What is the pelvic floor?

The female pelvic floor is composed of voluntary muscles, fascia and ligaments - the levator ani. These structures have a supportive component and a functional component. They support the bladder, vagina, uterus, rectum and sigmoid colon and are involved in bladder storage, voiding and continence.






They are also involved in providing support for the vaginal wall, cervix and uterus, and also with sexual function. They have a major role in defecation and continence of faeces.  Abnormalities of the pelvic floor manifest themselves as urinary incontinence, uterovaginal prolapse, sexual dysfunction and obstructed defecation and faecal incontinence.

What is a prolapse?

50% of women will complain of symptoms of vaginal prolapse; 10-20% undergo surgery. Genital prolapse involves a weakness of the pelvic floor support mechanisms allowing the organs to herniate through the opening in the pelvic floor muscles. These are divided into compartments.

Anterior vaginal wall prolapse (cystocele and urethrocele)

Uterine & vaginal Prolapse (Middle compartment)

The uterosacral ligaments primarily support the upper 20% of the vagina (apex) and the uterus. When the uterosacral ligaments break the uterus begins to descend into the vagina. Further uterine descension pulls the rest of the vagina down resulting in apical tears of the anterior (pubocervical) fascia and posterior (rectovaginal) fascia from its points of lateral attachment. Anterior vaginal wall lateral tears are called paravaginal defects and results in cystourethrocele. Continued uterine and vaginal prolapse can result in a complete uterine and vaginal prolapse such that the uterus falls outside the vaginal opening and the vagina falls inside out.

Posterior vaginal wall prolapse (rectocele and enterocele)

The supportive layer of the posterior vaginal wall is called the rectovaginal septum or rectovaginal fascia. It is attached distally to the perineal body, laterally to the levator ani muscle and proximally to the cervix (if uterus is present). When a break in the rectovaginal septum is present the rectal wall will come into contact with the vaginal skin and create a bulge on the posterior bottom side of the vagina.

In the posterior compartment we can also have a true hernia of the peritoneal body cavity which may involve small bowel which usually affects the upper third of the back wall of the vagina. This is called an enterocoele.

These bulges will usually increase in size with bearing down (Valsalva maneuver) especially when having a bowel movement. Patients with a rectocele may experience:

The skin between the vagina and the anus (perineum) may also be deficient and need repair.

Damage to these muscles can occur during childbirth, or due to a constant increase in intra-abdominal pressure caused by chronic lung disease (for example, asthma or heavy smoking), constipation, or heavy lifting or straining activities. When damage occurs, these muscles can no longer contract, losing their ability to support the pelvic organs in their accurate places.

A great strain is then created on the “passive” support system of the pelvis, the endopelvic fascia. The endopelvic fascia is a tough, fibrous sheet within the pelvis, consisting of collagen, elastin and smooth muscle fibers. Alone it cannot support the pelvic organs, which may be affected by consistent gravitational pull and/or an intra-abdominal pressure.

Exposed to prolonged pressure and tension from the pelvic organs, the endopelvic fascia may stretch and eventually break, resulting in the breakdown of the pelvic floor. This is female organ prolapse.

Anatomy

The vagina is supported on three different levels within the pelvis.

• The upper third is supported by the uterosacral ligaments, a pair of very strong fibromuscular structures originating from the lateral aspects of the sacrum going around the rectum and attaching to the cervix and upper part of vagina. These ligaments pull the top of vagina and cervix toward the sacrum and help to form the normal axis of the vagina.
  
• The middle third of the vagina is held in place by the lateral attachments of the endopelvic fascia to the pelvic side wall.
  
• The lower third blends into and merges with the fibromuscular tissue surrounding the opening of the vagina and anus.

In order to restore the vaginal depth and axis, all three levels of support must be attended at the time of surgery.

What Are the Symptoms?

Back pain, pelvic pressure or pain, or a sensation that something is bulging into/falling out of the vagina/rectum.








As a result, patients complain of discomfort when sitting, standing or actively carrying out normal daily activities; but is rarely bothered while lying down or resting. Any physical stress, such as coughing, sneezing or lifting usually aggravates the symptoms.

Sexual dysfunction becomes a problem because of the presence of a mass. Intercourse may be painful.  In its most severe presentation, the vagina and or bladder/rectum may evert and be located completely outside of the pelvis.

 

Solitary Rectal Ulcer Syndrome (SRUS)

What is it?

Solitary rectal ulcer syndrome (SRUS) is a condition in which a benign ulcer occurs in the rectum in association with prolapse or difficulty emptying the bowels (obstructed defecation syndrome ODS).

What causes SRUS? 

There are a number of theories as to how SRUS is caused. Many patients have a history of constipation and straining and some people believe that this causes the lining of the bowel to prolapse down. The ulcer then may occur from trauma to the bowel from it rubbing against itself. Some patients with SRUS have difficulty in opening their bowels and may insert a finger into the anal canal to aid defaecation and it is possible that the ulcer comes from the finger being inserted.

What symptoms does it cause?

The typical symptoms are of pelvic pain, bleeding and mucus discharge. Patients often report a sensation of incomplete emptying and a persistent feeling of fullness in the pelvis.

How is it diagnosed?

After an assessment in clinic, we may recommend a flexible sigmoidoscopy or colonoscopy to look at the bowel higher up and to biopsy the ulcer in order to rule out other causes of ulceration. We often recommend other tests including a proctogram which looks for evidence of rectal prolapse commonly seen in association with SRUS. This may direct future treatments.

How can SRUS be treated? 

Often people with SRUS can be treated with changes to their diet and laxatives. Biofeedback may retrain the voluntary and involuntary processes involved with opening your bowels, improving symptoms. In patients with persistent symptoms and bowel prolapse, operative treatment (STARR or laparoscopic ventral mesh rectopexy) of the underlying anatomical abnormality can give prolonged symptom relief.

Surgical Goals

Bristol Laparoscopic Associates goal for patients with uterovaginal, bladder and or rectal prolapse are:

• restore the normal vaginal depth and axis.
• restore the prolapsed rectum
• restore the prolapsed bladder
• relieve the symptoms of pressure.
• maintain satisfactory sexual, voiding and evacuatory function.

We believe that the uterus per se has no bearing or effect on vaginal support. Therefore, a hysterectomy should not be considered as part of repair surgery for uterovaginal or vaginal prolapse.

The length of the vagina in a normal adult female is approximately 10 to 12 cm.  When standing, the lower third of the vagina is pointing 90° to the floor whilst the upper two-thirds is at an angle almost parallel to the floor and is directed toward the sacal prominentry.

The traditional approach to the repair of prolapse and incontinence has involved a predominantly vaginal approach. This approach is approximately 150 years old. These procedures were refined 100 years ago and 50 years ago the first abdominal procedures were reported which appeared to show a quite marked improvement in the success rate compared to the time honoured vaginal approach.

The problem with the traditional abdominal approach was the associated morbidity of open surgery, the large unsightly scar and the longer postoperative recovery phase.  As the new techniques for abdominal surgery were evolving, so were the techniques for laparoscopic or keyhole surgery. The first laparoscopic incontinence operation was performed in l991 and since then the evolution of pelvic floor surgery has accelerated dramatically.

It became very clear to Bristol Laparoscopic Associates that with the magnification offered by the laparoscope, pelvic floor anatomy could be extremely well visualised and the defects that were causing each of the various types of prolapse could be accurately identified and repaired. Most of these defects were completely invisible using the vaginal approach.

Bristol Laparoscopic Associates have developed for the first time, a holistic approach to the pelvic floor- laparoscopic ventral mesh rectopexy [posterior colporraphy, vaginal sacrocolpopexy]. Pelvic floor dysfunction may present as uterovaginal prolapse, urinary or faecal incontinence, voiding and defecation disorders and sexual problems etc.

Each patient who presents with any of these symptoms needs to be assessed in terms of a site-specific anterior compartment defect, middle compartment defect and posterior compartment defect.  Surgery needs to be directed towards the site-specific repair of these defects restoring their normal function using the laparoscopic approach which reproduces the various abdominal approaches that have been used for many years and evolving some completely new techniques that would not be possible using the traditional approach. 

Bristol Laparoscopic Associates believe that this new approach to the problem is more anatomical and capable of restoring normal function without significantly distorting and fibrosing or scarring the vagina. Using these new techniques, the bladder neck can if necessary be anchored in a retropubic intra abdominal position. The bladder base can be reattached to the pelvic sidewall. The cervical ring of fascial tissue and ligaments can be reconstituted both with the uterus in position and after hysterectomy.

The fascial supports can be reproduced using polypropolene or polyester mesh and anchored to the ligaments around the cervix above the perineum below and the pelvic floor muscles laterally to try and restore normal anatomy.

So what are the benefits of laparoscopic pelvic floor repair?

• Excellent view of the pelvic floor from above
• Accurate identification of the pelvic floor defects
• Minimising the need and extent of vaginal repair, thus reducing the risk of painful internal scars and vaginal shortenibg/narrowing
• Hysterectomy for uterine prolapse may be avoided or deferred until childbearing is completed
• Restoration of normal pelvic anatomy is achievable
• Less invasive than the open procedure.

Risks and complications of pelvic floor repair:

Risks and complications are rare with laparoscopic pelvic floor repair and generally depend upon the complexity of the individual case. Back pain and constipation are fairly common in the first two to four weeks after surgery.  Movicol is sometimes needed for constipation.  Transient urinary retention can occur in the first few days.  Underlying preoperative urinary stress incontinence can deteriorate and indicate the need for "lifting up" the base of the bladder.  remember that in most women, urinary incontinence gets better. Infection, bleeding, and trauma to the repaired organs are very uncommon.  Occassionaly a small hole iis made in the bladder.  This will be repaired at the time; a catheter is left to drain the bladder for a week. Conversion to the open procedure may occur in case of unexpected complications.

What about the recovery?

• Resume normal activity level as you feel able remembering to rest as required.
• Gentle walking or swimming is allowed.
• Take analgesics to help back pain and laxatives until regular bowel movements.
• Avoid jarring activities such as jogging, jumping or heavy lifting.
• Postpone vigerous sexual intercourse for four weeks

What is the expected outcome of surgery?

A successful prolapse operation can be expected in over 95% of cases. This generally means restoration of normal pelvic anatomy and in the majority of cases improvement or return to normal of bladder, bowel and sexual function.

Remember.  Recto urogenital prolapse is very common. Although not life-threatening, it is a progressive condition which can cause physical discomfort and disfigurement and at times even personal and social embarrassment through loss of bowel and bladder control. It may also affect or restrict your sexual relationship. Prolapse is common but it is not necessary to suffer in silence.  Appropriate help can return you to a healthy and active lifestyle.