Bladder (Neck) Position Changes with Childbirth and the Effect on Continence

Your bladder sits upon the fantastic, and complex hammock of your pelvic floor, as does your uterus and bowel, and the pelvic floor acts as a gateway to the openings of these organs, in part responsible, or contributing to continence both urinary (wee) and bowel (faecal).

Here’s a simplistic diagram of the relationship of your pelvic organs and the pelvic floor - courtesy of the Continence Foundation of Australia (1).

Once upon a time we referred to the pelvic floor as the muscular structures belying the pelvic area, running front to back from the pubic bone to coccyx, and laterally between the ishium bones, or sitting bones as they are often referred to. A more modern understanding of the pelvic floor (2) encompasses the organs within the pelvis;  the bladder, uterus, bowel, as well as the nerve and blood vessels which supply them, and the muscles of the pelvic floor, upon which everything rests. 

We understand through the complex structure of the pelvic floor that the position of these organs, pressure in the urethra, (tube through which we pass urine) and pressure in the rectum (exit passage for faecal matter) is determined in part by pelvic floor function. 

The pelvic floor is understood in a layered approach, with superficial and deep components, and sub components within each section responsible for slightly different functions.

We hero the Levator Ani  (see image attached) as it has a U-shaped arrangement which causes a forward and upward pull on contraction. This has the ability to assist the faecal continence mechanism via increased angle of the rectum (creating a kink  in the rectum so faecal matter can’t pass through) and urinary continence by increasing pressure in the urethra so that the pressure is higher than the bladder than the urethra, and therefore urine tends not to leak out  note this is a very simplified outline, many different neurovascular, muscular and even psychosomatic factors are involved in pelvic floor contraction and the continence mechanism, which aren’t included here today!)

Pregnancy and childbirth tend to place excessive pressure not only on the pelvic floor, but the non- contractile components of the pelvic floor - (think ligamentous and connective tissue structures which hold the organs in place, nerves, organs and blood vessels…)  via mechanical pressure from the weight of the growing baby, as well as the pelvic floor muscles being stretched to the tune of 2.5-3.5 x resting length during vaginal delivery, and hormonal impact on the supportive connective tissue creating a generalised softening effect on many of the body's connective tissue structures.

So we often see a change in position of the pelvic organs, known as Pelvic Organ Prolapse - to varying degrees - from no known symptoms - through to significant symptoms and effect on a woman’s daily life. Other signs and symptoms related to prolapse can include:

• frequent voiding or the urge to pass urine
• urinary incontinence (unwanted loss of urine)
• not feeling relief right after voiding
• frequent urinary tract infections
• pain in the vagina, pelvis, lower abdomen, groin or lower back
• heaviness or pressure in the vaginal area
• sex that is painful
• tissue sticking out of the vagina that may be tender and/or bleeding

As mentioned, it is important to note that in some cases of prolapse may not cause any symptoms. 

Ordinarily the bladder and bladder neck are positioned as shown in the left hand diagram, but in women who have had a baby vaginally, the position of the bladder and the bladder neck is changed - the bladder often prolapses backwards into the vaginal canal, which affects the overall lie of the bladder the continence mechanism - see below. In severe cases, this can actually mask incontinence - due to a large kink being caused in the urethra, and in other more mild cases, pressure and anatomy changes make it more difficult to maintain continence under stress and strain.

Treatment can involve pelvic floor muscle training, pessaries, activity modification, and compression wear designed specifically for pelvic organ support - such as our Core Support products - Recover Postpartum Support Shorts and Sacred Support Maternity Shorts.

If you have symptoms of POP or SUI we recommend seeing a women’s health physiotherapist for an assessment, as there are many things to consider when deciding which treatment approach may be right for you, and to ensure you have the right diagnosis. You can also assist symptoms by maintaining a healthy weight, addressing chronic constipation, coughing or smoking, and avoiding repeated heavy lifting (especially without the correct technique) and seeing a womens health professional (did we mention that again?) - yes because we can’t stress highly enough how much this can help you along the road to accurate diagnosis and recovery. You can thank us later ;0

According to recent studies based in Japan (4,5) wearing a pelvic floor supportive garment is almost as effective as a pelvic floor training program, and can significantly alleviate symptoms of SUI, as well as improve the position of the bladder neck, meaning a reversal of some of the contributing factors as to why you may experience leakage in the first place. We recommend combining supportwear and exercise for best results, or as recommended by your health professional.

Our products are founded on this knowledge and are very excited to be forging ahead with our own research on our products and their positive impact on pelvic health, in partnership with Swinburne University, as part of our mission to understand, innovate, and advocate for women’s health issues.

References

1. Image courtesy of The Continence Foundation of Australia
2. ICS / IUGA definition of the Pelvic Floor  : An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for the conservative and nonpharmacological management of female pelvic floor dysfunction. Kari Bo 1, Helena C Frawley 2, Bernard T Haylen 3, Yoram Abramov 4, Fernando G Almeida 5, Bary Berghmans 6, Maria Bortolini 5, Chantale Dumoulin 7, Mario Gomes 8, Doreen McClurg 9, Jane Meijlink 10, Elizabeth Shelly 11, Emanuel Trabuco 12, Carolina Walker 13, Amanda Wells 14. Int Urogynecol J. 2017 Feb;28(2):191-213
3. Taniguchi T1, Kobayashi Y1, Takaoka S1, Kobayashi H2, Mitsui T1, Yoshiyama M1,Takeda M1. University of Yamanashi. Pelvic Floor Supportive underwear enhances alleviating effect of pelvic floor muscle training on lower urinary tract symptoms in pelvic organ prolapse patients. ICS, 2016
4. Taniguchi T1, Kobayashi Y1, Takaoka S1, Kobayashi H2, Mitsui T1, Yoshiyama M1,Takeda M1. University of Yamanashi. (2018) Evaluation of a novel underwear which supports the pelvic floor in pelvic organ prolapse patients. 
5. Hagen S et al. Pelvic floor muscle training for secondary prevention of pelvic organ prolapse (PREVPROL): A multicentre randomised controlled trial. Lancet 2016 Dec 20; [e-pub]. Further reading recommendation: Evaluation and Treatment of Urinary Incontinence, Pelvic Organ Prolapse and Faecal Incontinence (ics.org)