Pelvic Floor Disorders
What is the Pelvic Floor?
The pelvic floor is the term used to describe the muscles, ligaments, and connective tissue that provide support for a woman's internal organs; including the uterus, bladder, vagina, rectum, and the large and small bowel. The pelvic floor support muscle (Levator Ani) form a sling around the pelvic organs. It attaches to the inside of pubic bone and wraps around the urethra (tube from the bladder to the outside), bladder, vagina, and rectum to the tail bone (sacrum) on side and then wraps around these organs on the other side to attach to the opposite side of the pubic bone. This forms a sling which prevents the pelvic organs from falling down or out. The brain sends nerves to control the pelvic muscles. Anything that damages these muscles or their nerves (such as childbirth, diabetes, low back surgery etc.) can result in weakness and a falling of the pelvic floor.
What are Pelvic Floor Disorders (PFDs)?
Women can develop weakness (from nerve damage) or muscle tears (childbirth trauma) of the pelvic muscles or the connective tissue and begin to having trouble controlling their bladder (incontinence), difficulty emptying their bladder (voiding dysfunction), or difficulty with bowel movements (constipation). Some women also become aware of increasing vaginal pressure or a bulge out the vagina (prolapse).
Common PFDs are urinary or fecal incontinence (involuntary loss of urine or stool) or pelvic organ prolapse (POP) in which one or more of the pelvic organs (bladder, uterus, vagina, or rectum) fall downward and bulge out the opening of the vagina.
Pelvic Organ Prolapse (POP)
POP occurs when one or more of the pelvic organs (uterus, bladder, vagina, or rectum) fall down and bulge out (prolapse) the vaginal opening. The cause of pelvic organ prolapse is a weakness in the pelvic floor muscles, connective tissue, and ligaments to the point where they can no longer support the pelvic organs. The uterus "falls" down and out the vagina, the pelvic support tissue weakens, and an increase in abdominal pressure pushes against the vaginal walls causing a bulge in the vaginal walls to take place. These bulges can increase in size and cause discomfort and other symptoms.
Types of Prolapse
There are several types of pelvic organ prolapse that can occur. These different types are described according to the part of the vagina they affect:
It is not uncommon to have more than one type of prolapse at different stages of bulging at a time.
Uterine Prolapse: ( "Fallen" Uterus")
The uterus can "fall" down into the vagina when its supports break down. The amount it has fallen is divided into stages depending on the amount of the descent of the uterus. Symptoms of uterine prolapse include low back pain, a "pulling sensation, a feeling something is being struck during intercourse, or a feeling that something is "falling out." Vaginal discharge or spotting can occur if the uterus prolapses through the vaginal opening, causing the cervix to rub on a woman's underwear.
Vaginal Vault Prolapse: (Top or Apical Prolapse, Fallen Vagina)
The top or apex of the vagina can fall in women after a hysterectomy. In severe cases, the vagina can completely invert just like turning a "sock inside out."
Cystocele: (Front Wall Prolapse, Fallen Bladder, Anterior Vaginal Wall Prolapse)
When the bladder pushes into the front wall of the vagina, it is called a cystocele. The front vaginal wall prolapse can cause trouble starting urine flow, difficulty emptying the bladder, and pressure pain. In severe cases, some women find it necessary to push the bladder back up inside the vagina (bladder splinting) to be able to void. Large cystoceles increase the chance of having frequent bladder infections because of the continuous state of the bladder not being empty.
Rectocele: (Prolapse of Back Vaginal Wall, Posterior Vaginal Wall Prolapse, Bulging Rectum)
A rectocele can bulge out of the vaginal opening when straining due to a break in the support tissue between the rectum and the vagina. This bulging pocket can trap stool and cause incomplete emptying with a bowel movement. Rectoceles often lead to and are made worse by chronic constipation. Rectal splinting (pushing down on the back vaginal wall) is often necessary to empty the bowel.
Symptoms of Pelvic Organ Prolapse
Symptoms of POP depend on the location or locations and the extent of the prolapse. Some common symptoms are:
The evaluation for pelvic organ prolapse is similar to the evaluation done for urinary incontinence. This includes:
Evaluating Symptoms of Pelvic Organ Prolapse
Physical Exam – Staging prolapse on the pelvic exam as to the extent of the prolapse.
Urinalysis – To rule out infection.
Post Void Residual – To check for complete emptying of the bladder.
Urodynamic Testing - Many patients with POP do not have symptoms of urinary incontinence, but if the prolapsed vaginal walls are reduced back into normal position, the patient will have leaking. Urodynamic testing is the only way to pick up this occult "hidden" incontinence. This "hidden" incontinence requires a bladder sling to be added to the corrective surgery or the patient will experience urinary incontinence after corrective surgery for the pelvic prolapse.
Pelvic Floor Ultrasound – The use of 4D ultrasound (similar to the ultrasound used to show a baby's face in utero) is a powerful new tool in determining the cause and extent of pelvic organ prolapse. Dr. Ross is the only physician in this area that routinely uses 4D ultrasound, which is more sensitive than an MRI in the detection of pelvic organ prolapse. He was trained by Dr. Peter Dietz, a urogynecologist in Sydney, Australia, who is considered the world's expert in 4D pelvic floor ultrasound. A 4D scan allows the diagnosis of some problems that are not detectable on regular evaluation. Follow-up scans after surgical corrections are often done to determine the effectiveness of the treatment. The Center for Female Continence is the only clinic in the western United States that includes pelvic floor 4D ultrasound in all patient evaluations.
Treatment of Pelvic Organ Prolapse
Lifestyle Modifications: Changes in daily activities, such as prolonged standing or heavy manual labor increase pressure on the pelvic floor and can increase POP. It is recommended to not lift anymore than 10 to 15 pounds. The single worst thing causing severe pressure on the pelvic floor is straining hard with bowel movements. Constipation needs to be avoided at all costs. It is important to increase roughage in your diet. It might be necessary to take a stool softener daily (docusate). In addition, bulk laxatives nightly like Miralax are often necessary. Constipation is usually caused by nerve damage into the wall of the rectum, causing poor gut motility. This is part of the symptom complex of POP.
Pessaries: Pessaries are small silicon devices that come in several different shapes and sizes that are placed into the vagina to keep pelvic organs from "falling out". These are often used by women not ready to undergo definitive treatment. They can be taken in and out of the vagina for cleaning. They are not as popular as in the past because of the numerous minimally invasive procedures available today.
Uterine Prolapse: In most clinics the most common treatment offered for uterine prolapse is a vaginal hysterectomy. Dr. Ross offers several uterine sparing techniques to correct the uterine prolapse so that a hysterectomy is not necessary. These techniques include utero-sacral suspension and laparoscopic hysteropexy, which are both minimally invasive outpatient procedures.
Uterine Utero-sacral Suspension - The uterus is supported by a right and left uterosacral ligament that holds the uterus up in the pelvis. In a uterine uterosacral suspension, a small vaginal incision is made in the vaginal wall, and these ligaments are identified where they attach to the posterior lower portion of the uterus. The ligaments can be shortened with sutures which elevates the uterus into its normal position. Dr. Ross has developed a newer technique of passing strips of synthetic mesh up into these ligaments after they have been shortened. The mesh contracts and shortens more as tissue grows into it causing permanent uterine elevation.
Laparoscopic Hysteropexy - Laparoscopy consists of placing an operative telescope into the abdomen through a small incision below the umbilicus. Through an additional small port, a wide strip of synthetic mesh is sutured to the back wall of the uterus. The uterus is then elevated into its normal position, and then the other end of the mesh is attached to the sacral bone. This sling prevents the uterus from falling down.
Vaginal Hysterectomy - There are certain conditions in which the uterus should be removed (abnormal bleeding, painful periods, etc.). With a vaginal hysterectomy, the uterus is removed entirely through a vaginal incision with no abdominal incisions made. This is a minimally invasive procedure and usually only requires an overnight stay in the hospital.
Laparoscopic or Robotic-Assisted Hysterectomy - Other minimally invasive techniques include laparoscopic or robotic assisted hysterectomy. Dr. Ross is one of the early pioneers in laparoscopy, and all of these techniques are available at the Center for Female Continence.
Apical Vaginal Prolapse: In post hysterectomy patients, the top of the vagina can prolapse down through the vaginal opening. Modifications of the technique for uterine prolapse are used in this repair. This includes the following:
Uterosacral Ligament Suspension - The uterosacral ligaments are identified via vaginal incisions and then the ligaments are shortened and fixed into the top of the vagina in a similar fashion as described for uterine uterosacral suspension.
Laparoscopic Sacral Colpopexy - A laparoscopic sacral colpopexy consists of using a Y-shaped piece of mesh to support the top or apex of the vagina. One arm of the Y is attached to the top wall of the vagina and the other arm to the back wall, and then the leg of the Y is attached to the sacral bone. This is considered the gold standard in treating apical prolapse. Dr. Ross was one of the first to perfect this technique in the early 90's and is recognized worldwide for this pioneering work. He was the first to publish a study of complete total pelvic organ prolapse being repaired via laparoscopy. He has lectured and taught physicians worldwide on how to do these types of procedures.
Cystocele: (Front or Upper Vaginal Wall Prolapse)
A cystocele is a hernia of the front vaginal wall. There are several types of repair for cystoceles. They all include either resupport or replacement (grafts or implants) of the damaged tissue between the bladder and the vagina.
Anterior Repair (AR) - This is the oldest type of anterior vaginal wall repair. Through a midline vaginal incision in the front wall of the vagina, the weakened damaged tissue is brought back into the midline with sutures. Unfortunately, in severe cystoceles, there is a high recurrence rate with this type of repair. Dr. Ross tends to only use this type of repair in early to moderate size cystoceles.
Paravaginal Repair - A paravaginal cystocele occurs when the lateral vaginal walls tear from the pelvic sidewalls. Originally this repair was done by feel through an incision in the top wall of the vagina. Dr. Ross was the first physician to report on repairing this defect laparoscopically. The laparoscopic approach allows direct vision of the damaged tissue and is now the method of choice for paravaginal repair by most physicians.
Anterior Mesh Repair - Due to the high recurrence rate seen in large cystoceles, better methods than a classic anterior repair have been sought. Cystoceles and rectoceles are actually vaginal hernias. General surgery found that using mesh to repair abdominal or inguinal hernias was much more effective than trying to do repairs with a women's damaged tissue. Dr. Ross, using the concept that tissue replacement was superior to tissue repair, developed a minimally invasive synthetic mesh repair; while working with Bard Urology. The mesh used is made from polypropylene, a material that has been used in the body for more than two decades. The mesh is knitted and has large pores. Once it is implanted into the body, tissue grows through these pores replacing the weakened damaged tissue resulting in a strong and permanent graft. Dr. Ross' mesh design is placed through a small midline incision in the front vaginal wall and anchored by two arms of mesh on each side. It forms a basket under the bladder and prevents prolapse of the front vaginal wall. It can be attached to other deep pelvic ligaments and support the uterus or top vaginal wall in addition to supporting the front wall. This repair is reserved for severe cases and has a higher success rate than classical tissue repairs done with weakened tissue. This mesh kit is used across the world.
Rectocele: (Hernia of Back Vaginal Wall)
A Rectocele is a hernia of the back vaginal wall. When you strain the rectum will bulge up into this hernia sac. This sac can trap stool and make it difficult to empty as it gets larger. There are tissue repair and tissue replacement techniques available for rectocele repair.
Posterior Vaginal Repair - This procedure is very similar to the anterior vaginal repair. A midline vaginal incision in the posterior vaginal wall exposes either a discreet tear or splaying out of support tissue between the rectum and the vagina. If the defect is secondary to a tear, the tear line is closed with sutures. If a tear is not visible, the support tissue that has been thinned out is pulled back into the midline with sutures. Dr. Ross uses this repair technique for less severe defects because it also has a high recurrence rate when used in larger defects.
Posterior Mesh Vaginal Repair - Using the same principles as the anterior mesh repair, Dr. Ross has developed a similar synthetic mesh system for the back wall of the vagina. A small midline back wall incision allows a mesh "basket" to be placed over the rectum and is again held down by two mesh arms on each side. The five year success rate has been over 95% for posterior repairs at The Center for Female Continence.