Get the Pelvic ‘Floor-One-One’

**By Kathleen Kobashi, MD, FACS, FPMRS**

While pelvic floor health disorders can seem alienating, it is important to know that you’re not alone and there are a variety of ways to treat bothersome symptoms.

The pelvic floor is a group of muscles in the pelvic region, that can be described as a “hammock” of ligaments that sling between the pubic bone in the front and the tailbone in the back. For women, these muscles and ligaments work to support and control the uterus, vagina, bowel and bladder; whereas for men, they support just the bowel and bladder.

As a multidisciplinary team, the members of the Pelvic Floor Center at Virginia Mason treat virtually every pelvic floor health issue that can be experienced by both men and women. In this article we’ll dive into common health problems associated with the pelvic floor and why maintaining pelvic floor health is so important. Pelvic floor disorders can become huge quality-of-life issues that can interfere with our daily activities. It is vital for us to be aware that there are successful, minimally invasive treatment options available.

Common health issues associated with the pelvic floor

When it comes to pelvic floor health issues, there are several key terms to remember, like incontinence and prolapse. Incontinence is the lack of control of bladder or bowel function resulting in leakage, while prolapse is the displacement or dropping of pelvic organs through a weak pelvic floor, much like a hernia. There are other pelvic floor disorders that may result in the opposite problem of difficulty emptying the bladder or bowel.

Mother and daughter drinking coffeeThe two most common forms of urinary/bladder incontinence are stress and urgency leakage. Stress incontinence is the involuntary release of urine from coughing, sneezing or other similar actions and is commonly (but not exclusively) experienced by women who have had vaginal delivery of babies. Aging, genetics and gravity can also play a role. Conversely, urgency incontinence is exactly as it sounds – when nature calls, you don’t always have a say in when you answer, and it is urgent. This form of incontinence can be caused by the consumption of dietary irritants, such as coffee or wine, that aggravate the bladder, as well as hormonal changes that make the bladder more irritable. In men, urgency can also be related to prostate enlargement.

Fecal/bowel incontinence (aka accidental bowel leakage) is an involuntary loss of bowel control that can result in stool abruptly leaking from the rectum. Disorders associated with bowel function can range from constipation to complete loss of control of the bowel, and everything in between.

Prolapse occurs when pelvic organs – such as the bladder, uterus, bowels, vagina or rectum – drop down into or outside of the anus or vaginal canal. Prolapse can be due to a number of issues, including pregnancy, childbirth, obesity, chronic respiratory issues, constipation and cancer in the pelvic region.

Signs to look out for and when to see your doctor

If you’re concerned you might be dealing with a pelvic floor problem, here are a few signs and symptoms:

  • Urinary/bladder incontinence – symptoms can include leakage of urine with coughing, sneezing or exercise, and can also be associated with a sudden, intense and often uncontrollable urge to urinate. Other lower urinary tract symptoms may include frequent urination, slow or dribbling streams of urine or the inability to completely empty your bladder.
  • Fecal/bowl issues – symptoms can include chronic bloating, constipation, diarrhea or involuntary loss of fecal matter.
  • Pelvic organ prolapse – symptoms can include a feeling of fullness in the pelvic floor or vagina, a feeling that something is “falling” out of the anus or vagina, discomfort with sexual intercourse, urinary or fecal incontinence, a sense of trapping of stool or the inability to completely empty your bowels.

It’s important to note that any combination of the symptoms above can occur.

The importance of pelvic floor health

Given the critical bowel, bladder and sexual functions these muscles support, keeping your pelvic floor healthy and strong is crucial. There are a variety of exercises that can be done to improve overall pelvic floor health and functionality, with some of the more common ones being Kegels. Working your pelvic floor regularly is especially important for women in order to minimize the risk of developing prolapse, incontinence or other pelvic health issues that stem from pregnancy or aging.

If you’re experiencing any one or combination of the symptoms discussed above for an extended period of time, it may be time to call and arrange a visit with your doctor. From there, they can work with you to decide your best course of treatment, whether that’s pelvic floor therapy or proceeding with some tests that can help identify the root cause of your problem and facilitate treatment planning.

Kathleen.KobashiKathleen Kobashi, MD, FACS, FPMRS is board-certified in urology with a subspecialty certification in female pelvic medicine and reconstructive surgery. She is the section head of Urology and director of the  Pelvic Floor Center at Virginia Mason. Dr. Kobashi is a urologist/urogynecologist who specializes in the treatment of pelvic floor disorders, including urinary and bowel incontinence, pelvic organ prolapse, and urinary tract fistulas, with expertise in pelvic floor reconstruction through open and robotic surgery.

Pelvic Organ Prolapse: How a Restorative Treatment Helped Mother and Daughter

Kathy Silva describes the 12-acre farm where she grew up and where her mother, Rosemary Cockrill, still lives. Life in scenic Port Angeles, Wash. could be low key if you let it. But Rosemary, 86, kicks it up a notch, making time to go to concerts, see a play or a movie, or take a class at the senior center.

“She’s never going to get old,” says Kathy, who lives about 20 miles from her mom, in the town of Joyce, and works for the local school district.


Kathy Silva (right) and her mother, Rosemary Cockrill

But Rosemary’s life wasn’t always so active. For years, she suffered the symptoms of pelvic organ prolapse, when weakened pelvic floor muscles and ligaments allow organs such as the bladder, uterus or rectum to drop, sometimes protruding out of the vagina. Pelvic organ prolapse develops over time, often long after childbirth has stretched connective tissues. When the bladder is the affected organ, a feeling of heaviness or pressure, compounded by the frequent need to urinate and the fear of accidents, can keep women from getting out and doing the things they enjoy.

“My mom asked me to please look at Virginia Mason’s website to find a urologist who could help,” says Kathy. “I chose Dr. Una Lee, who specializes in pelvic organ prolapse, and all the information we needed about her was right there.”

Dr. Lee confirmed Rosemary would benefit from surgical intervention. A minimally invasive approach using small abdominal incisions to repair the prolapse, and a supportive sling placed to support Rosemary’s bladder and urethra would relieve the constant pressure and incontinence. There was just one problem. “My mom doesn’t like anything to do with hospitals and she wasn’t excited about any of it,” remembers Kathy.

It was her mom’s evaluation at Virginia Mason that got Kathy thinking about her own discomfort. She wasn’t having any urinary problems, but she’d been feeling like she was sitting on something, and was constantly adjusting her position to get comfortable. A visit to Dr. Lee confirmed Kathy was also suffering from pelvic organ prolapse, which she learned can be hereditary. If her mom wasn’t ready yet, maybe Kathy could blaze the trail.

Dr. Lee completed Kathy’s prolapse repair in one operation through the vagina. The success of her daughter’s surgery eventually moved Rosemary toward a decision. She would have the surgery.

“Mom goes anywhere she wants now,” says Kathy. “My son got married in Vegas, and Mom insisted on going. She flew on the plane and enjoyed the whole trip without worrying about the bathroom. I know the surgery is what helped her make that trip.”

At the two-year mark after Kathy’s surgery, a check-in with Dr. Lee confirmed there was still a problem with prolapsed tissue near the rectum. Kathy’s previous repair to support her bladder remained in place, but she needed a second surgery in another area to fix what’s known as a rectocele, or posterior vaginal prolapse. Kathy credits both procedures for making her good as new, “and that’s not bad for 66,” she says. She has an enduring gratitude for Dr. Lee and the care teams who have encouraged and supported her over the years at Virginia Mason.

“No one tells you when you get older what’s not normal, and women may not be confident talking about it,” says Kathy. “Dr. Lee is easy to talk to, and she really wants to know her patients.”

Rosemary wholeheartedly agrees with her daughter, and then some. “Dr. Lee and this surgery have given me my life back,” she says.

This story also appears in the Virginia Mason Health System 2017 Annual Report.  


Let’s Talk About Vaginal Prolapse. Don’t Worry, I’ll Start.

Dr. Lee with New Day Northwest host Margaret Larson.

Dr. Lee with New Day Northwest host Margaret Larson.

**By Una Lee, MD

Recently I was lucky enough to have a patient who wanted to help other women, even if it meant talking about something many would find way too personal. Amy joined me on the show New Day Northwest to describe what it’s like when your uterus falls into your vagina, a form of vaginal prolapse, a condition that can feel like a heavy ball is lodged between your legs. Like many women Amy had never heard of vaginal prolapse, but she was well aware of the backache and sore hips that kept her from winning at tennis, or doing anything active without pain.

As a urologist and female pelvic medicine specialist, my most fulfilling role as a doctor is helping women like Amy understand this part of their body and talk openly about it. Pelvic organ prolapse is a condition affecting millions of women, yet many suffer silently, unsure of what’s going on and embarrassed to seek help. Hard to talk about? Well maybe a little, but that didn’t stop Amy from finding expert help, and eventually, a cure. In the pursuit of better health, it’s time for women to get empowered, not embarrassed!

What is pelvic organ prolapse and what causes it?

A woman’s pelvic organs include the bladder, vagina, uterus and bowels. Normally these organs are held in place by a supportive “bowl” in the pelvis made up of muscles, ligaments and connective tissue. This is known as your pelvic floor, or pelvic floor muscles. If part of the support system becomes weak, one of the organs can drop, potentially bulging into (and sometimes out of) the vagina. Where the weakness occurs determines whether it’s the bladder, uterus or bowels that fall, but many women have more than one organ involved.

A common symptom of pelvic organ prolapse is the sensation of a bothersome vaginal bulge. Heaviness or pain in the lower back, like in Amy’s case, can result. Some women also notice painful intercourse, or changes in urinary or bowel function.

So why does this happen? One of the main risk factors for developing pelvic organ prolapse is vaginal childbirth. Childbirth can injure the supportive structures of the pelvic floor, particularly a prolonged labor or difficult birth. A resulting prolapse can happen soon after birth or may take years to fully develop. The good news is that of all women who develop some degree of pelvic prolapse, only about one in nine will ever need surgical intervention. Other risk factors for prolapse include genetics, some diseases that are associated with loose ligaments, increased weight, aging, menopausal changes, and the effects of smoking.

Who can treat pelvic organ prolapse?

If your symptoms are complex, it’s important to seek out a urologist or gynecologist with additional training. Look for those with a subspecialty in Female Pelvic Medicine and Reconstructive Surgery (FPMRS). This indicates a level of expertise specific to the pelvic floor, to help ensure an assessment of your urinary, vaginal, and bowel function and discussion of a full range of treatment options.

Amy gets ready backstage.

Amy and Dr. Lee get ready backstage to appear on New Day Northwest.

What are the options for treating pelvic organ prolapse?

One option is to do nothing – really! It’s a valid approach for women who have minimal symptoms or no symptoms at all. Even women who have evidence of pelvic organ prolapse may not require treatment. When the symptoms of prolapse get in the way of life, the time is right to discuss treatment. The types of symptoms vary greatly among women, depending on what structures are involved and individual anatomy. Some women can have severe prolapse and not be bothered by it, while others who have a mild or moderate case may have a lot of symptoms. Feeling the effects of prolapse also varies a lot based on activity level and even the time of day. Lying down or taking a break from being on your feet can improve prolapse symptoms.

And here’s more good news: There is no harm in having sexual intercourse. The walls of the vagina are designed to be elastic and mobile, and can flex comfortably during sex.

But if pelvic organ prolapse causes bothersome symptoms and is affecting your health and quality of life, it’s time to discuss your options with a specialist. You will undergo a complete medical history and vaginal examina­tion to determine your “stage” (degree of prolapse).

Non-surgical treatment options

  • Pelvic floor exercises (Kegel exercises). Yes, Kegels are key to pelvic floor health, and if done properly, can strengthen weakened muscles enough to improve or prevent the worsening of early stage prolapse. Be sure to get information on the proper technique from your doctor.
  • Pessaries. A pessary is a silicone device inserted in the vagina that provides mechanical support to the prolapsed or­gans, thus relieving symptoms. They may require some trial and error for sizing and fit, but pessaries work well for some women.

Surgical treatment options

Amy, my patient, started with both Kegels and a pessary to relieve her prolapse symptoms, but it was clear she needed more help. She remembers thinking she could have done a million Kegels and it would not have reversed her prolapse. For her the pessary was uncomfortable. Together, we made a surgical plan that would get her back to all her favorite activities.

Surgery to correct pelvic organ prolapse is as varied as the women who have it: even women with the same type of prolapse may need a different approach. Amy’s procedure was done vaginally (they also may be done through abdominal incisions). I performed a vaginal hysterectomy (removal of the uterus), a vaginal vault suspension (using sutures to restore the deepest part of her vagina to its natural position), and a cystocele (prolapsed bladder) repair.

Once Amy healed from the surgery, she was back to beating her husband at tennis and living her life without discomfort. Remember: Overcoming fear and the stigma of talking about your body (plus finding expert help) can have big rewards for your health.

Dr. Una Lee

Dr. Una Lee

Una Lee, MD, is board certified in Urology and subspecialty certified in Female Pelvic Medicine and Reconstructive Surgery (FPMRS) at Virginia Mason. Other Virginia Mason physicians certified in FPMRS include: Kathleen Kobashi, MD, FACS; Alvaro Lucioni, MD and Blair Washington, MD, MHA.