Treatment of descensus genitalis

Descensus genitalis (pelvic organ descent) describes the descent of the bladder (cystocele), rectum (rectocele), small and / or large bowel (enterocele), vagina (vaginal prolapse) or uterus (uterine prolapse) – usually due to weakened connective tissue. 

Connective tissue weakness can occur as a result of vaginal births, genetic predisposition or can, for example, be related to age. Heavy physical work, obesity, smoking or chronic constipation also increase the risk of prolapse.

Therapeutic goal: more quality of life

Genital prolapse usually has a considerable impact on the quality of life of the women affected: it often affects the function of the bladder and bowel. Their sexuality as well as physical and social activity can also suffer. Typical symptoms also include a sensation of a bulge, pulling in the womb area and a sagging feeling.

The goal of treatment is therefore not only to reconstruct the physiological anatomy, but also in particular to restore quality of life for those affected.

Genital prolapse can be treated with different conservative and surgical methods. Surgical procedures, however, are not usually the first choice for genital prolapse. Conservative options must first be exhausted. 

Conservative 

• Clinical observation
• Reduction of known risk factors such as obesity, nicotine abuse and chronic constipation
• Pelvic floor training
• Local oestrogen replacement therapy
• Pessary treatment

Surgical therapy should only be considered if none of these treatments work or if the psychological stress of those affected is too great. 

Surgical

• Colporrhaphy/vaginoplasty
• Surgery with synthetic or biological materials
• Paravaginal defect repair (anterior compartment)
• Sacrocolpopexy (middle compartment)
• Sacrospinous fixation (middle compartment)
• other surgical treatments

As a first step, a comprehensive diagnostic work-up and accurate indication are crucial for choosing the appropriate treatment for genital prolapse. Detailed observation of the individual needs of the patient is also vital – the patient must be questioned in detail (condition and circumstances) and given advice. The appropriate treatment method should always be chosen in close coordination with the patient personally and with the referring doctor. 

If surgical treatment is indicated, the appropriate surgical procedure should be chosen after carefully explaining to the patient all possible surgical procedures with their approaches, benefits and risks, and after considering the success rates and medical skills available. The best possible materials are just as important for successful surgery as pre- and postoperative complication management. In certain circumstances, it may be useful to perform the surgery in collaboration with a centre of excellence.1

Surgical treatment with mesh implants in the anterior compartment can be discussed if your patients have:1 

• Severe prolapse
• Recurrent prolapse
• Comorbidity
• Levator avulsion
• High demand for anatomically stable repair

Compared with single-incision meshes, the use of multi-armed meshes is associated with more complex surgical procedures. However, these bring many advantages, particularly in the case of severe or recurrent prolapses and in the case of a high requirement for patient safety in respect of anatomical repair.

These advantages were demonstrated for the titanium-coated TiLOOP® Total 6 in one of the largest studies in this field with 289 patients. 

Continue to study summary

1. DGGG-Leitlinie: Descensus genitalis der Frau. AWMF-Leitlinien-Register Nr. 015/006