The female pelvic floor is composed of voluntary muscles, fascia and ligaments - the levator ani. These structures have a supportive component and a functional component. They support the bladder, vagina, uterus, rectum and sigmoid colon and are involved in bladder storage, voiding and continence.
They are also involved in providing support for the vaginal wall, cervix and uterus, and also with sexual function. They have a major role in defecation and continence of faeces. Abnormalities of the pelvic floor manifest themselves as urinary incontinence, uterovaginal prolapse, sexual dysfunction and obstructed defecation and faecal incontinence.
What is a prolapse?
50% of women will complain of symptoms of vaginal prolapse; 10-20% undergo surgery. Genital prolapse involves a weakness of the pelvic floor support mechanisms allowing the organs to herniate through the opening in the pelvic floor muscles. These are divided into compartments.
Anterior vaginal wall prolapse (cystocele and urethrocele)
The anterior vaginal wall supports the bladder and the urethra. The anterior vaginal wall supportive layer is called the pubocervical fascia. It is attached distally to the pubic bone area and proximally to the cervix if the uterus has not been removed. The pubocervical fascia is also attached laterally (on both sides) to the pelvic floor muscles specifically the obturator internus muscle. As long as this vaginal wall stays in place, the bladder and urethra will stay in their normal anatomical positions.
Patients with cystocele or cystourethrocele may complain of:
• Pelvic/Vaginal pressure
• Dyspareunia (painful intercourse)
• Dragging or drawing vaginal sensation
• Urinary incontinence
• Difficulty emptying bladder
• Repositioning body to empty bladder
When there is break in the pubocervical fascia there is a loss of support of the urethra and/or bladder resulting in:
Cystocele : Loss of support at the level of the bladder.
Cystourethrocele or a combined "cystocele" and "urethrocele", in other words there is a loss of support for the whole anterior vaginal wall. The main supportive layer known as the pubocervical fascia is no longer supporting the bladder or urethra appropriately.
Urethrocele: Loss of support at the level of the urethra.
Uterine & vaginal Prolapse (Middle compartment)
The uterosacral ligaments primarily support the upper 20% of the vagina (apex) and the uterus. When the uterosacral ligaments break the uterus begins to descend into the vagina. Further uterine descension pulls the rest of the vagina down resulting in apical tears of the anterior (pubocervical) fascia and posterior (rectovaginal) fascia from its points of lateral attachment. Anterior vaginal wall lateral tears are called paravaginal defects and results in cystourethrocele. Continued uterine and vaginal prolapse can result in a complete uterine and vaginal prolapse such that the uterus falls outside the vaginal opening and the vagina falls inside out.
Vaginal vault prolapse usually refers to an apical vaginal relaxation in an individual who no longer has a uterus (post hysterectomy). As the apex of the vagina continues to descend it pulls the rest of the vagina down resulting in apical tears of the anterior and posterior fascia from its lateral points of attachment. Continued descent of the vaginal apex may result in complete eversion of the vagina. Complete eversion of the vagina means that the once highest point in the vagina is now the lowest point hanging out of the vagina.
Posterior vaginal wall prolapse (rectocele and enterocele)
The supportive layer of the posterior vaginal wall is called the rectovaginal septum or rectovaginal fascia. It is attached distally to the perineal body, laterally to the levator ani muscle and proximally to the cervix (if uterus is present). When a break in the rectovaginal septum is present the rectal wall will come into contact with the vaginal skin and create a bulge on the posterior bottom side of the vagina.
In the posterior compartment we can also have a true hernia of the peritoneal body cavity which may involve small bowel which usually affects the upper third of the back wall of the vagina. This is called an enterocoele.
These bulges will usually increase in size with bearing down (Valsalva maneuver) especially when having a bowel movement. Patients with a rectocele may experience:
• Vaginal pressure/discomfort
• Protrusion coming from the posterior vaginal wall
• Difficulty evacuating rectum
• Dyspareunia (painful intercourse)
The skin between the vagina and the anus (perineum) may also be deficient and need repair.
Damage to these muscles can occur during childbirth, or due to a constant increase in intra-abdominal pressure caused by chronic lung disease (for example, asthma or heavy smoking), constipation, or heavy lifting or straining activities. When damage occurs, these muscles can no longer contract, losing their ability to support the pelvic organs in their accurate places.
A great strain is then created on the “passive” support system of the pelvis, the endopelvic fascia. The endopelvic fascia is a tough, fibrous sheet within the pelvis, consisting of collagen, elastin and smooth muscle fibers. Alone it cannot support the pelvic organs, which may be affected by consistent gravitational pull and/or an intra-abdominal pressure.
Exposed to prolonged pressure and tension from the pelvic organs, the endopelvic fascia may stretch and eventually break, resulting in the breakdown of the pelvic floor. This is female organ prolapse.
The vagina is supported on three different levels within the pelvis.
The upper third is supported by the uterosacral ligaments, a pair of very strong fibromuscular structures originating from the lateral aspects of the sacrum going around the rectum and attaching to the cervix and upper part of vagina. These ligaments pull the top of vagina and cervix toward the sacrum and help to form the normal axis of the vagina.
The middle third of the vagina is held in place by the lateral attachments of the endopelvic fascia to the pelvic side wall.
The lower third blends into and merges with the fibromuscular tissue surrounding the opening of the vagina and anus.
In order to restore the vaginal depth and axis, all three levels of support must be attended at the time of surgery.
What Are the Symptoms?
Back pain, pelvic pressure or pain, or a sensation that something is bulging into/falling out of the vagina/rectum.
As a result, patients complain of discomfort when sitting, standing or actively carrying out normal daily activities; but is rarely bothered while lying down or resting. Any physical stress, such as coughing, sneezing or lifting usually aggravates the symptoms.
Sexual dysfunction becomes a problem because of the presence of a mass. Intercourse may be painful. In its most severe presentation, the vagina and or bladder/rectum may evert and be located completely outside of the pelvis.
Bristol Laparoscopic Associates goal for patients with uterovaginal, bladder and or rectal prolapse are:
restore the normal vaginal depth and axis.
restore the prolapsed rectum
restore the prolapsed bladder
relieve the symptoms of pressure.
maintain satisfactory sexual, voiding and evacuatory function.
We believe that the uterus per se has no bearing or effect on vaginal support. Therefore, a hysterectomy should not be considered as part of repair surgery for uterovaginal or vaginal prolapse.
The length of the vagina in a normal adult female is approximately 10 to 12 cm. When standing, the lower third of the vagina is pointing 90° to the floor whilst the upper two-thirds is at an angle almost parallel to the floor and is directed toward the sacal prominentry.
Because the defect in the pelvic floor support mechanism is usually multiple and not limited just to one component, the entire pelvic floor supporting system needs to be evaluated and all defects reconstructed at the same time. A prolapse rarely bothers patients when lying down and resting. It only tends to bother them when carrying out daily activities in an erect (either standing or sitting) position. Any physical stress such as coughing, sneezing or lifting aggravates the prolapse.
To evaluate the degree and site of the prolapse it is necessary to examine the patient in an erect position with the patient coughing, bearing down and straing. The aims of reconstructive surgery are to restore normal vaginal depth and axis, relieve the symptoms of pelvic pressure, faecal urgency, bleeding, bulging etc and maintain sexual function.
Advantages of the laparoscopic approach
The bright light and the magnification provided by the laparoscope allows superb views of the pelvic floor. The increased abdominal pressure also allows clear identification of the defects. The laparoscopic approach also differs from traditional vaginal and abdominal approaches in that during a laparoscopic repair, the surgeon not only see the supporting defects clearly, he/or she can also feel the defects when performing a vaginal examination under direct laparoscopic view.
With the traditional vaginal repair, the surgeon is almost depends entirely on tactile feeling to guide the surgery. This results in either over or under repair of the defects. Postoperative pain and discomfort are greatly reduced and the recovery period is shortened.
Laparoscopic Surgery for Uterovaginal and Vaginal Prolapse
The length of the vagina in a normal adult female is approximately 10 - 12 cm. In a standing female her lower 1/3 of the vagina is pointing 90 degree to the floor and her upper 2/3 of vagina is in an angle almost parallel to the floor and directly toward her lower backbone. The vagina is supported on three different levels in the pelvis.
The support of the upper 1/3 of vagina comes from the uterosacral ligaments, a pair of very strong fibromuscular structures that originate from lateral aspects of sacrum, going around the rectum and attaching to the cervix and upper part of vagina. These ligaments pull the top of vagina and cervix toward the sacrum and forms the normal axis of the vagina.
The middle third of the vagina is held in place by the lateral attachments of the fascia to the pelvic side wall. The lower third of vagina blends into and merges with the fibromuscular tissue surrounding the opening of the vagina and anus.
A hysterectomy should not be considered part of the repair for uterovaginal or vaginal prolapse unless there is distinct pathology of the uterus. In order to restore the vaginal depth and axis, all three levels of support must be corrected.
Under general anesthesia the laparoscope is placed through a small incision inside the navel. Two additional incisions are needed for the laparoscopic instruments. As the individual supporting defects are visualized and confirmed by digital vaginal palpation under the view of the laparoscope, defects are repaired with the placement of permanent non-absorbable sutures. Frequent digital vaginal examinations are performed throughout the surgery to ensure that all defects are repaired.
Because of excellent visibility of the operative field, the blood vessels can be avoided. My current surgical technique is to use prolene mesh to resuspend the vagina and cervix (if patient still has a uterus) to restore the depth and axis of the vagina.
I have been doing laparoscopic surgery for uterovaginal and vaginal prolapse for the past 9 years with good long-term results. Unlike traditional vaginal surgical repair, there is no cutting or trimming of the vagina and the risk of making the vagina too narrow or too short.
Laparoscopic Surgery for the Repair of Cystocele
Support for the bladder and urethra is provided by a strong layer of fibromuscular sheet that overlies the linings of the anterior vaginal wall; the pubocervical fascia. Superiorly it attaches to the upper part of vagina and cervix and laterally it attaches to the pelvic side walls. The pubocervical fascia supports the bladder and the urethra by forming a shelf allowing the bladder neck and the proximal part of urethra to be compressed in an anterioposterior fashion during the periods of stress (coughing, sneezing, laughing, or lifting heavy objects). When this supporting mechanism becomes loose due to trauma of childbirth the stability of this supportive layer of fascia diminishes and may ultimately fail, leading to the formation of a cystocele and the development of stress urinary incontinence if the fascial defects involves the support of the bladder neck and proximal urethra.
Technique of Laparoscopic Paravaginal Repair for Cystocele
Under general anesthesia the peritoneum above the bladder and behind the pubic bone is opened and the retropubic space is entered and dissected. The paravaginal defect(s), can be very easily picked up. A vaginal examination under the direct vision is performed to reconfirm the presence and extend of the defects; the defects are then repaired with several interrupted sutures. Mesh is sutured to the ventral aspect of the vagina, brought through the broad ligament and then attached to the sacral promintry. the mesh is then covered with peritoneum.
With positive intra-abdominal pressure (the pneumoperitoneum), paraviginal defects become much more apparent. Digital vaginal examination under the direct viewing, affords the surgeon additional tactile assessment of the defects. Intraoperative findings dictate the procedures to be performed.