Objective: To review the evaluation and management of complex pelvic floor disorders in elderly women.
Methods: Literature review and presentation of a clinical case.
Results: Pelvic floor disorders are a common problem in elderly women. Pelvic organ prolapse and voiding complaints often coexist and several treatment options are available. A step-wise approach should be used in which management of the most bothersome symptoms occurs first. Conservative, medication, and surgical options should be discussed with each patient depending on treatment goals and health status. Some effects do overlap; however, treatment of one condition may not preclude treatment of other symptoms.
Conclusion: In women with complex pelvic floor disorders, addressing the most bothersome symptom first will increase patient satisfaction. Patients should be counseled about the potential need for multiple treatments for optimal results.
The female pelvic floor consists of a complex relationship of muscles, connective tissue and fascia, ligaments, and neurovascular support. These structures are responsible for support of the pelvic organs (uterus, bladder, rectum, and vagina), maintain continence, and assist in normal bowel function. Pelvic floor disorders occur when there is a compromise in these structures, resulting in prolapse, urinary incontinence, bowel complaints, or pain. Often several symptoms coexist with overlapping pathophysiology. Examinations and studies should aim to correctly diagnose the disorders and guide treatments toward the most bothersome symptoms.
Pelvic organ prolapse occurs when there is a weakening of the pelvic floor connective tissue, muscles, and nerves, allowing a bulge or protrusion of the vaginal walls and their associated pelvic organs. Between 3% to 50% of women in the United States have some degree of pelvic organ prolapse depending on whether the definition is based on symptoms or anatomic evaluation [1–3]. Risk factors include vaginal delivery, obesity, Caucasian race, and prior prolapse surgery. Despite the non–life-threatening nature of pelvic organ prolapse, the associated social and physical restrictions can significantly impact quality of life [4]. The cost of prolapse surgery has been estimated to be over $1.4 billion per year [3].
The sensation of a vaginal bulge is the only symptom consistently related to pelvic organ prolapse, with patients typically reporting symptoms once the prolapse extends beyond the hymenal ring [5]. The diagnosis of pelvic organ prolapse is made based on symptoms and confirmed by physical exam.
Patients with pelvic organ prolapse may experience obstructive voiding symptoms, such as hesitancy, straining, or incomplete bladder emptying. In some cases, patients may have to manually reduce the bulge to be able to void, a practice known as “splinting.” Overactive bladder (OAB), a syndrome of urinary urgency, frequency, and nocturia with or without urgency incontinence, can also occur. In patients with lower urinary tract complaints, repair of a vaginal bulge, especially a cystocele, can be associated with improved voiding symptoms [6]. Additionally, prolapse treatment can unmask de novo stress urinary incontinence (SUI), leaking with cough, sneeze or other activity that increases abdominal pressure. Urinary tract infections, pelvic pain, dyspareunia and defecatory problems can also be present.
