Dr. Jeff Sankoff answers your tri-training questions.
Dr. Sankoff,
While running the Honolulu marathon, my Pelvic floor collapsed (about 15km into the race). I had to walk it in (there was no place to get help) I went straight to emergency room to get a catheter. I have competed in many Ironmen and marathons and I have never heard of this before. Is this common? Things have settled down now. Is it safe to try and run?
Rita
The short answer: Uterine prolapse, as a result of pelvic floor collapse, is common in women with risk factors. Depending on the severity of the problem, various solutions are available.
The long answer: In women, the pubococcygeus muscle, as well as a number of ligaments support the uterus. If these structures become weak or stretched, the uterus may slip down into the vagina. This is called uterine prolapse and is more commonly referred to as pelvic floor collapse.
Symptoms of pelvic floor collapse depend principally on how far the uterus prolapses. Minor prolapse may only cause a sensation of fullness in the vagina or a feeling of pulling in the lower pelvis. More severe cases may result in urinary incontinence or an inability to urinate, frequent urinary tract infections, abdominal, back or pelvic pain and in the most severe cases, the uterus may even protrude from the opening of the vagina.
There are several risk factors for pelvic floor collapse:
• Multiple pregnancies with vaginal deliveries predispose to a weakening of the pelvic floor and stretching of the retaining ligaments.
• A retroverted uterus is angled towards the back instead of the front and may prolapse more readily.
• Older women tend to have weaker and more relaxed muscles of the pelvic floor. This is related to lower levels of estrogen seen with advancing age-especially in the period after menopause.
• Obesity places larger amounts of stress on the pelvic floor and may lead to prolapse.
• Activities that increase the pressure in the abdomen may cause undue pressure on the muscles of the pelvic floor, causing weakening and eventual prolapse. These include long standing constipation, heavy lifting and running. Running exerts further stress on the pelvic floor secondary to the constant jarring of the internal organs with each step.
Taking a careful history and performing a physical examination including a gynecological exam easily leads to the diagnosis of uterine prolapse.
Once the diagnosis is made, there are several therapeutic options available. Which one is best suited to the patient will depend on many things, including activity level, personal preference and the severity of the problem.
• For mild cases of uterine prolapse, Kegel exercises are recommended to strengthen the pelvic muscles. These exercises are easy to do and can be done anywhere, at any time. To perform Kegel exercises:
- Squeeze the pelvic muscles as though you are trying to hold back urine.
- Hold this position for a count of ten, then release slowly.
- Do this ten times, four times daily.
• A pessary is a rubber ring that is inserted into the vagina and props the uterus up. It may have limited usefulness and needs to be removed periodically for cleaning. However, for many women it is a viable option.
• For women with more severe cases of prolapse, surgery may be required in order to remedy the situation. Surgical options include hysterectomy, suturing of the pelvic floor to add strength and vaginal shortening. Each of these options should be considered in consultation with a surgical gynecologist.
As in most cases of chronic medical problems, the best treatment is to prevent the situation from developing in the first place. There are a number of things that can be done to aid in prevention of uterine prolapse:
• Regularly performing Kegel exercises, especially before and after childbirth, can help keep the pelvic floor strong.
• Avoid constipation. Straining from constipation stresses the pelvic muscles.
• Maintain a healthy weight through diet and exercise.
• Discuss hormone replacement therapy (HRT) with your doctor. HRT at menopause helps retain muscle tone, which may prevent uterine prolapse. However, there are health risks associated with HRT. You should discuss all of the potential risks and benefits with your doctor.
With respect to Rita’s specific case, the fact that she never had issues with pelvic floor collapse before is no longer relevant. For whatever reason, she developed prolapse at the 15km mark of that race and although it has since ‘calmed down’ the problem is still there. After consulting with her gynecologist to ascertain the severity of the problem, Kegel exercises are certainly recommended to try and prevent the prolapse from becoming more severe. As mentioned above, there are several other viable treatment options. Rita’s best choice will have to be made in consultation with her physician. Nonetheless, with proper treatment, there is no reason that she should not be able to continue running.
Train hard, train healthy.
Dr. Jeffrey Sankoff, MD, FRCP(C), is a two-time Ironman triathlete and ER physician based in Denver, Colorado. To learn more, visit Sankoff’s Web site
.If you have a question for Dr. Sankoff, please e-mail feedback@triathletemag.com Triathlete Magazine Interactive. Please include “Dr. Sankoff” in the subject line.