Urinary Retention – Pelvic Organ Prolapse
Often healthcare providers think of incomplete bladder emptying as a male urological problem however, women can suffer from structural abnormalities that contribute to incomplete bladder emptying as well.
When the pelvic floor becomes lax due to childbirth, weight gain, pushing due to constipation, etc – there is a risk that the bladder, intestines, uterus, or rectum may fall into the vaginal vault. This pelvic organ prolapse may put pressure on the urethra and/or the bladder. It can also kink the urethra – preventing the bladder from emptying to completion.1
When a female presents to your clinic with complaints of slow urinary stream or describing a feeling that "... something is coming out of my vagina not allowing my bladder to empty” – think pelvic organ prolapse.
Usually, a woman with these complaints may be:
- In childbearing years
- Post-menopausal
- Has had previous surgical intervention to the vaginal vault – such as a hysterectomy
A woman can have a single organ prolapse or multiple organs prolapsing at one time. Either way, the patient may experience incomplete bladder emptying, recurrent urinary tract infections, and/or dyspareunia (painful intercourse).2
An easy visual for patients to help them understand organ prolapse.
“You have a trampoline holding up the anterior wall or upper wall of the vagina which supports the bladder; a trampoline at the top or apex of the vagina which supports the uterus and intestines; and a trampoline on the back wall of the vagina that holds the rectum in place.
Weakness to any of these trampolines could cause sagging or prolapse of pelvic organs into the vaginal vault. The organ prolapsing into the vaginal vault may lead to obstruction."
Vaginal prolapse or loss of the integrity of the vaginal walls can result in defects referred to as cystoceles, rectoceles and enteroceles.
A cystocele is the loss of support of the anterior vaginal wall often related to childbirth or weight gain. This muscle weakness allows the bladder to fall into the vaginal vault and potentially pinch off the urethra – making it difficult for the bladder to empty.3
A rectocele is a weakness of the posterior vaginal wall often related to constipation. This weakness can create pressure on the urethra and make it difficult to pass urine.1,4
Lastly, an enterocele is a vaginal wall weakness often caused by some sort of vaginal surgery. This weakness allows the small bowel to migrate into the vaginal vault, from the superior aspect of the vagina, often kinking the urethra and not allowing the bladder to empty.1,5
Each of these defects can affect the positioning of the urethra resulting in the inability to completely empty the bladder. A pelvic exam can help identify and confirm pelvic floor prolapse.
Incomplete bladder emptying can be confirmed using a bladder scan. If there is evidence of incomplete bladder emptying and patient’s symptoms are consistent with an obstructed voiding pattern, then there are a few clinical procedures which may confirm that treating the vaginal prolapse would improve bladder emptying.
A provider could place a pessary in clinic. Fill the bladder up with approx. 350 ccs of Normal Saline using a catheter, remove the catheter and then have the patient void. Repeat the bladder scan and see if the bladder empties to completion and voiding symptoms improve.
Urodynamics can also be completed to obtain this information. If the bladder empties more easily and voiding symptoms improve, then the focus should be on treating the pelvic organ prolapse.
There are times when intermittent catheterisation may be necessary to assist in bladder emptying – short term, while other interventions are in process, or as a long-term solution if that is in the patient’s best interest.
Surgery may be necessary to treat patients who are reasonable candidates. Reconstruction of the vaginal vault would hopefully provide adequate support improving bladder emptying.
Conservative interventions may include weight loss, physical therapy to help strengthen the vaginal vault, use of a pessary to alleviate the prolapse, or possibly manual manipulation of the prolapse to allow the bladder to empty.
References: 1. https://www.mayoclinic.org/diseases-conditions/pelvic-organ-prolapse/symptoms-causes/syc-20360557 2. https://www.urologyhealth.org/urology-a-z/b/bladder-prolapse-(cystocele) 3. https://my.clevelandclinic.org/health/diseases/15468-cystocele-fallen-bladder 4. https://my.clevelandclinic.org/health/diseases/17415-rectocele 5. https://my.clevelandclinic.org/health/diseases/16966-enterocele
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