Pelvic Floor Prolapse

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Pelvic Floor Prolapse

• M L Padwick MD FRCOG

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What is prolapse ?

• Prolapse is a condition in which organs, which
  are normally supported by the pelvic floor,
  namely the bladder, bowel and uterus, herniate or
  protrude into the vagina. This occurs as a result
  of damage to the muscles and ligaments making up
  the pelvic floor support. At least half of women
  who have children will experience prolapse in
  later life.

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Statistics

• ratio surgery for prolapse vs incontinence 21
• prevalence of 31 in women aged 29-59 yrs
• 20 of women on gynaecology waiting lists
• 11 lifetime risk of at least one operation
• re-operation in 30 of cases

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Factors associated with pelvic floor prolapse

• age
• parity
• big babies
• menopause
• obesity
• occupation
• home delivery
• family history

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Pathogenesis

• childbirth
• connective tissue disorders
• menopause
• chronic intra-abdominal pressure
• iatrogenic (hysterectomy)

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What are the symptoms of pelvic floor prolapse?

• This depends on the types and the severity of the
  prolapse.
• Generally, most women are not aware of the
  presence of mild prolapse.
• When prolapse is moderate or severe, symptoms may
  include sensation of a lump inside the vagina or
  disturbance in the function of the affected
  organs, such as

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Bladder

• stress incontinence
• urgency
• frequency
• incomplete emptying
• dribbling
• recurrent urine infections

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Bowel

• low back pain or discomfort
• incomplete emptying
• constipation
• manual decompression
• incontinence of flatus

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Sexual problems

• looseness and lack of sensation
• difficult entry and expulsion
• discomfort or painful intercourse
• vaginal bleeding in neglected cases

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Other

• can see and feel it
• back ache
• dragging sensation
• increased discharge
• skin irritation

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How can prolapse be prevented?

• appropriate antenatal and intrapartum care
• regular postnatal pelvic floor exercises to
  compensate for childbirth damage
• in postmenopausal women, oestrogen cream helps
  maintain tissue strength

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Living with pelvic organ prolapse
Avoid standing for long periods of time.
Do pelvic floor exercises
Prevent or correct constipation
Wear a girdle
Try yoga
Wear a pantyliner or incontinence pad
Explore alternatives to sexual intercourse
Carry wet wipes
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Pelvic organ prolapse Non-surgical treatments

• Physiotherapy - pelvic floor exercises and
  vaginal cones
• Hormone Replacement Therapy (HRT) - may be local
  oestragens
• Vaginal Pessaries - many choices but regular
  checks and changes needed and best combined with
  oestragen creams

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Genital prolapse and Pelvic floor muscle
exercises Summary We found no RCTs or
observational studies of sufficient quality
examining the effects of pelvic floor muscle
exercises on the symptoms of genital prolapse.
Comment Although pelvic floor muscle exercises
appear to be effective in reducing the symptoms
of urinary stress incontinence (see benefits of
pelvic floor muscle exercises in stress
incontinence chapter), their usefulness in the
treatment of genital prolapse is unproven.
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Nutrition Ensure you are getting the right
nutrition Follow dietary recommendations
outlined on the Foundation of Health page. And
for more information on the special dietary
recommendation for prolapse, see the rest of the
chapter on Naturalhealthpractice/Prolapse chapter
which you can download. Supplements The
supplement programme below should be taken for at
least three months in order to achieve best
results Your supplement plan A good
multivitamin and mineral tablet Vitamin C with
bioflavonoids (1000mg twice a day) Vitamin A
(as beta-carotene at 25,000iu per day)
Proanthocyanidins (50 mg per day) Manganese
(5mg per day) Cranberry supplement (only needed
for stress incontinence) At the end of three
months you should reassess your condition and
adjust your supplement programme accordingly.
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Pelvic Floor Workout Dr Rosie King's Pelvic
Floor Workout Dr Rosie King is an Australian
doctor with a difference! A sex therapist and sex
educator, she has helped thousands of men and
women achieve greater happiness and health
through her counselling practice and her
appearance on healthcare programmes on TV, radio
and articles in health magazines. In her course
of work, Dr Rosie realised that many women suffer
from bladder, bowel and sexual symptoms that are
directly related to the weakness of the pelvic
floor muscles. She also became aware that shyness
and inhibitions prevent many affected women from
seeking medical help and advice.  Women
commonly present with the following problems One
in three women experiences problems with bladder
control Sagging pelvic organs lead to prolapse of
the bladder, bowel and uterus - such problems
require medical attention and potentially a
surgical repair Many women experience reduced
sexual sensitivity after childbirth Many pelvic
floor problems can be prevented by effective
pelvic floor fitness programme that is designed
to keep the pelvic floor muscles in the top
condition. In an audio programme - the Pelvic
Floor Workout - Dr Rosie King tells women of all
ages everything they need to know about keeping
their pelvic floor in top shape.   Graphic
images of pelvic floor, pelvic floor problems and
pelvic floor changes during arousal taken from Dr
Rosie King's information booklet and workout
diary enclosed with the audio CD programme
entitled the Pelvic Floor Workout 
Dr Rosie King's Pelvic Floor Workout audio
programme on a compact disk costs just 15.98
inclusive of VAT.
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The Surgical Management of Prolapses

• Restoration of pelvic structures to normal
  anatomical relationship
• Restore and maintain urinary /or faecal
  continence
• Maintain coital function
• Correct co-existing pelvic pathology
• Obtain a durable result

Principles of Pelvic Reconstructive Surgery
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The Surgical Management of Prolapses
Patient assessment

• Careful history
• Physical examination
• Neurological assessment
• Urodynamic evaluation
• Anorectal investigations

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The Surgical Management of Prolapses

• Surgeons' own expertise, experience and
  preference
• Pre-op voiding or bowel dysfunction
• Duration of efficacy
• Complications
• Learning curve
• Quality of life factors
• First or repeat surgery
• The need to treat other pathology
• Fitness of the patient
• Underlying pathology
• Success rates for different procedures

Factors affecting choice of operation
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The Surgical Management of Prolapses

• Uterovaginal prolapse is multifactorial in origin
• Treatment needs to be individualised
• Approach often needs to be multidisciplinary
• Quality of life assessment is essential

Summary - Female Pelvic Organ Prolapse
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Types Of Surgery

• Anterior and posterior repairs
• Vaginal hysterectomy
• Laparoscopic vaginal vault suspension (Â mesh)
• Laparoscopic sacrocolpopexy
• Laser Vaginal Rejuvenation
• Designer Laser Vaginoplasty
• Vaginal approach to prolapse repair
  incorporating mesh
• Laparoscopic paravaginal repairs

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Sacrocolpopexy and paravaginal repair for total
pelvic floor prolapse