Pelvic Floor Surgery Conditions

Anal Sphincter Injury

What is a sphincter injury?

A sphincter injury refers to a tear or damage to the muscle that surrounds the anal canal.  The anal sphincter muscle consists of two muscles;  the internal sphincter and the external sphincter muscle.  These muscles are used to control bowel movements.   Damage to one or both of these muscles can result in the decreased ability to control bowel movements and can contribute to symptoms of accidental bowel leakage. 

What causes a sphincter injury?

Sphincter injuries can occur as a result of anal or rectal surgery, obstetrical trauma or other trauma to the rectum.  Obstetrical trauma can include tears, episiotomies or the use of vacuum or forceps with delivery. 

How is a sphincter injury diagnosed?

Patients should undergo a thorough history and physical exam.  History taking will focus on obstetrical history, previous anorectal surgeries, other trauma to the anal canal, and current bowel habits including the ability to control gas and stool.  Physical exam includes thorough inspection of the anus with digital exam by a specialized physician such as a Colon and Rectal surgeon.  Other tests that may be performed are anal manometry to measure the pressures of the anal canal and endoanal ultrasound to visualize the internal and external anal sphincter muscles or an MRI.

How is a sphincter injury treated?

Treatment options for sphincter injuries for patients who are experiencing accidental bowel leakage include surgical repair of the anal sphincter muscle and biofeedback therapy.  Surgical repair of the sphincter muscle involves an operation performed under general anaesthetic at the hospital.  Biofeedback therapy is a treatment used to help strengthen the muscles of the anus and pelvic floor to decrease incidents of accidental bowel leakage.  Sacral nerve stimulation is another treatment option available for persistent symptoms of accidental bowel leakage.  In the past there have been different versions of an artificial bowel sphincter to treat sphincter injuries, however there are none currently on the market.

Constipation:

Constipation can be an uncomfortable experience. The following information can help answer your questions about constipation and help you understand your doctor’s choice of treatment.

What is constipation?

Constipation may mean different things to different individuals. Most commonly, it refers to the passage of too few bowel movements per week.  It may also describe having hard, dry stools that are difficult to pass, a decrease in the size of the stool, or needing to strain to have a bowel movement.  Some individuals describe a sense of not emptying their bowel completely or the need for enemas, suppositories or laxatives in order to have a bowel movement. The definition of normal frequency of having a bowel movement ranges from 3 times a day to 3 times a week.

What causes constipation?

Common causes of occasional constipation include:

• Poor eating habits (for example, too much junk food, too much irregular eating times)
• Diet lacking in fiber and/or fluids
• Lack of exercise
• Some medications (including pain medications, tranquilizers, psychiatric medications)
• Stress
• Pregnancy
• Travel

More serious causes of constipation include narrowing of the colon or growths in the colon. Sometimes constipation is caused by problems with the function of the pelvic floor muscles. The muscles may not relax appropriately when trying to pass stool, making it difficult and sometimes painful to have a bowel movement.

What can I do about constipation?

Help yourself maintain regularity by adding some of these simple steps to your daily routine:

• Gradually add high fiber foods to your diet, including dried fruits (apricots, prunes, raisins, and dates) raw vegetables, bran cereals whole-grain breads. • Drink 8 to 10 glasses of decaffeinated fluid each day
• Follow a regular exercise program.
• Respond to the urge to have a bowel movement.
• If one is recommended by your doctor, take a high-fiber supplement.
• Use laxatives only as your doctor recommends.

Should I take a laxative?

Your doctor may prescribe a laxative for you. There are many types of laxatives, each one having benefits and drawbacks for certain patients.

Bulk-forming agents are not digested but absorb liquid in the intestine and then swell to form a soft, bulky mass that stimulates a bowel movement.  

Stool softeners do not cause a bowel movement but ease the difficult passage often associated with hard dry stool.

Stimulant laxatives encourage bowel movements through action of the intestinal wall.  They increase the muscle contractions in the intestine that lead to having a bowel movement.

Hyperosmotic laxatives work by drawing water into the bowel from surrounding tissues.  This softens the stool and sends the bowel the message to empty.

Enemas fill the colon with fluid, which softens the stool and stimulates a bowel movement.

It is always a good idea to look for natural ways to meet your body’s needs and avoid long-term use of medication. Excessive use of stimulant laxatives can actually cause constipation and dependence upon laxatives because the colon loses its normal tone and the ability to contract.

What is accidental bowel leakage (ABL)?

Accidental bowel leakage of stool means the inability to control the passage of stool or gas. Some people have mild trouble holding gas; while others have severe trouble holding stool. Incontinence is a miserable problem that many people have trouble talking about. People are frequently embarrassed and afraid there is no help. However, treatment is available. Dr Chamisa is specially trained to care for this problem.

How common is this problem?

One study showed that over 2% of the population suffers from accidental bowel leakage. More than 30% of nursing home patients are incontinent. It affects women more than men, and it becomes more common as people age and their sphincter muscles lose tone.

What causes accidental bowel leakage?

Normal control of the passage of stool depends on many factors. A problem in any of the following areas can contribute to lack of control. One factor is the time it takes for stool to pass through the bowel. If stool moves through the bowel too quickly, a person may not have warning and may have an accident. This happens most commonly to people with irritable bowel syndrome or inflammation of the bowel (colitis). Anything that causes diarrhoea can lead to incontinence. To prevent leakage, one must be able to tell that stool or gas is present in the rectum. People with neurological problems may have abnormal sensation in the rectum. They will not be able to sense that gas or stool has entered into the rectum and therefore have no warning to go to the bathroom. The sphincter muscle, a circle of muscle around the anus (rectal opening), keeps the anus closed. It needs to hold the anus closed at rest and squeeze to tighten the anus when stool or gas enter the rectum. As people age, the muscle gradually loses strength. The sphincter muscle can also be injured during childbirth or during rectal surgery. Two nerves stimulate the sphincter muscle. If the nerves are injured, the sphincter muscle may become weak.

What tests are available?

First, the doctor will ask questions about your symptoms, bowel habits, and other medical problems. You will then be examined with particular attention paid to the sphincter muscle, rectum, and lower colon. You may need to have additional tests like anal manometry and nerve tests. An ultrasound probe inserted into the anus can provide a picture of the muscles, which would show any area of injury. You may need an x-ray to check for rectal prolapse.

How is accidental bowel leakage treated?

• If present, the underlying problems are corrected e.g. inflammation of the bowel, infection, or irritable bowel syndrome.
• Diarrhoea and constipation are treated with dietary changes, usually emphasizing a high fibre diet.
• Accidental bowel leakage caused by injury to the sphincter muscles may require surgery.

Biofeedback or pelvic floor muscle training may also be recommended. This program teaches people to consciously identify and exercise their pelvic floor muscles. Finally, for patients with severe incontinence, a colostomy greatly improves their lifestyle. Patients with accidental bowel leakage are encouraged to speak with their doctors. Help is available.

Pelvic organ prolapse:

What is Pelvic Organ Prolapse?

Pelvic organ prolapse (POP) occurs when the muscles and connective tissue in the pelvis weaken, resulting in prolapse or shifting of the pelvic organs from their normal position.  This weakening is most commonly a result of pregnancy, childbirth, advanced age, connective tissue disorder, obesity, pelvic surgery or repetitive straining and heavy lifting.  The organs in the pelvis that can be affected by POP include the rectum, uterus, cervix, vagina, urethra and bladder. 

What are the common symptoms of POP?

• Feeling heaviness, fullness, pulling, or aching in the pelvis, vagina or rectum. It gets worse by the end of the day or during a bowel movement.
• Seeing or feeling a “bulge” or “something coming out” of the vagina or rectum
• Having a hard time starting to urinate or emptying the bladder completely
• Leaking urine with coughing, laughing, or exercise
• Feeling an urgency to urinate
• Leaking stool or having a hard time controlling gas
• Straining to have a bowel movement or feeling constipated
• Feeling an urgency to have a bowel movement
• Returning to the bathroom several times to finish having a bowel movement or repetitive wiping.
• Using digital support or manipulation to assist in having a bowel movement

What tests are available to help identify POP?

A thorough physical exam can help to identify the presence of POP.  Additional tests may also help to better determine the extent of POP and which organs are specifically involved. 

• Defecography: One of the most useful tests to evaluate POP is defecography. This is a fluoroscopic x-ray study that allows for visualization of the pelvic organs during defecation.  Shifting and prolapse of different organs can be seen during this special x-ray. 
• Urodynamic Testing: Urologists and urogynecologists may also perform urodynamic testing.  This testing focuses on both the ability to hold urine and the ability to empty the bladder. 
• Additional tests: Your healthcare provider may order one or more of the following tests: anorectal manometry, endoanal sonar, uterine ultrasound and colonoscopy.

How is pelvic floor organ prolapse (POP) treated?

Both non-surgical and surgical options are offered for treatment of POP.  The severity of prolapse and which organs are most affected by POP will determine which treatment option is best. 

Non-surgical treatment options for POP include

• Pelvic Floor Exercises: A type of exercise to strengthen the pelvic floor by contracting and relaxing the muscles that surround the opening of the urethra, vagina, and rectum. The exercises are commonly referred to as Kegels.
• Biofeedback therapy: A type of therapy that helps to retrain the pelvic floor muscles how to effectively squeeze and push the muscles.
• Pessary: A removable device that is inserted into the vagina to support the pelvic organ(s) that have prolapsed.

Surgical treatment:

• Sacrocolpopexy: Mesh is used to restore support to the vagina.
• Ventral Rectopexy: Mesh or sutures are used to restore support to the rectum and improve symptoms of leakage or constipation caused by prolapse.
• Bladder sling: Mesh is used to support the bladder and improve control and evacuation of urine.

Pelvic Pain

What is Pelvic Pain?

Pelvic pain is a common complaint in both men and women, affecting 12% of the population. This pain can be intermittent, constant, or related to certain events. In order to diagnose a pelvic pain syndrome, reproductive, urologic, and gastrointestinal sources of the pain must be ruled out. A careful history and physical must be performed to diagnose each of these syndromes. 

What is Coccygodynia?

Coccygodynia or coccydynia is identified by pain with pressure or movement of the tailbone (coccyx). This may be due to a fracture or bruising of the tailbone, disc disease within the spine, or thinning of the bone itself. X-rays may help to evaluate fractured or weakened bone.

How is Coccygodynia Treated?

Injection of anaesthetics or anti-inflammatory medications may provide pain relief. Manipulation of the tailbone in the office or under anaesthesia may improve the symptoms in certain patients. Cases that do not respond to nonoperative management may require removal of the tailbone. 

What is Levator Syndrome?

Levator syndrome is episodic pain in the rectum, sacrum, or coccyx, also associated with aching pressure in the buttocks and thighs. The exact causes of Levator syndrome are not known, but it is largely attributed to spasm or inflammation in the muscles of the pelvic floor (levators). The pain may be vague or localize to the rectum, anus, rear of the pelvis, or tailbone. This is intermittent but may last for days in certain cases. Digital rectal examination by a practitioner may reproduce this pain.

What is Proctalgia Fugax?

A variant of Levator syndrome is known as proctalgia fugax (fleeting rectal pain). This is characterized by brief, intense pain in the rectum that lasts for just seconds to minutes. The spasms often wake patients from sleep but may happen during the day as well. Proctalgia fugax is difficult to evaluate due to its brief episodes, but often may be diagnosed on history alone. 

How is Levator Syndrome Treated?

Physical therapy, including massage of the pelvic floor muscles, is extremely effective at treating the symptoms. Biofeedback therapy relieves the pain by modifying the pelvic activity. Muscle relaxants provide excellent relief, though with the side effect of drowsiness. Local anaesthesia or steroid injections have been performed, but are less consistent than therapy or muscle relaxants.

What is Pudendal Neuralgia? 

Pudendal neuralgia is pain in the areas supplied by the sensory nerves of the pelvis. It typically affects the reproductive organs, rectum, or prostate gland. It is caused by muscle entrapment or repetitive injury to the nerves of sensation. It is diagnosed by reproduction of the pain when the pudendal nerve is pushed through the rectal wall.

How is Pudendal Neuralgia Treated? 

Anti-inflammatory agents, either steroidal or NSAIDS, are the mainstay of treatment, as are muscle relaxants. Routine injection nerve block may be used for patients who do not improve with an oral regimen.

Rectal prolapse:

Rectal prolapse occurs when the upper portion of the rectum telescopes itself inside out and comes out through the rectal opening. It is seen most often in elderly women, but it can occur in men and women of any age.

What causes rectal prolapse?

Rectal prolapse is associated with chronic straining to pass stool. It is known that the attachments of the rectum to the pelvic bones progressively weaken. When these attachments are weak, straining to pass stool causes the rectum to turn itself inside out.

In many cases, the cause is unknown.

What symptoms occur with rectal prolapse?

The primary symptom is the feeling of tissue coming out of the rectum. Bleeding and mucus drainage frequently accompany rectal prolapse. When the problem first starts, the rectum may turn itself inside out but not come out the rectal opening. During this phase a common symptom is the frequent urge to have a bowel movement when there is no need to pass stool. As the prolapse progresses, the rectum comes out with bowel movements and returns inside by itself. Later the prolapse may occur with any activity and finally just standing up may cause it. It may become necessary to push the rectum back inside. Constipation commonly occurs with rectal prolapse. The chronic straining associated with constipation may be a predisposing factor, or constipation may occur because the prolapse partially blocks the rectal opening. Continued straining and the prolapse itself may damage the sphincter muscle that controls the passage of stool. If that occurs, accidental bowel leakage or results. It can be difficult at times to differentiate true accidental bowel leakage from mucus discharge directly from the prolapsed tissue.

How does rectal prolapse differ from haemorrhoids?

Haemorrhoids are a cluster of anal cushions (spongy tissue with a lot of blood vessels). If an inside haemorrhoid enlarges, it may come out the rectal opening with a bowel movement or during exercise. However, only the lining and the blood vessels come out, unlike rectal prolapse where all layers of the rectal wall come out.

How is rectal prolapse diagnosed?

Your doctor can usually diagnose rectal prolapse by taking a careful history and performing a complete anorectal examination. To demonstrate the prolapse, the patient may be asked to strain as if having a bowel movement.  If the prolapse is internal or the diagnosis uncertain, a video defecogram (x-ray pictures taken while the patient is passing contrast instilled in the rectum) can help the doctor determine whether surgery would be helpful and what procedure would be best. Anorectal manometry, a test that measures whether or not the muscles around the rectum are functioning normally, may also be used.

How is rectal prolapse treated?

Rectal prolapse can be corrected. Options are available for treatment, regardless of age and condition of the patient. Treatment depends on the age of the patient and the severity of the condition. In adults, a high fiber diet to prevent constipation and straining is recommended if the symptoms are mild. Surgical correction is required in adults if the prolapse does not resolve by itself. Rectal prolapse can successfully be repaired through either an abdominal or rectal procedure. Your doctor will discuss which procedure is most appropriate for you. Rectal prolapse in children frequently corrects itself. The doctor will instruct parents how to reduce the prolapse when it occurs and how to prevent constipation in their child.

What is a rectocele?

A rectocele is a bulge of the front wall of the rectum into the back wall of the vagina. The tissue between the rectum and the vagina is known as the rectovaginal septum and this structure can become thin and weak over time, resulting in a rectocele.  Other pelvic organs such as the bladder (cystocele) and the small intestine (enterocele), can bulge into the vagina, leading to similar symptoms as rectocele.

What causes a rectocele?

The exact cause of a rectocele is unknown, but symptomatic rectoceles usually occur in association with weakening of the pelvic floor. There are many causes of weakening of the pelvic floor, including advanced age, multiple vaginal deliveries and birthing trauma during vaginal delivery (e.g. forceps delivery, vacuum delivery, and episiotomy during vaginal delivery).  A history of chronic constipation and excessive straining with bowel movements are thought to play a role in developing a rectocele.  Multiple gynaecological or rectal surgeries can also lead to weakening of the pelvic floor and rectocele.

What are the symptoms associated with a rectocele?

The majority of patients with a rectocele have no symptoms.  When symptoms are present, they may be classified as either rectal or vaginal.  Rectal symptoms may include:  difficulty with evacuation during a bowel movement and the need to press against the back wall of the vagina and/or space between the rectum and the vagina in order to have a bowel movement.  Vaginal symptoms can include the sensation of a bulge or fullness in the vagina, tissue protruding out of the vagina, discomfort with sexual intercourse, and vaginal bleeding. Symptomatic rectoceles can lead to excessive straining with bowel movements, the urge to have multiple bowel movements throughout the day, and rectal discomfort.  Faecal incontinence or smearing may occur as small pieces of stool can be retained in a rectocele, only to later seep out of the anus.

How is a rectocele diagnosed?

Examination of the pelvic region typically includes both a vaginal and rectal examination.  Additionally, a digital rectal exam will be performed which usually demonstrates a weakness in the anterior wall of the rectum. A special x-ray, called defecography, can also visualize and confirm a rectocele. In general, if the rectocele is larger than 2 centimetres and/or has significant retention of contrast, it is considered abnormal.

What is the treatment for rectoceles?

A rectocele should only be treated if you are having significant symptoms that interfere with your quality of life.  There are both medical and surgical treatment options for rectoceles. Surgical treatment is reserved for only the most severe cases of symptomatic rectocele.

Non-surgical treatment of rectoceles?

The vast majority of a patient’s symptoms associated with a rectocele can be managed effectively without surgery.  It is very important to have a good bowel regimen in order to avoid constipation and straining with bowel movements.  A high fiber diet can help with this goal.  Additionally, an individual should also increase her water intake, with 6-8 ten-ounce glasses daily.  The combination of fiber and water will allow for softer, bulkier stools that do not require significant straining with bowel movements.  Stool softeners are also recommended.  During bowel movements, it is important to avoid straining. In addition, it is always important to avoid prolonged sitting periods on the toilet.  Biofeedback refers to exercises one performs with a provider to strengthen and retrain the pelvic floor and can also lessen the symptoms of a rectocele.

Surgical treatment options:

The surgical management of rectoceles should only be performed if you continue to have symptoms. There are multiple ways to approach the surgery including: transanally (through the anus), through the perineum, and through the vagina.  All of these aim to remove the extra tissue that makes up the rectocele and reinforce the rectovaginal septum (the tissue between the rectum and the vagina).  This can be done by plication (stitching the tissue together).  Occasionally, mesh (a prosthetic material or patch) can be used to reinforce the repair. A rectocele can also be repaired through the abdomen, either laparoscopically or open.  The approach will depend on the size of the rectocele and the symptoms associated with the rectocele.

Outcomes of surgical repair:

The overall success of the surgery depends on the symptoms, length of time symptoms have been present, and approach of surgery.  As with any surgical procedure, there are associated risks including bleeding, infection, new onset dyspareunia (pain during intercourse), faecal incontinence, rectovaginal fistula (a communication between the rectum and vagina), as well as a risk that the rectocele may recur or worsen. Some studies report significant improvement in about 75-90% of patients.

Rectovaginal Fistula

What is a rectovaginal fistula?

A rectovaginal fistula is a medical condition where there is a fistula or abnormal connection between the rectum and the vagina. Although generally uncommon, rectovaginal fistulas may be extremely debilitating. If the fistula is wide it will allow both gas and stool to escape from the rectum into the vagina, leading to faecal incontinence. Patients can experience recurrent urinary and vaginal infections due to this leakage. The severity of symptoms will depend on the size of fistula.

What causes a rectovaginal fistula?

Rectovaginal fistulas are often the result of trauma during childbirth, such as tearing, episiotomy or forceps/vacuum extraction. Rectovaginal fistulas are also seen where there is inadequate health care, such as in some developing countries. The rectovaginal fistula can become evident within 1 week of delivery. Rectovaginal fistula can also be a symptom of various diseases, including Crohn’s disease or less commonly rectal cancer.  Or, they can be an unintended result of surgery, such as vaginal hysterectomy, haemorrhoidectomy, abscess drainage or sexual reassignment surgery. They are seen rarely after radiotherapy treatment for cervical cancer.

How is a rectovaginal fistula diagnosed?   

Patients should undergo a thorough history and physical exam. History taking will focus on obstetrical history, previous abdominal and anorectal surgeries, history of radiation treatment, and signs and symptoms of Crohn’s disease.  Physical exam includes a thorough inspection of both the anus and the vagina, including anoscopy of the distal rectum and anal canal. Endoanal ultrasound and/or MRI may be performed to help in identifying the fistula.

How is a rectovaginal fistula treated?

After diagnosing a new rectovaginal fistula, it is best to wait for 3-6 months to allow the inflammation to subside. Surgical treatment of a rectovaginal fistula can greatly improve a patient’s quality of life. However, these can be challenging to repair successfully, and many patients require multiple attempts at repair. Several different operations have been described to fix rectovaginal fistulas.  The most common surgical options are a sliding endorectal advancement flap or an overlapping sphincter repair. While most rectovaginal fistulas will require surgical repair, patients with Crohn’s disease may be treated with medications, which can sometimes help in closing the fistula.

Pelvic Floor Disorders: Frequently Asked Questions

Q: What is the pelvic floor?

A: Both men and women have a pelvic floor. In women, the pelvic floor is the muscles, ligaments, connective tissues and nerves that support the bladder, uterus, vagina and rectum and help these pelvic organs function. In men, the pelvic floor includes the muscles, tissues and nerves that support the bladder, rectum and other pelvic organs. The pelvic floor muscle layer has hole for passages to pass through. There are two passages in men (the anus and urethra) and three passages in women (the anus, urethra, and vagina). The pelvic floor muscles normally wrap quite firmly around these holes to help keep the passages shut. There is also an extra circular muscle around the anus (the anal sphincter) and around the urethra (the urethral sphincter).

Q: What are pelvic floor disorders?

A: Pelvic floor disorders occur when the “trampoline” that supports the pelvic organs becomes weak or damaged. The three main types of pelvic floor disorders are:

• Faecal incontinence, or lack of bowel control.
• Pelvic organ prolapse: rectal prolapse, a condition in which the bowel can bulge through the anus.
• Obstructive defecation, or the inability to pass stool through the digestive tract out the anus.

Q: What are the symptoms of pelvic floor disorders?

A: People with pelvic floor disorders may experience:

• Constipation, straining or pain during bowel movements.
• Pain or pressure in the rectum.
• A heavy feeling in the pelvis or a bulge in the rectum.
• Muscle spasms in the pelvis.

Q: Are pelvic floor disorders a normal part of aging?

A: While pelvic floor disorders become more common as women get older, they are not a normal or acceptable part of aging. These problems can have a significant impact on a person’s quality of life. Fortunately, these disorders often can be reversed with treatment.

Q: What causes pelvic floor disorders?

A: Common causes of a weakened pelvic floor include childbirth, obesity, heavy lifting and the associated straining of chronic constipation.

• Childbirth is one of the main causes of pelvic floor disorders. A woman’s risk tends to increase the more times she has given birth.
• Having pelvic surgery or radiation treatments also can cause these disorders.
• Women who are overweight or obese also have a greater risk for pelvic floor disorders.
• Other factors that can increase the risk include repeated heavy lifting or even genes.

Q: When should I seek help for pelvic floor disorders?

A: Many people don’t feel comfortable talking about personal topics like pelvic floor disorders and symptoms such as incontinence. But these are actually very common medical problems that can be treated successfully.  If you have a pelvic health issue, don’t hesitate to learn more about your treatment options.

Q: What is faecal incontinence?

A: Faecal incontinence, also called bowel or anal incontinence, is the inability to control your bowels. It is the second most common pelvic floor disorder. People with faecal incontinence may feel the urge to have a bowel movement but may not be able to hold it until they reach the toilet. Or they may leak stool from the rectum. Faecal incontinence is not normal at any age and can be treated successfully. This can lead to a significant improvement in a person’s quality of life.

Q: How is faecal incontinence diagnosed?

A: Your physician will start by asking questions about your medical history. Then he or she will conduct a physical exam and order some tests.

Physicians have several tools to understand the cause of faecal incontinence. These include:

• Anorectal manometry, which checks the anal sphincter muscles that keep stool inside. This test also checks how well the rectum works.
• Defecography, which shows how much stool the rectum can hold, how well it can hold it and how well it can empty it.
• Magnetic resonance imaging (MRI), which is sometimes used to examine the sphincter.
• Other tests may be ordered to look inside the rectum or colon for signs of disease or damage that could cause faecal incontinence.

Q: How is faecal incontinence treated?

A: Treatment can improve or restore bowel control for most people with faecal incontinence. Often, a treatment plan includes many approaches, depending on the cause of the problem. These may include:

• Diet changes, such as eating smaller meals and avoiding caffeine, which relaxes the sphincter muscles and can make incontinence worse.
• Medication, which may be appropriate for some people to help slow down the bowel.
• Biofeedback, which helps people learn to strengthen their pelvic muscles so they can control their bowel movements.
• Surgery, which may help people whose faecal incontinence is caused by damage to the pelvic floor or anal sphincter. Surgeons can repair the anal sphincter using advanced techniques that restore bowel function. Surgeons also can improve bowel control by injecting bulking agents into the anus or stimulating the nerves in the lower pelvis.

Q: What is pelvic organ prolapse?

A: Pelvic prolapse is the third most common pelvic floor disorder. A prolapse occurs when the pelvic muscles and other supporting tissues becomes weak, which causes the organs in the pelvis to fall out of place. Rectal prolapse occurs when part or all of the wall of the rectum slides out of place, sometimes sticking out of the anus. Rectocele occurs when the lower wall of the vagina loses support and the rectum bulges upward into the vagina.

While these conditions are usually not associated with serious health risks, they can cause symptoms such as:

• A heavy feeling or discomfort from something that feels like it is “falling out” of the vagina.
• A pulling or “bulge” in the lower abdomen or pelvis.
• Frequent urinary infections, caused by a reduced ability to release urine from the urethra.

Q: How do you treat prolapse?

A: There are several nonsurgical treatment options for pelvic organ prolapse. These include:

• Kegel exercises and other pelvic floor exercises that can help strengthen the muscles that support the pelvic organs.
• To repair rectal and multi-organ pelvic organ prolapse, surgery may be the best option for some women. Often, these procedures can be done using minimally invasive techniques.

Q: What is pelvic floor dysfunction, and what are the symptoms?

A: Pelvic floor dysfunction is when you are unable to control the muscles that help you have a complete bowel movement. It can affect women and men. The symptoms include:

• Constipation, straining and pain with bowel movements.
• Unexplained pain in the lower back, pelvis, genitals or rectum.
• Pelvic muscle spasms.
• A frequent need to urinate.
• Painful intercourse for women.

Q: How is pelvic floor dysfunction treated?

A: Treatment can have a dramatic effect on pelvic floor dysfunction. For most people, this usually involves:

• Behaviour changes, such as avoiding pushing or straining when urinating and having a bowel movement. This also might include learning how to relax the muscles in the pelvic floor area. For example, warm baths and yoga can help relax these muscles.
• Medicines, such as low doses of muscle relaxants like diazepam.
• Physical therapy and biofeedback, which can help you learn how to relax and coordinate the movement of your pelvic floor muscles.