Urogynecology Expert Forum
Weak pelvic floor after hysterectomy
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Questions in the Urogynecology forum are answered by Bruce Crawford, MD, J. Kyle Mathews, MD, and other medical professionals and experts. Topics covered include overactive bladders, bladder pain, fallen/drooping bladder, bowel urgency, bowel prolapse, cystitis, incontinence, pain with intercourse, rectal prolapse, surgery, urinary urgency, and uterine prolapse.

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Weak pelvic floor after hysterectomy

Hello,
Thank you for taking my question. I am 42 years of age and 6 months ago I had a TAH-BSO due to complex endometrial hyperplasia with atypia. There were no complications post-op and I began taking Estrace 6 weeks after surgery once the pathology report revealed I was free of cancer. I am fit, eat very well and exercise daily (run 6 to 9km daily).

Since surgery I have been unable to fully evacuate my stool. Initially I thought that I was constipated and took measures (stool softeners) to assist, yet never did the consistency of my stool suggest constipation, nor did the stool softeners make evacuation any easier. It seemed as though I no longer had any strength in my pelvic floor. By good luck rather than good management, I happened upon a "procedure" that helps. If I place my had (wrapped in toilet paper), on the area between the vagina and the rectum, and push up while trying to evacuate- VOILA!! I am able to easily evacuate the stool. Frequently throughout the day I am subjected to preforming this manoeuvre as I often feel the need to pass a bowel movement even if the movement is very small. If I don't help myself along, I can sit and strain (forever) and absolutely nothing will come out, but add a little lift and all is well.

I'm not a fan of this situation and wonder why I'm experiencing this symptom and if I can expect to regain strength or if this weakness is something with which I will need to learn to live? I should add - I have had two vaginal births, the first resulted in a tear from vagina to rectum, the second just a small tear. I did have a colonoscopy one month ago as a routine check due to colon cancer in our family and nothing was mentioned regarding any irregularities.

Thank you kindly for any insight you can provide.
Sincerely,
Warmwave
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Hello, Thanks for your question.

I am not clear on why this problem arose when it did.  The need to splint the perineum or back wall of the vagina to facilitate bowel movements is fairly common among women with posterior vaginal wall (back wall) prolapse.  In a recent article I read it seemed somewhat common among women without prolapse as well.  I suspect you are correct in your opinion that this is a neuromuscular problem.  

We have not done a very good job education women (and men) about the relevance of pelvic floor neuromuscular fitness.  It seems that routine exercise may not be sufficient to maintain fitness of the pelvic floor. There is not much data on the effects of hysterectomy on pelvic floor performance but it stands to reason that they may be a negative impact.  

We have long recognized the need for greater offerings in the field of pelvic floor fitness training; offerings beyond the traditional recommendation to "do your Kegel's).  We spent a year studying the effects of classic mat Pilates, Yoga, and personal training movements on the pelvic floor.  We created the PFilates program (available on line) which is a available.  The ten Pfilates movements are simple movements but must be done correctly.  The program is designed to develop strength, endurance, and coordination and may be of benefit to you.  good luck

Bruce Crawford MD
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