Disorders of pelvic floor & UV prolapse

BY

DR. J.U.E. ONAKEWHOR, MBBS, M.SC, FWACS, FICS

(Consultant Ob-Gyn and Coordinator, PMTCT Program,
UBTH, Benin City)
Presentation made at the Revision Course
organised by the National Post Graduate Meidcal
College of Nigeria at the University of Benin
Teaching Hospital ,Benin City, Nigeria September 5-
10 ,2005.
 Pelvic floor disorders : Background
Many women will spend hours each week exercising
their legs and abdomen muscles in order to "keep in
shape."
Unfortunately, one of the most important sets of
muscles is overlooked and ignored leading to pelvic
floor problems.

A report from the Temple University researcher found

72 percent of women reported suffering from one or

more pelvic floor disorders

70 percent had not sought medical help.

 Background contd.
•Onset of incontinence compel them to see the doctor; multiple
urogynecological problems are seen.

Of all pelvic floor disorders, it is incontinence that brings most

women to the doctor. "They cannot tolerate leaking urine and
the disruption to their daily lives.

But incontinence is usually just the tip of the iceberg. Many also
sufferifrom such pelvic floor disorders as uterine or rectal
prolapse." (Women's Health NewsPublished: Tuesday, 28-Jun-
2005)

More than 50% of women age 55 and older suffer one or more of
the problems caused by pelvic floor dysfunction.
 Background contd.
1 in every 9 women will undergo surgery for a pelvic floor
disorder.
Women who suffer from pelvic floor disorders underreport
their condition due to embarrassment.
1 in every 3 women will suffer sphincter muscle damage
due to vaginal childbirth; a damage that may lead to loss of
bowel control.
30% of women with overactive bladder or urinary
incontinence also suffer from loss of bowel control.

20% of patients suffer from vaginal organ prolapse also

experience loss of bowel control.
Most women suffer from pelvic floor disorders (PFD), the
majority don't seek help until they are incontinent
60% of nursing home occupants suffer from loss of bowel
control and/or urinary incontinence.
 The pelvic floor structures
Made up of muscles & ligaments:
Pelvic diaphragm - Mucsular:
-Levator ani
-Coccygeus
•Ligaments
-Transverse cervical lig.(Mackenrodt)
-Utero-sacral lig.
-Others - Broad lig., round lig. of the uterus,
Pubocervical lig.
 PELVIC FLOOR- "pelvic floor" muscles
The pelvic floor (pelvic diaphragm ) is composed of a group of
muscles, which span the inferior, or underlying surface of the
bony pelvis.

The muscle group, originate at the pubis anteriorly, at the

frontal portion of the pelvis, just above the genitals.

The pelvic floor muscles extend back to the coccyx,(tailbone)

This thick sheath muscular floor is pierced by

-the urethra- the sphincter mechanism of the lower urinary tract,
-the vagina,-the upper and lower vaginal supports, and
-the anal canal-the internal and external anal sphincters.

and gives off fibers that connect it to these organ structures.

Ligaments- Transverse
Female Pelvis Showing the Position of the Pelvic
Organs and Pelvic Floor Muscles
Fig. 3: Vagina & Perinreal pouches in coronal
section
Fig. 2: Female perineum
Fig. 4: Urogenital & Anal triangles
 Functions of pelvic floor muscles
1) support of the organ systems (Uterus , Bladder and rectum&
colon) within the pelvis and lower abdomen;
2) closure of the urethra and anal canal to maintain continence; -

3) signaling to the bladder, rectum and colon when voiding or

defecation is desired; and

4) opening of the urethra and anal canal by total relaxation to allow

for complete and effortless defecation and urination. If any of the
above functions are disturbed, normal bowel and bladder control
will be disrupted
5). The pelvic floor muscles play an important role in bladder and
bowel control and sexual sensation.

• The pelvic floor muscles are normally under voluntary control,

When torn or weakens, the organs may shift, bulge and push
 Factors associated with weakness of the pelvic
floor muscles
Pregnancy and childbirth; esp multiparity & big babies
- those who experienced tears in the perineum and pelvic floor during
childbirth, are at higher risk for pelvic floor disorders.

Continual straining to empty bowels; constipation

Persistent heavy lifting;

Chronic cough (such as smoker’s cough or chronic bronchitis and

asthma);
Obesity / overweight- Excessive body weight adds extra strain to the
pelvic floor resulting in pelvic organ prolapse, incontinence, and sexual
dysfunction

changes in hormone levels at menopause (change of life);

lack of general fitness.

connective tissue disorders, degenerative neurologic conditions, and prior
pelvic surgery
 Pelvic floor disorders include
Incontinence
- bowel control
-urinary incontinence
constipation
Rectal pain
Utero-vaginal and/or rectal prolapse
Pelvic pain/trauma
Sexual dysfunction (Dyspareunia, Apareunia)
Others- Disorders of elevated levels of pelvic muscle
activity
 Others: Disorders of elevated levels of pelvic muscle activity
considerable overlap in symptoms; same
underlying cause.
Proctalgia Fugax - severe and sudden attacks of sharp pain
in the rectum and anal canal -stabbing, burning, or
grinding pain localized in the anal canal or rectum.
Attacks often follow defecation, sexual activity or stress,
but may occur spontaneously as well.
Levator Ani Syndrome
- continual discomfort in portions of the anal canal and can
extend throughout the pelvic region and into the vagina.
-syndrome as having the anal canal pulled in knots, or
feeling there is a hard object, like a golf ball, in the anal
canal. Dyspareunia
-pain or muscle spasm that extends across the buttocks,
down the legs and up into the lower back.
Others: Disorders of elevated levels of pelvic muscle activity

Coccydinia - pain around the coccyx ; C/o coccyx "on fire.“

Pelvic Floor Tension Myalgia - pain and discomfort

associated with the three syndromes described above.

Anismus - failure to relax or, a paradoxical contraction of the

pelvic floor muscles with defecation.
- abnormal increase of pelvic floor muscle activity with
defecation rather than the normal decrease in muscle activity.
-leads to constipation, incomplete evacuation and straining with
stool.
Voiding Dysfunction- - associated with bladder disorders,
which include symptoms of voiding hesitancy, interrupted
stream, urinary urge and painful urination.
 Problems caused by vaginal birth &
advancing age
1.Pelvic Organ Prolapse

2. Incontinence
-occurs when women have trouble controlling their
urine or their bowels;
urinary incontinence or of fecal incontinence.

3. Both Incontinence + 1.Pelvic Organ Prolapse ;

- May require multidisciplinary approach;
urogynecology & colorectal surgery.

Functional problems of pubococcygeal muscles

-urinary and fecal incontinence,
- cystocele, rectocele, enterocele, interstitial cystitis,
 Significant risks for PFD
older age,
high body mass index- obesity
Minor incontinence and other PFDs.
Uterine or rectal prolapse and incontinence.
multiple vaginal births
giving birth to large babies (more than 9 pounds)
difficult instrumented deliveries (forceps, vacuum)
presence of a pelvic tumor
Diabetes
Asthma
Chronic bronchitis
 Utero-Vaginal Prolapse –
Definition – Downward displacement of the uterus
&/Vagina towards or through the intoitus
- The bladder, ,urethra, rectum & bowel may be
secondary involvement
Degrees
1st- degree-descent of the cervix to the introitus

2nd degree- descent of the cervix and part of , but

not the whole uterus through the introitus

3rd degree- Descent of the cervix and the whole

uterus through the introitus- Procidentia,
UV prolapse complicated by bladder ± rectal ±
enterocele
 The signs and symptoms of the condition
Mild prolapse may not cause any symptoms
With more severe prolapse, a woman may have:
-a falling out sensation
-a feeling like she's sitting on a ball
-sensation of pelvic heaviness
-low backache
- lower abdominal discomfort
-increased vaginal discharge
-increased urinary tract infections
-increased desire to urinate or more frequent urination
-stress incontinence, or leakage of urine that is worsened by coughing,
sneezing, or lifting objects
-a feeling of not having completely emptied the bladder
-Dyspareunia (pain with intercourse)
-Apareunia (no sexual intercourse).

-painful bowel movements - constipation

- rectal and/or vaginal heaviness or pain, constipation,
 Urinary Incontinence
Is Involuntary loss of urine that is socially unacceptable to the
patient
-It impacts a woman’s self-esteem, affecting both her
emotional well being as well as her independence.
- 20-30% of women 65years or older have significant degree
of incontinence; it could be more!!

-Many women suffer in silence either because they are too

embarrassed to discuss this issue with their physician or
are fearful that surgery is the only treatment option.
-Good news : After a comprehensive evaluation nearly 60%
of women with incontinence can be successfully treated
using non-surgical techniques.
 Types of Urinary incontinence contd.
1.Stress incontinence
- loss of small amount of urine during exercise, coughing, sneezing, or
straining.
Occurs when intravesical Pressure (IVP)> MUP (Maximum Uretrhal
Pressure) without detrusor activity.

2. Urge Incontinence - involuntary loss of urine in the presence of strong

desire to mictuirate

3. Motor urgency- due to uninhibited detrusor contractions

4. Sensory incontinence -due to irritative lesion (Cystitis, calculus, tumors,
etc)

5. Reflex Incontinence - abnormal spinal reflex

6. Overflow Incontinence - when intravesical Pressure (IVP)> MUP
(Maximum Uretrhal Pressure) with bladder distension without detrusor
activity

7. True Incontinence - due to anatomical abnormality of the urinary tract.

 Types of Incontinence.

• Genuine Stress Incontinence- due to alter-

ation in position of the bladder neck to
pelvic flow

Detrusor Instability- present in 60-70% of

women
- cause unknown,
- Seen naturally in children
• Genitourinary fistulae
 Diagnosis
1.History & Clinical examination
2. Investigations
a) Routine ; MSU→ MCS,
b) Special
- IVU
- Cystoscopy
Cystometry (CMG)
- test the reservoir function of the bladder
-Filling Cysytometrogram – assess derusor activity &
leakage during the filling phase.
- Voiding CMG-to assess urinary flow ; differentiate
obstruction from under active bladder
- Urehtral pressure profile- assess urethral closure
pressure
Special investigation contd
• Video-cystourethrography
-assesses anatomical relationship of urethra
urethrovesical junction and bladder base;
bladder press is measured , urine flow and
volume- useful in complex or failed surgical
cases
fluoroscopic urodynamics
endoanal manometry
pudendal nerve testing
 Treatment of Uterine Prolapse
for uterine prolapse depends on many things,
including:
the severity of the prolapse
the severity of the symptoms
the presence of other signs and symptoms
a woman's wishes to preserve her fertility
the woman's age
It may be medical, conservative surgery of
definitive surgery
 Treatment contd.
• Conservative method
b) medicine to treat the incontinence
- imipramine, an anti-depressant that stimulates the
closure of the bladder neck.
- Other adrenergic drugs (anticholinergic not
effective in GSI)
-b) Kegel exercises to strengthen the muscles
around the bladder and sphincter.
c. . Biofeedback is one learning procedure that uses sensitive
electronic instruments to measure.

The responses are displayed on a computer screen in a way

which helps the patient differentiate and practice those
responses that are associated with better physiological
function.
 Conservative Treatment contd.
Because pelvic floor muscles are controlled voluntarily,
their function can be improved through various learning
procedures

Biofeedback treatment for bowel or bladder dysfunction

-a small EMG sensor is placed in the anal canal or vagina that
measures and then displays the electrical activity of the
muscles being recorded.

d) Injection of a bulking agent (Collagen) into the bladder neck-

usually pretty effective.
 Other, conservative treatments for disorders
related to excessive pelvic floor muscle activity

e). various physiotherapy modalities including

rectal diathermy,
hydrotherapy,
massage,&
postural adjustments.

Electrical stimulation to the pelvic floor muscles is

sometimes used to fatigue or normalize muscle
activity to augment their relaxation.

All these techniques can be used independently or

in conjunction with biofeedback.
Conservative management Contd.
Pessary, a plastic doughnut-shaped device placed into
the vagina to push up the uterus eg Hodge pessary

Double vaginal rings Non-surgical treatment of

uterovaginal prolapse using

Estrogen therapy given directly into the vagina with

creams – HRT in menopausal women
 2. surgical approach:
a) Conservative surgery
when all else has failed, a sling is surgically inserted to
hold up the bladder neck,
suspension of the uterus and bladder without a
hysterectomy

Laparoscopic suspensions but the best results still seem to be with

the more major procedures.
- Pelviscopic uterine suspension using Webster-Baldy and Franke's
method.

Round ligament suspension procedure, an operation to provide

muscle support to the uterus

When multiple PFDs are involved, it's important for a multi-

disciplinary team of experts to work together on solutions.
 Surgical approach
Sacrocervicopexy and combined operations in
the treatment of uterovaginal prolapse in women
with desire to preserving.

Surgical support and suspension of genital prolapse,

including preservation of the uterus, using the Gore-
Tex soft tissue patch -Abdominal-retroperitoneal
sacral genito-colpopexy using the expanded
polytetrafluoroethylene (ePTFE) soft tissue patch has
been found to be highly effective for repair of genito-
vaginal prolapse
 Surgical approach contd.
A new technique of uterine suspension to pectineal
ligaments in the management of uterovaginal prolapse ;
-Through a Cherney incision, the uterus is suspended to the
pectineal ligaments on both sides with mersilene tape. . A
simultaneous Burch colposuspension can be useful in
selected cases

Anterolateral hysteropexy via abdominal approach.

-abdominal suspension is reserved for young patients in whom
retention of sexual function is desirable.
-Fixation to the sacral promontory is the reference method but
has some contraindications.
-Anterolateral suspension of the uterine isthmus to the anterior
superior iliac spines by a strip of non-absorbable mesh, as
described by Kapandji, is then a good alternative.
 Surgical approach contd
Uterine preservation in the surgical management of genuine
stress urinary incontinence associated with uterovaginal
prolapse.
-Retropubic ventral suspension of both the uterine isthmus and the
vesical neck ; designed to correct uterovaginal prolapse as well as
genuine stress urinary incontinence while preserving the uterus.

b) Definitive Surgery

Hysterectomy and pelvic floor repair

vaginal route
abdominal route
Sacrospinous Fixation for - Vault Prolapse and at the
Time of Vaginal Hysterectomy for Marked Uterovaginal
Prolapse
 The side effects of the treatments?

The side effects depend on the treatment.

Hormone replacement therapy may
cause nausea, weight gain, abdominal
bloating, increased vaginal discharge, and
breast tenderness.
After a hysterectomy a woman will need 6
to 8 weeks to recuperate.
possible side effects with any surgery..
 Advice after treatment for the condition
After surgical treatment of a prolapsed uterus,
Avoid all necessary risk factors:
avoid lifting heavy objects
prevent constipation by drinking plenty of fluids, using stool
softeners for a short time, and increasing her fiber intake

perform Kegel exercises daily during pregnancy and after

giving birth to strengthen pelvic muscles
avoid smoking
lose weight through diet and exercise, if she is overweight
continue with hormone replacement therapy, if she was
using it before surgery for a long time ; during and after
menopause to maintain the tone of the pelvic muscles ? For
Africans

avoid wearing tight girdles or other garments that put

pressure on the abdomen
Surgical vs. nonsurgical repair of prolapse in
elderly woman
A Case Senarioo
A grandmother has a prolapsed uterus and bladder and I am
trying to help her decide on the best option for an 85 year old
woman. She is in fairly good health but I'm concerned about
the anesthesia at her age. Are there any non-invasive
procedures? What are the benefits/risks to a stitch vs. removal
of the uterus?

The only nons-urgical treatment would be a pessary

Surgically, the stitch of sewing the vagina shut (colpocleisis) is

about 85% successful and carries less risk of surgical complications
than a hysterectomy.
If either a vaginal hysterectomy or colpocleisis is done, it can be
performed under spinal or epidural rather than general anesthesia.

This is safer for the heart in an elderly woman.

 Summary of surgery
Condition Intervention
1.Urinary Stress -Burch colposuspension
Incontinence (GSI) -urethropexy (Marshal – Marchetti
& Kranz technic)
-Endoscpic bladder neck
susupension ( Stamey procedure)
-Artificial Sphincter implant – in
failed repeated surgeries
-Urinary diversion- ileal conduit
When all methods fail
 Summary of surgery
Condition Intervention
2.Detrusor Difficult to Treat
instability (DI) •Bladder training
• Drug RX
- anticholinergic drugs ± beneficial
-Oxybutalin intravesical in
refractory cases.
3. Refractory • Surgery ; not usually indicated;
idiopathic -Clam csystoplasty
/hyperreflexic DI -Detrusor myomectomy
 Summary of surgery
Condition Intervention
4. Uterine Prolapse Hysterectomy + anterior/
posterior colpoperineorrhaphy/
Colposuspension
5. Pelvic prolapse Watkins Interposition operation
Reserved for the woman who has
completed her family.
Amputation of the Cx, the ligs.
Sturmdorf (absorbable) -The posterior lip of the lower uterine
suture segment is covered by post vaginal
epithelium by bringing the stitch thro
the post vaginal mucosa x2 to the into
the endocanal of the LUS covered at
ant stump by the ant vag mucosa
 Summary of surgery
Type of PFD Operation Remark/
Purpose
Cystourethrocele Anterior Repair ↓cystourethrocele;
Colposuspension reinforce PVF support
of bladder &urethra
Burch technic
Cystourethrocele + Anterior Repair + ± vaginal
Stress incontinen. Kelly Plication of Hysterectomy;
urethra ↓urethra diameter
Physiological changes ↑es intra urethra intravesical press in the
(Kelly’s Operation) resting & stress state
Pressure to level >
i.e with valsava maneuver
Vaginal Prolapse Sacrospinous Ideal for sexually
lig suspension active women with
complete prolapse
 Summary of surgery
Condition Intervention
2nd or 3rd degree UV Manchester (Futhergill)
Prolase + operation/ repair
Csystourtethrocele Advantage– no entry into the
peritoneal cavity;
-Op time is reduced; low
morbidity
2nd or 3rd degree UV Manchester operation + Kelly
Prolase + plication of the urethrovesical
Csystourtethrocele+ sphincter
Stress incontinence
Complete prolapse in the elderly woman with no
desire for sex in the future

RX: Le Fort Operation- advantage

- failure /recurrence extremely rare;

Complication: overflow /stress incontinence

- To avoid this remove upper 2/3 of vagina
wall & leave lower 1/3 behind
Thank you All