Treatment of pelvic organ descent

Are you unable to let out a hearty laugh because you can't control your bladder? Are you no longer able to cycle because it causes lower abdominal pain? Are you afraid to leave your home because you feel you need to go to the toilet every few minutes?

This might be because of a weakened or descended pelvic floor. Many women are affected by this kind of pelvic organ descent at some point in their lives. A mild descent is usually hardly noticeable. However, if the descent is more pronounced, or if there is even genital prolapse due to the protrusion of organs such as the bladder, uterus or bowels, the symptoms are very distinct and can have a great negative impact on the affected person's quality of life.

On this page, we have put together some information about how descents and prolapse occur, how it can be identified and how it can be treated.

Weakened pelvic floor muscles very often result in urinary or faecal incontinence.

Many women also have to contend with a downward shift of their bladder, uterus or vagina if the muscles of their pelvic floor weaken. Almost half of all women who have given birth to children are affected by this. In the worst cases, it may lead to a prolapse (organ prolapse) in which the bladder, the vagina, the uterus or even the bowel cause eversion of the vaginal wall.

The most common symptoms are here:

• Cystocele (prolapsed/dropped bladder)
  Bulging or dropping of the bladder into the front wall of the vagina
• Rectocele (prolapsed/dropped rectum)
  Herniation (bulging) of the rectum into the back wall of the vagina
• Uterine prolapse (prolapsed/dropped uterus)
  Dropping of the uterus

There are various symptoms that could indicate pelvic organ prolapse. The most common are

• Stress incontinence (leakage of urine, for example, when coughing, sneezing, laughing or when lifting heavy loads)  
• Urge incontinence (frequent and very sudden strong and uncontrollable urge to urinate with involuntary loss of urine)
• Pain when urinating
• Pain during sex
• Problems or pain during bowel movements

Weakness of the connective tissue that can lead to pelvic ogan prolapse can occur as a result of vaginal birth or genetic predisposition. It can also be age-related, as a result of many years of pressure being placed on the abdominal organs. Heavy physical work, obesity, smoking or chronic constipation also increase the risk of prolapse.

It is not possible to completely prevent pelvic organ prolapse through preventive measures - the muscle tissue can be exercised but the connective tissue cannot. However, it is possible to reduce the risk through certain behaviour patterns. 

Regular exercising of the pelvic floor muscles, avoiding unnecessary strain and appropriate lifting and carrying techniques reduce the strain and stress on the pelvic floor. In post-menopausal women, targeted vaginal oestrogen administration can have a positive effect on the tissues. 

As a first step, a comprehensive diagnostic work-up and accurate indication are crucial for choosing the appropriate treatment. 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 physician. 

Treatment is usually begun with conservative treatments. These include:

• Reduction of risk factors such as obesity, smoking or chronic constipation.
• Local oestrogen therapy: Post-menopausal women may benefit from local oestrogen therapy to strengthen the tissues. Vaginal administration of the hormone avoids unwanted side effects. 
• Exercise: Targeted pelvic floor exercises - under the instruction of a physiotherapist - can stabilise a dropped organ if it has not cet advanced to a prolapse.
• Pessaries: Pessaries can be inserted if surgery is not yet indicated, not useful, not desired or not possible because of the overall health of the person affected.  
  Pessaries are rings, cubes or shells made of silicone that are inserted into the vagina during the day. They help to stabilise the pelvic floor and push the dropped organ back up again. Different pessaries are useful or necessary depending on the diagnosis. Medical support here is therefore essential. Pessary therapy can also check whether existing symptoms are actually to be attributed to a prolapse.  
• Minimally invasive surgery: In the case of stress incontinence, it is possible, in some cases, to use a ribbon-like synthetic mesh (in women and men) in a minimally invasive procedure that supports the urethra, thereby restoring continence. 

A surgical procedure should only be considered when the conservative therapy options have been exhausted, if the prolapses are very pronounced or if they recur repeatedly. 

In order to achieve a high success rate with surgical treatment, the skills and experience of the physician and the right materials are crucial, as is the correct choice of the treatment method. For this reason, it is recommended that the patient receives treatment in very experienced clinics (in Germany there are many centres of excellence specialised in disorders of the pelvic floor).

Diagnosis

The following examinations are usually performed for a detailed diagnosis. They are the basis for selecting an appropriate surgical method: 

• Ultrasound or X-ray examination to assess the change in position of the urethra, bladder, vagina, uterus and bowel
• Urodynamic testing to evaluate the functioning of the bladder's sphincter
• X-ray examination or magnetic resonance imaging to check bowel function
• Endoscopic examination of the bladder or rectum 

After the diagnosis, the patient should be informed of all possible surgical procedures, the relevant approaches and the prospects, risks and success prognoses, so that a joint decision can be made. 

Essentially, a clear distinction can be made between two procedures:

• Use of the patient's own tissue to stabilise the organs
• Use of synthetic meshes

Use of polypropylene meshes has increased in the last few years, in particular in the event of recurring prolapses (relapse) or if maximum stability is desired. Thanks to improvements in material and improved surgical techniques, the use of mesh implants can today achieve good anatomical and functional outcomes today. (Study results: Improvement in quality of life through multi-armed mesh TiLOOP® Total 6)

The surgical procedure is determined by the area in the lower abdomen in which the dropping or prolapse has occurred. Here, a distinction is made between prolapses in the anterior compartment (bladder and urethra), middle compartment (vagina and uterus) and posterior compartment (rectum).

Anterior compartment

• Anterior mesh
  During this procedure a synthetic mesh is inserted between the bladder and the anterior wall of the vagina.The mesh is then fixated in the stable structures of the pelvic floor via the arms of the mesh. 
• Anterior colporrhaphy/anterior vaginoplasty
  This procedure involves the tightening of the anterior or posterior vaginal wall with surgical sutures, thereby counteracting the prolapse.
• Colposuspension/paravaginal defect repair
  This procedure involves lifting the vaginal wall and the neck of the bladder and fixating them to the front of the pelvis with retention sutures.

Middle compartment 

Today, organ-saving surgery is usually performed. However, in the event of a uterine prolapse, it may be better to remove the uterus (hysterectomy). However, this is usually only considered in women who do not want to have (any more) children. 

• Sacrocolpopexy
  In the case of dropped or prolapsed organs in the middle compartment, the vagina can be raised again by stretching a synthetic mesh between vaginal vault and sacrum. 
• Sacrospinal fixation
  The vagina is fixed to ligaments in the back of the pelvis by means of retention sutures.

Posterior compartment

• Posterior mesh
  During this procedure a synthetic mesh is inserted between the posterior wall of the vagina and the rectum. The mesh is then fixated in the stable structures of the pelvic floor via the arms of the mesh. 
• Posterior colporrhaphy/posterior vaginoplasty
  This procedure involves the anterior or posterior vaginal wall being tightened with surgical sutures, thereby counteracting the prolapse.

Please be aware that this information is not meant for self diagnosis. It does not substitute a physicians diagnosis.