Written by Written by Achilles Ploumidis, MD, BSc, MSc, PhD, FEBU, Surgeon Urologist - Urogynaecologist, Centre of Robotic & Laparoscopic Surgical Urology - Andrology in Athens Medical Centre
What is pelvic floor prolapse?
This is the projection of one or more organs of lesser pelvis through the vagina, which end up extending beyond the labia. These organs may be: the uterus, the vaginal cuff (in case of preceding hysterectomy), the bladder, the intestine strands, or even the rectum. This prolapse occurs during intra-abdominal pressure increase (sneezing, coughing, weight lifting), and it is due to the relaxation of ligaments, fascias and the peritoneal muscle wall, all of which form a complex network of dynamic and static support of the pelvic organs.
What are the symptoms of pelvic floor prolapse?
- Permanent feeling of heaviness in the perineum or vagina, which is often also transfered to the lumb (waist).
- Displacement (descent) of the uterus or a soft organ in various movements, which can project outside the vagina.
- Lower urinary tract symptoms, such as: weak urination, difficulty in urination, feeling of obstruction during urination, feeling of incomplete bladder emptying, frequent urination, urgency, urinary incontinence.
- Gastrointestinal system symptoms, such as constipation, feeling of incomplete emptying during defecation.
- Discomfort during sexual intercourse.
 A. Normal anatomy of the female pelvis. II. Various types of pelvic floor prolapse: prolapse of the anterior compartment (cystocele), prolapse of the central compartment (uterine prolapse) and prolapse of the posterior compartment (rectocele). III. The correction of pelvic floor prolapse is achieved robotically through the suspension of the vagina to the sacrum |
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How common is pelvic floor prolapse?
Pelvic floor prolapse is one of the most common urogynaecological problems that adult women face. The impact increases with age and, in fact, one in three women over 50 will seek medical attention due to the symptoms. Unfortunately, many women are overwhelmed by shame, reduced sexuality and as a result, self-esteem, leading to the disease often remaining in a latent state, with serious impact on quality of life.
Types of pelvic floor prolapse:
When prolapse occurs in the anterior wall of the vagina, then it is called anterior compartment prolapse. Since the organs projecting from the anterior compartment are the bladder and/ or urethra, it is often called cystocele or urethrocystocele, respectively. This type of prolapse is the most common and affects, in most cases, urination function (obstructive symptoms). Correspondingly, when the prolapse concerns the posterior wall of the vagina, then it is called prolapse of the posterior compartment. In this case, the organ projecting is the rectum, which is why the prolapse is called rectocele.
However, part of the small intestine may be also projecting from the upper part of the posterior vaginal wall, known as enterocele. Finally, when the uterus or vaginal cuff projects (in case of hysterectomy), it is a prolapse of the central compartment. Uterus or vaginal cuff prolapse is the second most common type of pelvic floor prolapse. It should be emphasised that the separation of the condition into three compartments (anterior, central and posterior) is of particular diagnostic and therapeutic importance, although a woman may have a combination of the above: i.e. she may have a cystocele with vaginal cuff prolapse, especially following hysterectomy surgery. For this reason, the condition should be treated as a single disease.
The causes of pelvic floor prolapse:
Pelvic floor prolapse is mainly due to the relaxation of muscles, ligaments and fascias supporting the pelvic organs. This, in turn, is caused by the following conditions:
- Pregnancy and childbirth are considered among the most important factors. In fact, one in three women who have given birth will ultimately suffer from the disease, which may even occur some years after pregnancy. However, it is important to note that only 1 in 9 women will need surgery.
- Increased age and menopause are among the factors that cause pelvic floor ligaments relaxation.
- Most of the times chronic increase of intra-abdominal pressure is released on the pelvic floor, resulting eventually in its downwards displacement. Conditions that increase intra-abdominal pressure include: obesity, chronic cough, constipation and weight lifting.
- There are women who are prone to pelvic floor prolapse, while there are also some connective tissue disorders, which affect ligaments’ strength.
Treatment of pelvic floor prolapse:
Pelvic floor prolapse is not a life-threatening condition, while some women actually have minimal symptoms, and their daily lives are not affected. Therefore, depending on the degree of prolapse, the woman's age and the symptoms, the physician can recommend the corresponding treatment. Treatments are mainly divided into conservative (non-surgical) and surgical.
Conservative Treatments:
- Behavioural change: Body weight reduction (in case of overweight women), avoiding weight lifting and avoiding any cause of intra-abdominal pressure increase, such as chronic constipation and chronic cough (frequent in smokers).
- Transvaginal pessary placement: The pessary is a device (usually silicon) placed by the physician into the vagina, with the aim to mechanically support the prolapsing organs. Therefore, the woman feels released of the symptoms to some extent, while the main advantage is the avoidance of surgery. It is not recommended for young women as it complicates intercourse and frequent changes are needed.
- Exercises for the strengthening of the pelvic floor (Kegel exercises): Since perineal muscle relaxation is one of the factors of pelvic floor prolapse, strengthening these muscles through appropriate exercises, which will be recommended by the physician, can improve symptoms and prevent further relaxation at that area. These are the first treatments to be applied, especially in cases of small prolapse.
Surgical Treatments:
 With robotic surgery, the large incisions of classic open surgery are replaced by 4 small openings on the abdominal wall. |
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Surgical treatment is recommended in cases where conservative measures have failed, to young women as well as in moderate and high degree of prolapse. There are several techniques applied, and they are classified mainly as: transvaginal procedures (through the vagina) and transabdominal procedures (through the abdomen). Surgical repair may be performed with or without the use of a mesh. It is important to note that, according to international literature, the use of a mesh provides a permanent solution to the problem with lower chances of relapse. Current concerns over the use of the mesh relate mainly to its use in transvaginal (through the vagina) repair operations. As is known, the vagina has a normal microbial flora, which may subsequently contaminate the mesh. The operations performed transabdominally are free from such risks, since the abdominal cavity has bacteria. Besides, transabdominal use of a mesh is the gold standard in other general surgical operations with similar aetiolopathology, such as restoring hernias of the abdominal wall and the inguinal region.
Robotic Sacrocolpopexy & Robotic Hysteropexy:
Sacrocolpopexy is an operation aiming at restoring normal anatomical position and function of the vagina (in women who have undergone hysterectomy), and in preventing pelvic organs descent. This is achieved with the placement of a mesh in the anterior wall of the vagina, i.e. between the vagina and bladder (thus repairing any cystocele), as well as in the posterior wall of the vagina, i.e. between the vagina and rectum (thus repairing any rectocele and enterocele). These two meshes are placed on the sacrum, thus providing strong support to the vaginal cuff (and thus repairing vaginal prolapse). It is proven (CochraneReview) that the above procedure has the fewer relapses. However, the disadvantage of the above operation (so far) in relation to transvaginal operations, is that it requires open abdominal incision and it is more time consuming. Today, however, with the application of robotic surgery, which is the method of choice for pelvic operations in particular, the above procedure (robotic sacrocolpopexy) can be performed in a minimally invasive manner. This way, low recurrence rate of a transabdominal surgery are combined with minimal complications and inconvenience of a transvaginal operation.
 With the robotic platform the surgeon’s moves are transferred to the robotic instruments to a scale (Downscaling), providing accuracy in tissue preparation |
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Furthermore, with robotic surgery women can undergo uterus and cystocele proptosis repair operation, while their uterus is preserved with minimally invasive manner (robotic hysteropexy).
The long-held view that in cases of uterus prolapse the uterus should be removed has been revised, and today it has been proven that uterus drop is the result and not the cause of the disease.
