Ask an expert about prolapse and pelvic floor problems (UCLH web chat) 

Pelvic floor problems are a silent epidemic - up to 20-30% of women are affected by a prolapse, and many more experience general pelvic floor problems.  Symptoms are wide ranging and life changing – difficulty in emptying bladder and bowel, recurrent urinary infections, difficulty with intercourse and backache are just some of the symptoms that blight the lives of many women. 

Our expert Mr Arvind Vashisht is a consultant gynaecologist who specialises in treating women with pelvic floor problems, including prolapse, as well as symptoms resulting from child birth at the Elizabeth Anderson Wing at University College Hospital.  His research interests include minimal access, laparoscopic and vaginal surgery.  If you had any questions about this topic - whether prevention, treatment options, or what’s happening in the latest research – you put them to Mr Vashisht in our web chat and you can read a transcript of the chat below.

12:30 UCLH: 
Good afternoon and welcome to our web chat. We will begin at 1pm but you can submit your questions now in preparation for the chat. Please note: your questions will not appear in the main chat window until after 1pm.

Mr Arvind Vashisht, consultant gynaecologist will be joining us to take your questions on prolapse and pelvic floor problems, and will try to answer as many questions as possible within the hour long web chat.
1:04 Dr Vashisht: 
Welcome to our web chat on the subject of prolapse and pelvic floor problems. My name is Arvind Vashisht, Consultant Gynaecologist and I am ready and waiting to take your questions.
1:04 [Comment From Guest: ] 
I am suffering from incontinence. When I asked one consultant about it he asked if I had had an epistiotomy. I did, with my first child (almost 60 years ago). Is there now anything that can be done? I find that if I spend a great deal of time clenching and unclenching those muscles daily I can control the incontinence. But it is a bit of a bore.
1:05 Dr Vashisht: 
Dear Guest
Many thanks for your question
I presume that you refer to urinary incontinence? Some women who have had extended episiotomies, large vaginal tears at the time of delivery, particularly involving the muscles around the bottom (“anal sphincter”) may actually have problems with faecal incontinence.
If it is urinary incontinence, even 60 years on, there are plenty of useful interventions.
Indeed pelvic floor exercises are helpful, but importantly you have to make sure that you are doing the right ones with the right technique. A women’s health physiotherapist is invaluable in guiding this, and of course there are many other treatments to consider.
1:08 [Comment Frommauguerita: ] 
Any special treatment needed for those with severe lichen sclerosus/
1:09 Dr Vashisht: 
Lichen sclerosis is a difficult painful and important condition that causes vaginal and vulval pain. Having concomitant incontinence or prolapse is probably compounding the discomfort, but there are separate treatments for both that you should consider.
1:11 [Comment From Interested of Scotland: ] 
What questions should I ask about my options when I go to my appointment with my surgeon? And what is recovery like after surgery?
1:13 Dr Vashisht: 
Dear Interested of Scotland

Very good question.
I would suggest:

What are the surgical treatments available?
What are the possible complications?
What can I expect during the recovery?
Are there alternatives?

Most importantly, you should ask yourself, what are your primary complaints, and does it appear that surgery will help those? Often, a surgeon and a patient may inadvertently be talking a different language / at cross purposes. Your symptoms and expectations have to be the clear priority.
1:13 [Comment From Guest: ] 
I have listed some of the problems I have with my bladder function - 1. I have a severe problem with my waterworks - in fact my bladder is haywire! I can get a strong signal that I need to pass urine but only a trickle comes out; another time I get the same signal and the urine gushes out! 2. I can go out, having emptied my bladder at home, and in about an hour I need to pass urine again. The amount also varies from a trickle to a flood. 3. I have had several ‘flooding’ episodes which have been difficult to cope with when out on the high street. 4. I wear protection but this does not always protect against a flood. 5. My GP suggested I took water tablets but I take enough tablets already and would prefer to try to control the muscles by exercise. I have been trying to squeeze my pelvic floor muscles but I’m not certain that I’m contracting the right muscles. 6. I had a total hysterectomy in 1971 and did manage to get my pelvic floor working again following the exercises I was given then. 7. I have multiple myeloma and 6 months ago I had an injection in my spine to help with constant pain from a trapped nerve in my spine. The injection has made a huge difference to the pain. 8. Most nights I only get up once to use the loo but sometimes it’s a rush to get there in time! 9. I have tried monitoring how much and what I drink but I haven’t noticed a difference. Drinking plain water rather than tea or coffee didn’t make a difference as far as I could tell. I did try cutting down, for a short time, on the amount I drink but don’t think this is a sensible thing to do. I have always drunk between 6-8 large cups of tea or coffee a day but I’ve noticed that I don’t always finish the cups in the way I used to. 10. I think it could be something in my mind over-ruling my body when it gets signals from my bladder. I’ve tried ignoring the signals but it just results in an accident or a rush to the loo! 11. Lastly one thing I’ve noticed I do is go to the loo ‘just in case’. I will go even if I don’t need to just in case I get stuck in traffic or a loo may not be available on route. Could I have trained my bladder to need to empty itself before it is full?
1:14 Dr Vashisht: 
Dear Guest

That’s a fair bit to work through!

Your first 4 points are very common symptoms that women regularly complain of.

Certainly as your GP suggests, tablets may be useful, but I understand that you are loathed to necessarily try any more. Many of the conservative treatments are effective for many women, but as you demonstrate they do not always work.

The fact that you have had spinal injections may complicate things somewhat. Given that you have tried a range of lifestyle factor modifications, are unkeen to try medication straight away, and have had spinal injections, I would suggest that you are seen by a specialist who can help explore your symptoms further, make a diagnosis, and start you on a pragmatic and sensible treatment pathway.
1:21 [Comment From Isabel: ] 
Why are the surgical outcomes for prolapse repair so variable?
1:21 Dr Vashisht: 
Dear Isabel
Many thanks for your question

There are so many techniques and outcomes because of so many factors.
Firstly there are so many different types of prolapse, that may require different approaches. One size doesn’t fit all.

Patients may present with a particular set of symptoms, have other medical problems, or have had previous surgery. In addition there are training issues in that surgeons will of course feel inherently most comfortable with the techniques they are familiar with, which cannot be all of them!

In terms of outcomes, studies may tend to have different criteria or yardsticks that they look at to define “success”. The stricter the definition, in general the lower the success rates.

Finally, prolapse is a condition due to weak tissue and structures- these are difficult to repair completely and permanently over a long period of time, and yet this is the goal we strive towards, and I believe are getting closer to.
1:22 [Comment From Chloe Thomas: ] 
Hello. Is there a surgical alternative to the TVT mesh ? I am very concerned about evidence of scar tissue growing over the mesh and the pain resulting from this.
1:27 Dr Vashisht: 
Dear Chloe

Thanks for your question

This is extremely topical area, as there is a lot of patient, medical, legal and media interest in vaginal mesh, and the “tapes” for incontinence. It is an extremely difficult and contentious area.
In short, yes there are alternatives for a TVT which is a treatment for stress incontinence:
Other conservative treatments (anti-incontinence vaginal aids, pelvic floor exercises)
Other surgical techniques include injections in to the urethra (but these are generally short-lived success rates), and indeed in my own practice there has been a resurgence in the previous gold-standard operation for stress incontinence, the “colposuspension”. This can be performed in its modern day form – laparoscopically (“keyhole”).
1:27 [Comment From Isabel: ] 
I've been told to wait as long as possible before having a surgical repair due to the high failure rate. But isn't it better to achieve a lasting repair before the prolapses reach a more severe grade? (I have mild cystocele and moderate rectocele but symptoms are awful)
1:31 Dr Vashisht: 
Dear Isabel

There are always pros and cons to surgical intervention, and “the right time” is debatable. Both of the arguments you present are well made.

I would suggest that you have an evaluation to grade the type and extent of prolapse you have: a cursory examination may underestimate things, especially as you seem to be so symptomatic.

The time for intervention is when you feel that you have exhausted conservative treatments, and the symptoms are having a significantly detrimental effect on your quality of life.

I don’t advocate “preventative” surgery, chiefly because surgery may cause complications, and may not last forever.
1:32 [Comment From Catherine: ] 
i have urinary incontinence - how can I tell if I'm clenching the right muscles to strengthen my pelvic flloor muscles.
1:34 Dr Vashisht: 
Thanks Catherine
Indeed this is the crux of trying to get effective results.
I would ask to be seen by a Women’s health Physiotherapist. They can make an assessment and guide you through techniques and other aids.
I often find that women are performing the exercises wrong, or have bought ineffective devices online
1:35 [Comment From Emma: ] 
On a related issue, are there further precautions a woman can take to ward off recurrent UTIs, apart from drinking plenty of fluid? Are there drinks (eg tea/coffee) which one should avoid altogether, and others that are positively recommended, as a protection against UTIs?
Wednesday November 11, 2015 1:35 Emma
Dr Vashisht: 
Dear Emma

Thank you for raising this issue.
Recurrent infections are a poorly treated common condition with a multitude of treatment strategies.

If you have a typical one off urine infection, antibiotics are the treatment. For the prevention of recurrence, there may be lifestyle (dietary, behavioural, perineal hygiene) and hormonal factors to consider. Ensuring a good fluid intake is important, empting your bladder before and after sex, possibly taking probiotics and cranberry tablets may also be helpful. The impact of these interventions can be variable. Some women need to go on a regular “baby-dose” of antibiotic, or even take high doses of repeat antibiotics to break the infective cycle.

If you see blood in your urine, you should urgently see your GP
1:41 [Comment From Sarah: ] 
I a have a moderate cystocele and rectocele after a forceps delivery with my first child - is there anything I should try to do or be concerned about during a second pregnancy?
1:47 Dr Vashisht: 

Dear Sarah

Thanks for your question.

Prolapse is surprisingly common following pregnancy. If I examine most women, I will see a degree of prolapse: it’s rarely that you have it or not, it’s all about the extent of it and the amount it bothers you or causes you symptoms.

I don’t think that you need to be unduly concerned about future pregnancies or delivery, but awareness is important. Pelvic floor exercises ought to be mainstay of treating any symptoms during pregnancy. Sometimes women find using a vaginal support pessary to be beneficial.

A small number of women have a set of symptoms, or previous experiences, or medical history, that mean that they have to carefully consider future pregnancy delivery options
1:55 [Comment From Sally: ] 
Do c sections reduce the risk of prolapse?
1:56 Dr Vashisht: 
Dear Sally

Thanks for raising this question. Looking through some other questions I am being sent it’s a popular one.
Again, this is a contentious and difficult area to be clear about.
Many women have vaginal deliveries and have no pelvic floor symptoms; some women have caesarean sections and still have symptoms, so a caesarean section is not entirely protective.
What is important, and is the basis of a lot of research, is trying to find those women who are most likely to inherently (i.e genetically”) suffer with prolapse – there are a group of women with connective tissue weaknesses that are most prone. The trick is to identify these women, and we are currently only at the tip of an iceberg with respect to diagnosing these women.
There is some evidence that a caesarean section may lower the chances of some types of incontinence and prolapse, but of course a caesarean carries its own set of risks and impacts on future pregnancies and delivery.
A complicated question!
1:56 [Comment From Joan: ] 
Thank you for offering this Webchat today. In your opinion, is prolapse caused by pregnancy or by delivery?
2:00 Dr Vashisht: 
Thanks Joan

I suppose this echoes in part my previous answer, but also I am glad you raise the issue because I think it is important that we understand that the causes of prolapse are multifactorial: its rarely a single factor. Prolapse arises as a result of one’s inherent susceptibility (dictated by our genes) coupled with what happens during our lives (pregnancy, method of delivery, other medical conditions, lifestyle). Pregnancy alone will play a part in this.
2:04 Dr Vashisht: 
Here are some useful links:

UCLH Urogynaecology service

British Society of Urogynaecology

NHS Choices
2:04 Dr Vashisht: 
Thank you for joining us today in our live web chat. We hope you found the chat useful and some of your questions have been answered.

 Useful links