Saturday, October 17, 2009

Are Women with Pelvic Organ Prolapse at Risk for Other Hernias Elsewhere in Their Bodies?

This is such as interesting question, because when I see patients who present with a cystocele, vaginal vault prolapse or rectocele, I will often help describe it as a “bladder hernia” or “rectum hernia”. In essence it is, since a hernia is a defect in muscle or fascia (connective tissue) that when sufficiently weak will allow another organ usually to push out or through. We think classically of a male groin hernia, after lifting a heavy box. The fascia in the groin will tear or become weak, allowing the small intestine to push through creating pain and a bulge.

The same can be said of pelvic organ prolapse. Muscle weakness and fascia injury from hysterectomy, childbirth or age/menopause develop and will allow the pelvic organs to push down on the various vaginal walls creating a bulge. The more severe the hernia/prolapse, the more bulge/pain and symptoms are created, whether urinary, defecatory, or with sex.
The next question is: if hernias are more common in women with POP (pelvic organ prolapse), where in the body should we look out for it, and why is this happening in the first place?

A recently published study addresses at least the first question, but a lot of research in the past 5 years has addressed the second question. Researchers in Israel performed quite a simple chart review of 60 patients they had treated surgically for POP and compared them to 60 controls. They found that the total prevalence of hernias in the POP group was significantly higher vs. those without POP. Nearly 32% in the POP had hernias elsewhere in the body vs. only 5% in controls. This was a huge difference! Women with POP were more likely to have hiatal hernias (16.6% vs. 1.6%), as well as inguinal (groin) hernias (15% vs. 3.3%). [Hiatial hernias can lead to gastric reflux).

Collagen is the substance of connective tissue in the body and there are many collagen types. Some are stronger than others. There is mounting evidence that certain proteins which degrade collagen faster or at higher levels in women with POP. These proteins are often regulated by estrogen which can affect the balance of destruction of old collagen and production of new collagen. Add childbirth, menopause, and hysterectomy and you’ve got a “golden recipe” for POP (and stress incontinence). This logically suggests that weaker collagen is not just a pelvic problem but a problem of collagen throughout the body wherever collagen is relied upon to confer strength to an organ or tissue.

Of course most women do not undergo surgery for POP or incontinence, in fact just over 10% do over the course of their lifetime. However, POP and incontinence do run in families and now we are finding out why. So now you ask your mother, aunt or grandmother if they have pelvic floor problems to see what your risk factors are, but also ask them about other hernias as well.

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