Pelvic Floor Surgery

Sydney Women's Endosurgery Centre Advanced Gynae-Endoscopic Unit Department of Obstetrics and Gynaecology St George Hospital University of New South Wales

What is pelvic floor 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.


What causes pelvic floor prolapse?

Childbirth is the most common cause of damage to the pelvic floor, particularly where prolonged labour, large babies and instrumental deliveries were involved. Other factors include past surgery such as hysterectomy, lack of oestrogen due to the menopause, and conditions causing chronically raised intra abdominal pressure such as chronic constipation, coughing, and heavy lifting.


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: Bladder: stress incontinence, urgency, frequency, incomplete emptying, dribbling, recurrent urine infections.

Bladder: stress incontinence, urgency, frequency, incomplete emptying, dribbling, recurrent urine infections.

Bowel: low back pain or discomfort, incomplete emptying, constipation, manual decompression.

Sexual problems: looseness, discomfort or painful intercourse, vaginal bleeding in neglected cases.

How can prolapse be prevented?

As with any illness, prevention is better than treatment. This means appropriate antenatal and intrapartum care and regular postnatal pelvic floor exercises to reduce the risk of childbirth damage. In postmenopausal women, oestrogen cream helps maintain tissue strength.

Where prolapse is severe, symptoms are troublesome and conservative treatment has failed, surgery is the next option.

Vaginal surgery is the usual method of repair. Abdominal surgery, on the other hand, is usually performed when there is urinary stress incontinence or when vaginal surgery has failed. The choice of technique will generally depend upon the type, the severity of the prolapse and the surgeon’s experience.

LAPOROSCOPIC PELVIC FLOOR REPAIR

Recent advances in laparoscopic surgery have helped surgeons repair many pelvic floor defects, which are often difficult to reach by the vaginal method. Examples include prolapse of the vaginal vault, enterocoele and paravaginal cystocoele.

How is laparoscopic repair performed?
In the laparoscopic procedure, the surgeons insert a tiny telescope (laparoscope) through a small incision at the umbilicus. This is attached to a camera-television setup, giving the surgeons a magnified view of the pelvic floor.

Via three keyhole incisions in the abdomen, the surgeons use specially designed instruments to lift and attach the prolapsed organs back to the ligament and muscle support with many non-absorbable sutures. The sutures act as a bridge allowing scar tissue to form the long-term support.

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
• 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 common in the first two to four weeks after surgery and are due to the tightening of muscle-ligament support. Transient urinary retention and painful defecation may occur in the first several days. Infection, bleeding, and trauma to the repaired organs are very uncommon. Conversion to the open procedure may occur in case of unexpected complications.

The recovery phase

• Resume normal activity level gradually 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 sexual intercourse for six weeks

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.

Prolapse is common after childbirth. 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.

Laparoscopic pelvic floor repairs

Paravaginal repair