cancer control fall prevention health consumerism mental fitness mental health nutrition physical fitness weight control wellness center

andropause incontinence kegel exercises men's sexuality prostate health women's sexuality find a pelvic health specialist

addison's disease arthritis diabetes center eating disorders gout center heart disease caregiving chronic pain

bookstore ebooks wellness store underwear buying guide product catalogs

overview viagra the complications of medication the future vulvar/vaginal disease another viewpoint resources diabetes and sexual health sex and the heart

anatomy physiology anatomical problems diagnosing the problem the hormone theory of treatment vasculogenic theory

home pelvic health women's sexuality overview anatomical problems

women's sexual anatomy problems

by Chris Steidle, MD

Symptomatic Pelvic Relaxation

While childbirth definitely has rewards, children do not arrive without lasting effects, both good and bad, on their mother. After childbirth, many women begin to have problems with loss of urine while coughing, sneezing, laughing or movement and a few even have difficulty maintaining rectal sphincter control. Childbirth or hard manual labor can also lead to prolapse of the uterus, bladder or rectum.

If a woman’s bladder begins to “drop” she may experience increased difficulty in both social and intimate situations. Fortunately, many women may experience only slight dropping of the bladder, called cystocele, without experiencing any loss of urine. When a woman’s urethra loses support, she will leak urine when the pressure on the bladder exceeds the capacity of the urethral sphincter to hold the urine back. This is often called stress incontinence. Many women notice this during coughing, sneezing or when they push or pull something heavy. Some women experience loss of urine while walking, especially when their bladder becomes full. Not only is the loss of urine a problem, but also the bladder can actually change its position enough so that it becomes somewhat of a barrier in the anterior portion of the vagina and makes penetration during intercourse more difficult.

In addition, women that experience loss of urine may suffer damage to their self-image and they may not feel that they can stay as clean as they would like to be. Both feelings can indirectly affect spontaneous intimacy. Women who lose urine during intercourse often begin to avoid the act entirely because of the embarrassment they feel.

Women with stress incontinence may benefit from a surgical repair if other such conservative measures as Kegel exercises, insuring that adequate estrogen levels are present, or biofeedback exercises do not work.

Urge incontinence, which may or may not be associated with an anatomical defect, is another indirect concern for many women in terms of their sexuality. Women who have detrusor muscle instability (urge incontinence) often may be getting up more than two times a night just to urinate. These women may lose urine even without an increase in anterior abdominal pressure and they become fearful of this happening in various situations. This condition can often be successfully treated with medication.

Uterine Prolapse

When symptomatic pelvic relaxation progresses until the uterus and cervix relax into the vagina or even sometimes outside the vagina, the potential for problems with intercourse become obvious. Often a patient complains about pressure when standing for long periods or that their partner is bumping something with deep penetration during intercourse. An examination may reveal that the cervix appears to be in a normal position when the woman is lying on the exam table. However, when she is asked to bear down, the cervix may progress to the vaginal opening and sometimes beyond. In this situation, a pessary (a rubber or vinyl-covered wire inserted into the vagina) can stabilize the patient until surgery can be performed. Once the cervix bulges beyond the vaginal opening, no training regimens are effective at bringing the organs back to their normal position.

In women that have had hysterectomies, the top of the vagina where the cervix once was may also be prone to bulge beyond the vaginal opening. This area is commonly referred to as the vaginal apex or vaginal cuff.

Women can have partial or complete inversion of the vagina to the point where the tissue bulges out beyond the vaginal opening and sometimes stays there. This is often the result of the small intestine pushing into the vagina to create a hernia called an enterocoele. These may occur by themselves or in combination with the bladder (cystocele) and or with the rectum (rectocele.) Many women can be effectively treated for these conditions with a pessary. Since women are living much longer and are more active in later stages of life, they may use a pessary initially and then later require more definitive surgical therapy. The repair of vaginal apex support can be performed either from a vaginal or abdominal approach. The vaginal approach is favored by many gynecologists because they can obtain good anatomical results and the patient does not have to endure the discomfort of an abdominal wall incision.

One method of repair is to use remnants of the utero-sacral ligaments, which are thickenings of connective tissue and not true ligaments. The utero-sacral ligaments extend from the base of the uterus and the cervix to the sacral area. Often these are plicated or brought together and shortened, and once the enterocoele or hernia sack is reduced, they can provide support to the vaginal apex.

Many women will benefit from having the top of the vagina attached directly to the right sacrospinalis ligament. This is a true ligament that extends from one bony process to another in the pelvis. The right side is most commonly used because using the left side often involves displacement of the sigmoid colon. Sacrospinalis ligament fixation of the vaginal apex is often done in conjunction with both an anterior (bladder) repair as well as posterior repair (rectocele).

When a woman has marked, genuine, stress incontinence many gynecologists see dramatic short term and long term improvement when a sling type procedure is used to support the urethra. This is either done by the gynecologist or in conjunction with a urologist that is familiar with women’s incontinence.

Rectocele is a herniation of the rectal bowel into the posterior side of the vagina, which also may present as tissue bulging outside the vaginal opening. For some patients, a rectocele bulging outside the vagina may be their only complaint and they have absolutely no difficulty expelling bowel movements. Other women may have much smaller rectoceles and yet they have many problems. Treatment of rectoceles involves a long term strategy including but not limited to avoiding constipation, possibly changing employment, and learning not to hold one’s breath when pushing, pulling or lifting. This may take many training sessions. Furthermore, women who smoke are advised to dramatically reduce or eliminate their smoking. Not only does smoking seem to weaken the tissue but also the accompanying “smoker’s cough” can be disastrous to surgical repairs. Many gynecologists prefer that the patient have her constipation evaluated and under control prior to any surgical repairs. In addition, patients that have experienced a progression of their pelvic relaxation condition should be counseled that their body is prone to this kind of problem and they must modify their life style at the same time as their surgical procedure to achieve the desired postoperative affect.

References

1. Take pressure off your sex life. High blood pressure can contribute to sexual problems, as can some treatments for it. Harv Heart Lett, 2004. 15(2): 4.
2. Exercise can spice up your sex life, the American Council on Exercise says. 2005, Medical News Today.
3. Survey of literature. J Sex Med, 2005. 2(2): 279-282.
4. Althof, S.E., et al., Psychological and Interpersonal Dimensions of Sexual Function and Dysfunction. J Sex Med, 2005. 2:793-800.
5. Althof, S.E., et al., Current perspectives on the clinical assessment and diagnosis of female sexual dysfunction and clinical studies of potential therapies: a statement of concern. J Sex Med, 2005. 2 Suppl 3: 146-53.
6. Basson, R., et al., Summary of the recommendations on sexual dysfunctions in women. J Sex Med, 2004. 1(1): 24-34.
7. Basson, R., et al., Assessment and management of women's sexual dysfunctions: problematic desire and arousal. J Sex Med, 2005. 2(3): 291-300.
8. Berman, J., L. Berman, and E. Bumiller, For women only: a revolutionary guide to overcoming sexual dysfunction and reclaiming your sex life. 2001, New York: Henry Holt and Company.
9. Berman, L., J. Berman, and A.B. Schweger, Secrets of the sexually satisfied woman: ten keys to unlocking ultimate pleasure. 2005, New York: Hyperion.
10. Block, J.D. and S.C. Bakos, Sex over 50. 1999, New York: Penguin Putnam Inc.
11. Bohlen, J.G., et al., Heart rate, rate-pressure product, and oxygen uptake during four sexual activities. Arch Intern Med, 1984. 144(9): 1745-8.
12. Bultrini, A., et al., Possible correlation between type 1 diabetes mellitus and female sexual dysfunction: case report and literature review. J Sex Med, 2004. 1(3): 337-40.
13. Cetel, N., Double menopause: what to do when both you and your mate go through hormonal changes together. 2002, Hoboken, NJ: John Wiley & Sons, Inc.
14. Comfort, A., The new joy of sex. 1991, New York: Crown Publishers, Inc.
15. Davis, S.R., et al., Endocrine aspects of female sexual dysfunction. J Sex Med, 2004. 1(1): 82-6.
16. Esposito, K., et al., The metabolic syndrome: a cause of sexual dysfunction in women. Int J Impot Res, 2005. 17(3): 224-6.
17. Farnham, A., Is sex necessary? 2003, Forbes.com.
    http://www.forbes.com/2003/10/08/cz_af_1008health_print.html
18. Gisquet, V., Better sex diet. 2005, Forbes.com.
    http://www.forbes.com/2005/03/17/cx_vg_0317feat_print.html
19. Goldstein, I., Sexual medicine treatment: lifestyle or life quality? The import of language. J Sex Med, 2006. 3(2): 191-3.
20. Goldstein, I., et al., Women's sexual function improves when partners are administered vardenafil for erectile dysfunction: a prospective, randomized, double-blind, placebo-controlled trial. J Sex Med, 2005. 2(6): 819-32.
21. Hakim, L.S. and D.M. Platt, The couple's disease: finding a cure for your "lost" love life. 2002, Delray Beach, FL: DHP Publishers, LLC.
22. Harrar, S. and J. VanTine, Extraordinary togetherness: a woman's guide to love, sex and intimacy. Prevention Health Books for Women. 1999, Emmaus, PA: Rodale Inc.
23. Hatzichristou, D., et al., Clinical evaluation and management strategy for sexual dysfunction in men and women. J Sex Med, 2004. 1(1): 49-57.
24. Hayes, R. and L. Dennerstein, The impact of aging on sexual function and sexual dysfunction in women: a review of population-based studies. J Sex Med, 2005. 2(3): 317-30.
25. Heinemann, L.A., et al., Scale for Quality of Sexual Function (QSF) as an outcome measure for both genders? J Sex Med, 2005. 2(1): 82-95.
26. Hitti, M., Weight loss may help your sex Life, in Medscape Today. 2005.
    http://www.medscape.com/viewarticle/514784
27. Hooper, A., Anne Hooper's Kama Sutra. 1994, London: Dorling Kindersley.
28. Hooper, A., K-I-S-S guide to sex. Keep It Simple Series, ed. J. Williams. 2000, New York: Dorling Kindersley Publishing, Inc.
29. Kaya, C., et al., Sexual function in women with coronary artery disease: a preliminary study. Int J of Impotence Research, 2006, 1-4.
30. Kendall, P., Nuts gaining heart-healthy image, in Nutrition News--Colorado State University Cooperative Extension. 2002.
    http://www.ext.colostate.edu/pubs/columnnn/nn020225.html
31. Laumann, E.O., A. Paik, and R.C. Rosen, Sexual dysfunction in the United States: prevalence and predictors. JAMA, 1999. 281(6): 537-44.
32. Leiblum, S.R. and R.C. Rosen, eds. Principles and practice of sex therapy: update for the 1990s. 2nd ed. 1989, The Guilford Press: New York.
33. Lewis, R.W., et al., Epidemiology/risk factors of sexual dysfunction. J Sex Med, 2004. 1(1): 35-9.
34. Martin, A.C., It's never too late to start: seven steps toward good health, in Topics in Advanced Nursing Practice eJournal. 2002.
    http://www.medscape.com/viewarticle/421471
35. Meston, C. and P. Trapnell, Development and validation of a five-factor sexual satisfaction and distress scale for women: the Sexual Satisfaction Scale for Women (SSS-W). J Sex Med, 2005. 2(1): 66-81.
36. Meston, C.M., Aging and sexuality. West J Med, 1997. 167(4): 285-90.
37. Munarriz, R., et al., A review of the physiology and pharmacology of peripheral (vaginal and clitoral) female genital arousal in the animal model. J Urol, 2003. 170(2 Pt 2): S40-4; discussion S44-5.
38. Nappi, R., et al., Clinical biologic pathophysiologies of women's sexual dysfunction. J Sex Med, 2005. 2(1): 4-25.
39. Oberg, K. and K. Sjogren Fugl-Meyer, On Swedish women's distressing sexual dysfunctions: some concomitant conditions and life satisfaction. J Sex Med, 2005. 2(2): 169-80.
40. Quirk, F., S. Haughie, and T. Symonds, The use of the sexual function questionnaire as a screening tool for women with sexual dysfunction. J Sex Med, 2005. 2(4): 469-77.
41. Salonia, A., et al., Chocolate and women's sexual health: an intriguing correlation. J Sex Med, 2006. 3: 476-482.
42. Seftel, A.D., et al., eds. Sexual dysfunction: male and female. 2004, Mosby: New York. 312.
43. Sheehy, G., Sex and the seasoned woman: pursuing the passionate life. 2006, New York: Random House.
44. Siebert, D., Sexual health: counseling in primary care, in Medscape Today - National Conference for Nurse Practitioners 2001. 2001.
    http://www.medscape.com/viewprogram/852_childindex
45. Somers, S., The sexy years: discover the hormone connection: the secret to fabulous sex, great health, and vitality, for men and women. 2004, New York: Crown Publishers.
46. Tariq, S.H. and J.E. Morley, Maintaining sexual function in older women: physical impediments and psychosocial issues. Women's Health in Primary Care, 2003. 6(3): 157-162.
47. Tikiz, C., et al., Sexual dysfunction in female subjects with fibromyalgia. J Urol, 2005. 174(2): 620-3.
48. Wagner, G., et al., Ethical aspects of sexual medicine. J Sex Med, 2005. 2(2): 163-8.
49. Weijmar Schultz, W., et al., Women's sexual pain and its management. J Sex Med, 2005. 2(3): 301-16.
50. Yassin, A.A., Brain sex--testosterone role in personality evolution; females and males are different? J Sex Med, 2006. 3 Suppl 2: 81-82.
51. Yu, S. and J.W.G. Yarnell, Exercise for the prevention of cardiovascular disease: how vigorous and how often? Cardiovasc Rev Rep, 2004. 25(6): 274-276.

Posted January 2000
Last Updated July 2008

26 South Main Street, PMB #162 . Concord, NH 03301 . Phone: 603 397-0103