https://doi.org/10.1002/14651858.CD004010.pub4 Mao, M., Ai, F., Kang, J., Zhang, Y., Liang, S., Zhou, Y., & Zhu, L. (2019). Successful long-term use of Gellhorn pessary and the effect on symptoms and quality of life in women with symptomatic pelvic organ prolapse. Menopause (New York, N.Y.) , 26 (2), 145–151. https://doi.org/10.1097/GME.0000000000001197 Vasconcelos C, Gomez M, Geoffrian R ,et al. Pessary evaluation for genital prolapse treatment: From acceptance to successful fitting. Neurourology and Urodynamics. 2020;39:2344–2352.