Pelvic floor prolapse

Introduction

The pelvic floor muscles are a series of muscles that form a sling or hammock across the opening of the pelvis. These muscles, together with their surrounding tissue, are responsible for keeping all the pelvic organs (bladder, uterus, urethra and rectum) in place and functioning correctly. For example, they normally tighten to help control the release of urine from the bladder.

What is pelvic floor prolapse?

When the muscles of the pelvic floor are damaged or weakened by overstretching, they are sometimes unable to support the weight of some or all of the pelvic organs. When this happens, one or more of the pelvic organs may drop below their normal positions, causing symptoms that range from mild discomfort to significant pain and disturbance of normal function.

Pelvic prolapse is a general term that refers to the displacement of any or all of the affected pelvic organs. Uterine prolapse refers specifically to the dropping of the uterus down into the vagina. When the bladder drops from its normal place in the vagina, it is called a cystocoele. When the rectum bulges into or out of the vagina it is called a rectocoele. The bulging or herniation of the small bowel (intestine) into the space between the vagina and the rectum is an enterocoele. These distinctions are important because their symptoms and treatment options differ.

What causes pelvic floor prolapse?

Childbirth is the most common cause of the damage to the pelvic floor. Other factors include past surgery such as hysterectomy, lowering of oestrogen levels due to menopause, and conditions that cause chronically raised abdominal pressure such as chronic constipation, coughing and heavy lifting.

What are the symptoms?

The symptoms of pelvic floor prolapse depend on the type and severity of the prolapse. In mild conditions you may not be aware of any problems at all. When prolapse is moderate or severe, symptoms may include the sensation of a lump or dragging discomfort inside the vagina, or a disturbance in the function of the affected pelvic organ. For example, if the bladder is affected you may experience incontinence and/or frequent urine infections. When the bowel is affected you may experience low back pain, constipation or incomplete emptying. There may also be pain or discomfort during sexual intercourse, and protrusion of the vagina and/or uterus from the vaginal opening.

How can prolapse be prevented?

As with any illness, prevention is better than treatment. This means appropriate antenatal care and regular postnatal pelvic floor exercises (Kegel exercises) to reduce the risk of childbirth damage. We strongly encourage all women to learn to do Kegel exercises.

In post menopausal women oestrogen cream helps maintain tissue strength.

How is prolapse treated?

There are several ways to treat pelvic floor prolapse and these generally depend upon the type of prolapse and its severity. Your first step should be to consult your own doctor who will refer you to a specialist if your condition needs further diagnosis or treatment.

Mild degrees of cystocoele, rectocoele or uterine prolapse may not require any surgical treatment, especially if there is no discomfort. Special exercises to strengthen pelvic floor muscles (Kegel exercises) can improve symptoms such as urinary stress incontinence and pelvic discomfort. Electromagnetic stimulation using the Neotonus chair can be used to facilitate pelvic floor strengthening. Also, changes in lifestyle such as eliminating heavy lifting or treatment and suppression of a chronic cough, can half the progression of pelvic prolapse.

In menopausal women, oestrogen replacement therapy (combined with a progestin) can improve the strength of the pelvic floor ligaments and muscles, bringing an improvement in symptoms and increasing the effectiveness of Kegel exercises.

However where these measures are not enough to correct the problem, surgery to repair and reconstruct the weakened pelvic floor and restore normal function is the best option for treatment.

1. Laparoscopic Reconstructive Surgery

Pelvic floor repair by laparoscopy is a comparatively new technique that enables surgeons to repair many of the pelvic floor conditions which are difficult to reach by other surgical methods. This approach also provides much better suspension of the vagina because the stitching of the vagina can be attached much higher up in the abdominal cavity than is possible when working from below in the vagina. If needed, a hysterectomy can also be performed laparoscopically and combined with the prolapse operation.
In the laparoscopic procedure, a tiny telescope (laparoscope) is inserted through a small incision below the umbilicus (belly button). This is attached to a camera that enables the internal organs to be viewed on a television screen to give your surgeon a magnified view of the pelvic floor.
Via three or four tiny “keyhole” incisions your surgeon uses specially designed instruments to lift and attach the prolapsed organs back to the ligament and muscle support with many non-absorbable, (and therefore permanent) stitches. The stitches act as a bridge allowing fibrous tissue to form the long-term support.

What are the benefits?

As noted above, laparoscopic techniques allow an excellent view of the pelvic floor and enable accurate identification of the pelvic floor defects. Laparoscopic surgery is less invasive than other procedures. It minimises the extent of vaginal repair, thus reducing the risk of painful internal scars.
As with all laparoscopic procedures, hospitalisation is comparatively short, pain is minimised and recovery is fast.

Risks and complications

Risks and complications are rare with laparoscopic pelvic floor repair and generally depend upon the complexity of the individual case. Some urinary retention may occur in the first several days and back pain and constipation can be experienced in the first two to four weeks after surgery due to the tightening of muscle-ligament support.

The recovery phase

You should resume your normal activity level gradually, but avoid lifting for one month following surgery.

2. Mesh pelvic floor prolapse repairs

In recent years new biotechnological breakthroughs have seen the development of synthetic polypropylene mesh materials which can be placed within the pelvic floor tissues replicating normal anatomy and allowing connective tissue which realigns anatomical defects.
A number of effective products and procedures have been developed and have the advantages of all minimally invasive procedures. These include shorter operation time, less pain and early resumption of normal activities.
Your surgeon will advise on the appropriate procedure to correct the prolapse problem but in general patients can anticipate restoration of normal anatomy, correction of prolapse and treatment and relief from both urinary and faecal incontinence.

Summary

Prolapse is relatively common after childbirth, hysterectomy and menopause. Although not life-threatening, it is a progressive condition which can cause physical discomfort and disfigurement and at times personal and social embarrassment through loss of bowel and bladder control. It may also affect or restrict your sexual relationship. It is not necessary to suffer in silence. Appropriate help can return you to a healthy and active lifestyle with minimum discomfort.
If you suspect you might have a pelvic floor problem you should consult your doctor as soon as possible.