Hug To Health

1. definitions:

For uterine tumors, also known as fiber fibroids (fibromyoma), uterine fibroma (fibroid). But mainly composed of smooth muscle fibers, the smooth muscle of the uterus known as (uterine leiomyoma) is more precise. As uterine fibroids (uterine myoma).

To see most of the female pelvic tumor, it is estimated that 35 women over the age of every four or five people out of a uterine fibroid patients. Many uterine fibroids and asymptomatic patients in the census found, or because of other diseases laparotomy or autopsy found. At present, all over the reported incidence rates are from the Department of the number of hospitals for treatment.

Uterine fibroids occurred in more than 40 years of age and over 50-year-old age group. In the United States, the incidence of black higher than whites, but in the growth of black African native notification rate is very low, and that its occurrence has nothing to do with genetic.

2, pathophysiology:

The largest growth in the womb of the Department, even some who grew up in the Department of the cervix. Most of the growth in muscle intramural (intramural fibroids intramural myoma), accounting for 62% of the total number of fibroids, or in subserosal (subserosal fibroids subserousmyoma, for the muscle to the intramural fibroids subserous prominent, highlighted the extent Different, and sometimes serosal fibroids-only based Linked), accounting for 15% or submucosal (submucosal fibroids submucousmyoma, also highlighted the extent of different, sometimes there are still some muscle intramural fibroids, and sometimes completely To highlight intrauterine), accounting for 21 percent. More and more of uterine fibroids (multiple uterine fibroids mutiplemyomata), the same type or a different type can also be a single, great disparity between the size, can be only a small grain of rice, even under the microscope can only identify large to achieve the full-term Uterine pregnancy; general for the middle, over five to six months of pregnancy, the uterus is rare, there may be regional differences, such as in Africa can see that larger (but for the poverty-stricken areas may also visit late this reason), when to visit For more than two to three months of pregnancy the uterus. Tumor growth can change shape of the uterus, especially multiple uterine fibroids or subserosal fibroids, but only a single muscle submucosal fibroids or intramural tumor may also maintain the original shape of the uterus, but larger than normal. In the growth of uterine fibroids can be wall extended around the same side of the broad ligament between, known as the broad ligament fibroids (intrabroadligamentous myoma). But there is a broad ligament of the fibroids in the uterus by the broad ligament adjacent smooth muscle fiber from the growth in the broad ligament in growth, and completely unrelated to the uterus wall.

Submucous fibroids grow up gradually from the cervix after prominent in the vagina, it is the Book of Changes vaginal examination found that gradually grow up extraoral also prominent in the vagina. Submucous fibroids may Pokui, infection, with submucosal fibroid growth, from outside, the attachment of the pedicle wall can be inside the Palace depression, as depression degree of attachment location and extent of tumor emerge vary Palace at the end of attachment, the degree of ptosis Weight, the greater the degree of depression, or even a Man Xingzi intrauterine up.

Subserous individual, based on their growth process more detailed, finally cut off from the original attachment site, and the tumor was attached near the organ, or peritoneal omentum to survive, grow and become parasitic tumor (parasitictumor).

Cervical fibroids can grow in the first lip of the cervix, after the lip or the entire cervix, the size of normal at this time is located in the Palace on the cervix. Swell of the cervix and the rich blood supply, greatly increasing the difficulty of the surgery and dangerous. XIONG Qing Lung, and other reports two cases of cervical huge leiomyoma, an isthmus in the cervix, after a cervical lips, Jieru size of the first child, has abdominal growth, the growth has always been the vagina.

There is no package wall uterine fibroids, muscle intramural, fibroids oppression around the muscle fibers, when the incision surrounding tissue, fibroids prominent, with clear boundaries around the organization, around the uterine muscle wall compression organizations like fibroids “capsule “Fibroids around very easily from the” envelope “of separation.

Sedan fibroids surface, shiny, smooth, profile visit was vortex, cable Strip.

For the smooth transfer of a very rare disease, and foreign literature about a dozen cases reported so far. Uterine tumors associated with lung metastasis, but also in the para-aortic lymph nodes, limbs rhabdomyosarcoma, and the scar on the skin, vagina stump, etc. are smooth organization. Guoguan in the autumn of 1957 reported cases of a tumor was smooth transfer of the right lung on the lesions, see under the muscle fibers of the disease.

Peritoneal dissemination of the smooth muscle of smooth muscle in ovarian tumors, round ligament, in the genital serosal surface, the omentum, mesenteric wall and gastrointestinal cancer, etc. like the cultivation, roughly the same shape and smooth muscle tumor, sometimes cell rich, but Few split of the surrounding tissue without infiltration or sabotage, clinical process as benign, that is, when the whole uterus and bilateral annex removal, abdominal lesions can retreat. The causes of this disease is not clear, generally considered to be a multi-center.

Vascular smooth muscle of the uterine tumors can enter the vein, less into the lymphatic vessels. Organization of benign lesions, but into the vein, like emboli can be induced into the death. General inspection of uterine anomalies increased, as a leiomyoma, bladder and uterus broad ligament deconvolution peritoneal Biancu harden the vein, intravenous the leiomyoma was gray polypoid, 1 ~ 2 mm, 5 ~ 6mm or even 20 ~ 30mm thick, can still be extended to IVC, for more than 40 cm. 5 percent of patients confined to the blood vessels in the uterus, the vascular smooth muscle in blood vessels within the tumor can be pulled out, that is, there can be free in the cavity, can also be connected with the muscle wall. There are two sources of its argument, first, from vascular smooth muscle wall to the lumen in the development, first from outside the vascular smooth muscle of the vessel within Shenru. Examination of vascular smooth muscle cells within the tumor by the composition, such as smooth muscle tumor-like, on the rehabilitation of vascular endothelial cells, the tumor is thick wall of the small blood vessels. Cells were normal, with no split. Masson with three-color stain, that have different amounts of collagen fibers exist.

Strip-Search-muscle bundle was staggered by the connective tissue fibers interval, cutting面呈fascicular muscle cells or muscle cells type face, small blood vessels. Muscle cells from the uterine muscle layer, and some people think that the source for small remnants of embryonic cells, but also from that intramural vascular smooth muscle cells, and that its occurrence and to stimulate estrogen-related, occurred in reproductive age women, In the late menopause gradually shrinking. Oral contraceptives also contributed to its growth. Pregnancy swell of the entire muscle muscle hypertrophy, and not due to the increase in the number (Randoll and Odell).

Endometrial examination process to the smooth muscle of the uterine endometrial have the machinery of oppression, so that endometrial thinning, crushed glands, and around each other. Epithelium was cubic or flat, after ovulation response to the lack of secretion. Intrauterine deformation, often shedding endometrial abnormal. Muscle intramural uterine fibroids to increase the area; simple subserosal fibroids, uterine cavity may increase. Both the endometrial images can be a normal shape.

3, diagnosis:

Most of the result of menorrhagia, can find a small number of abdominal mass or from infertility treatment, in the abdomen and do a double vaginal hysterectomy swell up when found, or nodular smooth surface, thus diagnosed as uterine fibroids, And to identify tumor size, single or multiple, generally the growth of sites, activities or not, whether tenderness, a history of menopause should pay attention to whether the possible merger of pregnancy. 4, clinical manifestations: First, can no discomfort even if the tumor has reached a certain size, often due to other circumstances gynaecological examinations or occasionally to touch the abdomen when discovered.

Second, the majority of patients have menstrual changes in menstrual changes, for the period of performance and more by volume, menstrual prolonged menstrual extension, the volume does not significantly increase the number and volume of menstrual normal, but shorten the cycle, or for the volume, Date long, shorten the cycle; amount of bleeding more and more frequent, in submucosal fibroids and the larger intramural fibroids, endometriosis, submucosal area expanded significantly, and easy to necrosis, infection, bleeding, a long time , Or even shorten the cycle is an inevitable consequence of the large muscle intramural fibroids no doubt increased endometrial surface. Subserosal fibroids mainly for the growth period can not change. Normal endometrial cavity area of about 15 cm2, in the larger fibroids, endometrial area can be as high as 225 cm2, near the endometrial uterine fibroids are common in the large blood vessels, around a rich blood supply.

Can be associated with uterine fibroids without ovulation of menstruation, so that endometrial proliferation. It was reported 36 per cent of uterine fibroids with endometrial proliferation. In addition to uterine fibroids volume increase, affecting uterine muscle fibers contract, for the reasons for the increasing volume of menstruation.

Third, oppression symptoms of tumor growth due to location and size of produce different symptoms. Such as the anterior growth in the womb of a diameter of about 10 cm or more, they can pressure the bladder, a frequency, urgency, growth in the posterior wall of the uterus, uterine backward after Qu, the uterus before the tendency to shift, or Growth in the cervix, urethra and oppression can be in urine retention or dysuria, the back wall of uterine fibroids can also be greater pressure rectum, a defecation difficulties uterine fibroids incarcerated in the pelvis can both urination and defecation difficult . Growth in the broad ligament within the larger fibroids can be oppressive ureter, causing the side of the ureter, hydronephrosis.

Fourth, the general pain symptoms without pain, but in serous membrane under the pedicle fibroids may reverse acute abdominal cramps. In addition, the tumor may have degenerative changes have Duntong or more serious abdominal pain (red degeneration). Submucosal uterine fibroids through the cervix into the vagina from a more serious when the abdominal pain. Although large-uterine fibroids in the pelvic cavity, the same can be oppressed around the organs and tissues have Duntong and falling from flu, muscle intramural fibroids can produce or increase dysmenorrhea.

5, infertility uterine fibroids can change shape and uterine cancer itself as a foreign body can prevent implantation Yunluan, video sperm run, the growth of uterine fibroids in the corner of the fallopian tubes are changed or Gap between the Department of the Ministry of site or by Yunluan Sperm delivery. Syria on ovulation and menstruation without a higher rate. A lot of the uterine fibroids enucleation after conception is corroboration.

6, sometimes found in patients with abdominal change gradually Penglong abdomen, and even asymmetrical, easy to get up in the morning before the discovery, because often the bladder will swell to a pelvic uterine cancer, so that patients with relatively easy to hit hard, more surface is not smooth Mass, I found that because many of those attending come from.

So far, the cause of uterine fibroids is not yet clear. However, according to a large number of observation and experimental results show that fibroids is a dependent on the growth of tumors of estrogen. Such as clinical common in women of childbearing age, 30 to 50-year-old Most of especially in High-estrogen environment, such as pregnancy, high estrogen exogenous circumstances such as significant growth, and gradually narrow the fibroids after menopause. Fibroids in patients with congestive also accompanied ovarian, swell, endometrial hyperplasia, suggesting that this And too much estrogen to stimulate relevant.
In fact, fibroids including estrogen receptor-dependent. As in recent years from uterine fibroids and the endocrine-related research, experiments have confirmed leiomyoma by the estrogen receptor (ER) and progesterone receptor (PR ), Its density than the surrounding normal muscle tissue. ER, PR and changes in the menstrual cycle. There are reports of foreign sex hormones and uterine fibroids after Keluomifen increase, inhibit or prevent sex hormone levels reduce the growth of fibroids, shrinking muscle And of improving the clinical symptoms, suggesting that hormone-dependent tumors fibroids. Antagonism of hormone drugs can cure fibroids, but the determination of patients with fibroids peripheral blood of women without fibroids in the sex hormones, there was no significant difference between them. Description fibroids The occurrence of more patients with fibroids hormone related to the environment than with their own local fibroids endocrine abnormalities related to the environment. Estrogen such as fibroids in the uterine muscle than the concentration of high fibroids near the high degree of endometrial hyperplasia. Receptor So the situation, fibroids in the E2R (estrogen receptor) and PR in the uterus muscle than high.
From the Organization in view, have a uterine fibroids from the uterus muscle cells, blood vessel wall of the smooth muscle cells without mature into muscle cells, but the latter has not been clear on the organization of the concept. Organization study found that the growth is not long Small uterine fibroids, not only will the rich silk mature smooth muscle cells, but also found in fetal uterus to see immature smooth muscle cells. Uterine fibroids showed that the incidence of human potential from the undifferentiated mesenchymal cells into smooth muscle cell differentiation Process. Multiple uterine fibroids may be due to the origin of the myometrium, and more focus potential. This is not the points of mesenchymal cells are primitive cells fibroids, is the embryo of a multi-functional differentiation of cells. It has a biological media, Dependent on the proliferation of estrogen, progesterone on differentiation, mast. Enter sexual maturity, the residual muscle in the undifferentiated mesenchymal cells and smooth muscle cells of immature, estrogen and progesterone cycle under its own role continuity (self - perpetuating) proliferation, differentiation and mast during the long period of time again and again, until the formation of fibroids.

Pathological changes:

Typical of uterine fibroids is a substantive spherical mass, smooth surface or are convex.surface was cut white spiral Xianwen, microstrip grievances. Xianwen is fibroids in the formation of fibrous tissue, the hardness of fibroids Decided to fiber components, including the fibrous tissue, the more fibroids the white and hard. Instead, more fibroids in the smooth muscle cells, less fibrous tissue, uterine fibroids and the section of the muscle wall little color difference, And the quality is also soft. Fibroids appearance with a thin layer of coating, a fake capsule fibroids, the Department of fibroids from the connective tissue around the muscle wall beam and a bundle of muscle fiber. Coated with fibroids The links between osteoporosis and easy to Intramural fibroids from the muscle stripping. Coated in a cloth-like blood vessels with radiation to the blood supply fibroids nutrition. Fibroids is, the more rough vessel, the number more. Fibroids in the central and reduce blood vessels branch, when the fibroids Diameter of more than 4 cm above, fibroids centre that is vulnerable to degeneration.
Uterine fibroids the size difference between a great, the general cause of the clinical symptoms for more than eight to 16 weeks of pregnancy large, single infants are generally no more than the first, more generally, not more than six months of pregnancy large. Individual up to dozens of kg.
Uterine fibroids according to their location and growth of the relationship between the various floors of the uterus wall can be divided into three categories.
Uterine fibroids are starting from a muscular, if the fibroids has been in the muscle, known as the “intramural fibroids” or “mesenchymal fibroids,” most common. Intramural fibroids often multiple, the number of volatile, often One or several of the larger, sometimes for a large number of small nodules, all of the uterus wall, a massive integration of irregular Mission, a multiple uterine fibroids. Some people involved in the development of cervical or deep Fornix, and easy primary cervical fibroids and confused. Intramural fibroids because of better blood circulation, the less of a general degeneration, could severely deformed Palace, and the impact of the uterus to contract, due to increased volume of the uterus, within Membrane area increased from menorrhagia Guchang, the frequency and duration of menstrual extension.
Fibroid growth in the course of development, often less resistance to the direction. When its process to the uterine cavity, covered only the surface layer of endometrial, known as “submucosal uterine fibroids,” and even only a pedicle Connected with the uterus. Submucosal uterine fibroids become a foreign body cavity and cause the uterus to contract, the exclusion of decline of pedicle have gradually been extended, when up to a certain extent fibroids through the cervix, down from the vagina or even prominent in the Yam mouth, while Beattie attached by the Department of the Palace walls were pulling, and the inward Depression, when the depression increased, can form different levels of uterine inversion. Submucosal fibroids because of poor blood circulation based, and Tsunenobu Into the vagina, the vulnerable and necrosis, bleeding.

If the uterine fibroids to the surface prominent, and on its cover by a layer of peritoneal (not coated), referred to as “subserosal uterine fibroids.” If it continued to develop in the direction of abdominal cavity, can only end by a pedicle connected with the uterus , A pedicle of the subserosal uterine fibroids. Pedicle of the vessel containing fibroids is the only blood circulation as a result of torsion, tumor necrosis can be broken away from Beattie, fibroids loss in the abdominal cavity, the paste on nearby organs such as Omentum and mesentery, nutrition and access to the blood become a “parasitic fibroids” or “free of fibroids.” However, the omentum can reverse some or blocked blood vessels in case of leakage, formation of ascites caused by abdominal symptoms.

Fibroids in the uterus of a wall to the broad ligament stretching between two of the peritoneum, known as the “broad ligament fibroids,” under a serous type. But there is a broad ligament fibroids, by the broad ligament in the uterus of the next Growth from smooth muscle fibers, and completely unrelated to the uterus wall. Broad ligament in his growth fibroids often to the development of pelvic organs, blood vessels, such as changes in location and shape, especially ureter shift, resulting in surgery for the difficulties.
Round ligament of the uterus, uterine sacral ligament fibroids may also occur, but rare. Cervical Department with the development of uterine fibroids body. But because of its anatomical features, when the fibroids to increase the development of a certain extent, prone to the neighborhood Organs of oppression symptoms, often caused by childbirth obstacles, but also to increase the operation very difficult.

Uterine fibroids more than 90 percent growth in the uterine body, only a small number (4 to 8 per cent) occurred in the cervix, and after more than lip. In the body, more than at the end of the uterus, followed by the back wall, who in the anterior Less than half of the back wall, at least to both sides. Fibroids on the type, to the most intramural fibroids, subserosal fibroids followed by submucosal fibroids relatively rare.
Microscope can see: the muscle fiber with fibroids and normal muscle fibers are similar, but the muscle fibers fibroids than osteoporosis, sometimes with a “S” shape fan, a special Xuanwo Zhuang. Muscle fiber than regular long tired or Cuduan. In a long time Uterine fibroids fiber than the muscle fibers and long rough. Muscle fibers of the connective tissue between the more or less fiber, and occasionally the fibroids that many vessels (vascular fibroids) or the rich lymphatic fibroids (lymphatic muscular :). Muscle cells of diverse forms, but most were oval or rod-shaped, deep nuclei staining. In the muscle fiber cross sections, the cells were round or polygonal, is rich in the cytoplasm and in the central circle Nucleation; profile, and the spindle cells were more clearly the long-nuclear.

(A) infection and suppuration: fibroids of infection of more than torsion or intrauterine uveitis Ji Xingzi the consequences of blood-borne infection is extremely rare. Purulent infection can sometimes, a small number of cases in the tumors formed in the abscess.
Subserosal fibroids torsion after intestinal adhesion, may be subject to bacterial infections, inflammation of the uterine fibroids and annex adhesion, caused suppurative inflammation.
Submucous fibroids most vulnerable to infection, often associated with abortion or puerperal Ji Xingzi intrauterine uveitis coexist. Curettage some of obstetric surgery or injury caused by. As prominent tumor surgery or trauma often the tumor capsule rupture, after the rupture Vulnerable to rot and collapse occurred. Rot collapse often lead to serious irregular bleeding and fever. From the debris of corruption because of necrotic tissue loss of coloring reaction. Examination often can not get the results.

(B) reverse: subserosal fibroids may occur in the pedicle reversed, cause acute abdominal pain. Torsion of serious if not immediate surgery or can not be back, probably because of a free and Beattie Niuduan fibroids, If the foregoing has. Reverse the fibroids can also bring along the entire uterus, uterine axis of reversing cause and reverse the uterine cervix in many parts of the population within the vicinity, but this rarely occurred more because of the larger attachment subserosal fibroids In the bottom of the uterus and the cervix is caused by a slender. Symptoms, signs and ovarian torsion capsule of the past only to be hard mass.

(C) the merger of uterine fibroids in the uterus cancer: uterine fibroids in the uterus cancer, the merger of two percent, than the merger of uterine fibroids, cervical cancer is higher. Uterine fibroids with menopause is a continued bleeding, there should be vigilant Endometrial cancer exist. In determining treatment, consultation should be done scraping.

(D) of uterine fibroids with pregnancy

Uterine fibroids are the most common benign gynecology, many women have a lifetime “zone of survival”, therefore, to increase understanding of the disease is necessary. Experts point out that the fibroids can not groundless fear, after all, most people can be peaceful coexistence with them; can not take it lightly, because the growth of fibroids by many factors, in the changes. Science is the attitude of the person, dynamic grasp ?

Written by Cao Xueqin in “A Dream of Red Mansions”, smart and competent Poshen Wang Xifeng impressive, but in the long term by saying that she “Xuebeng” problem, died of the disease last. Analysis of modern medical scientists, according to Wang Xifeng’s age and symptoms, she most likely suffering from a “submucosal uterine fibroids.” In those days, people helpless in the face of uterine bleeding, uterine fibroids are not fully understand. “Now, although the incidence of uterine fibroids is still not very clear, but with medical advances, uterine fibroids on women’s lives have not constitute a major threat,” even if the larger fibroids, the patient has symptoms, medical Also a very good solution.

The most common gynecological cancer

Uterine fibroids are the most common gynecologic cancer in women of childbearing age, about 1/4-1/3 have this problem. Some women a “tumor”, very tense. Uterine fibroids is a benign tumor, the cancer risk is very small, only 0.2 percent, there is no need to talk about:the color by changed. Most of the patients with smaller fibroids, no symptoms, does not affect life, does not affect fertility, without special treatment, as long as the regular observation of it.

According to reports, in accordance with the growth of fibroids site, uterine fibroids divided into three categories:

The first category is subserosal fibroids, uterine fibroids-in outside the uterus long as the bags, often through a pedicle connection with the uterus. Such patients may not necessarily increase the uterus, the smallest of the impact of menstruation, normally does not cause bleeding.

The second category is muscle intramural fibroids, the most common of these patients. General uterus will be increased, more of menstruation.

The third category is submucosal fibroids. To this type of uterine fibroids in the cavity growth, will become the uterine cavity, the period was significantly increased, there will be irregular bleeding, patients will feel some pain, is the most obvious symptoms of a class of fibroids. Some women because of fibroids Zhang Dehen, even from prominent to the vagina, cervix.

Growth symptoms and location of the fibroids

The symptoms of uterine fibroids with the growth of fibroids location, size and growth rate are concerned, the most critical positions. Period of increased uterine fibroids are the most common symptoms. Pain in the uterine fibroids in the rare, it accounted for about 1 / 10, more common in submucosal fibroids, fibroids red degeneration, growth too quickly, and subserosal fibroids in torsion, and so on.

Generally speaking, in accordance with gynaecological examinations, blood and B-result, the majority of patients with uterine fibroids can be confirmed. However, there are the uterus and increasing pain patients have to adenomyosis identification. The latter are often more obvious pain, increased uterine uniform, not more than 10 multi-size gestational age. For patients with menorrhagia, it is necessary to identify and uterine mucosa disease, the diagnosis can be confirmed and curettage or hysteroscopy. Pedicle of the subserosal fibroids, have to identify ovarian cancer, B-general can make a judgement, if necessary, need to be confirmed laparoscopy or laparotomy.

Sex hormones affect the growth of fibroids

The cause of uterine fibroids is still unclear, but its growth is closely related to sex hormones and is in the affirmative, therefore, any change in the level of sex hormones led to the factors may stimulate the growth of uterine fibroids, the following conditions should be concerned with:

First, the sex hormone drugs, including contraceptives, progestin, estrogen, such as mifepristone, if not non-use, we must weigh the pros and cons. This was followed by the pregnancy. Pregnancy may cause fibroids red degeneration. The so-called red degeneration, is pregnant after an increase of uterine blood supply, the fibroids blood supply has increased, therefore fibroids in internal bleeding. Third, ovarian dysfunction will affect the growth of fibroids, such as polycystic ovary syndrome, functional bleeding, and so on, need aggressive treatment. Finally, some containing the sex hormone food and health products will also stimulate the growth of uterine fibroids, should avoid eating.

Treatment to surgery, drug efficacy imprecise

If you need treatment, surgery is the most reliable way to effect. So far, there is no precise effect of the drug treatment of uterine fibroids, said that some medical institutions, such as drug Mifepristone can rule uterine fibroids, is not based on evidence-based medicine.

In addition, due to unknown causes, uterine fibroids can not be eradicated, there are still After discounting the possibility of recurrence, individual fibroids removed after the risk of recurrence is 20 to 30 percent, compared with multiple fibroids 60 percent chance of recurrence. To the menopause, uterine fibroids are shrinking, but some patients with fibroids is still great, still need surgery.

Uterine fibroids female genital mutilation is the most common benign tumor, is also commonly found in human tumors one. The incidence of uterine fibroids high, more common in women aged 30 to 50. And more than 10 years ago, uterine fibroids increasingly favored San Sishi-year-old middle-aged women, especially those that are not sterile, sexual disorders and depression these three categories of female temperament. Common to multiple uterine fibroids.
Uterine fibroids from the uterus mainly formed smooth muscle cell proliferation. Among them, only a small amount of connective tissue fibers as a support organization exists. Therefore, the exact name should be smooth muscle of the uterus, known as uterine fibroids. Uterine fibroids and more growth in the womb body, for the most common intramural fibroids, followed by subserosal fibroids and submucosal fibroids. Department of the cervix may have fibroid growth. Uterine fibroids of unknown etiology may be related to long-term and excessive estrogen stimulation of the ovary. Most patients with asymptomatic, the main clinical manifestations of menorrhagia, irregular. Fibroids may be more palpable abdominal mass, falling and oppression caused symptoms and oppression of the bladder can cause frequency, urination or bowel difficulties.