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Recto-Urogenital Prolapse & LVMR

What is the pelvic floor?


The female pelvic floor is composed of voluntary muscles, fascia and ligaments - the levator ani. 

- Pelvic floor muscles through durability and contractility act as a dynamic backstop, which absorbs most of the load.

- Endopelvic fascia is also important, but in a less direct way. It attaches the the pelvic organs to the axial skeleton and so stabilises them over the centre of the levator plate.  the endopelvic fascia has considerable mechanical strength and can resist short term expulsive forces.  However, any fascial suspension is prone to fail under sustained load, especially if ravaged by age and childbirth damage.

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. 

 





The 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.

The pathogenesis of prolapse

Pregnancy itself softens the pelvic connective tissue, thus potentially weakening apical supports.  However, the key event is vaginal delivery. 

- Perhaps the prime insult is a direct avulsion of the pelvic diaphragm from its origin on the levator tendon, seen in about 20% of parous women.

- Elongation of the the nerve to levator ani during descent of the fetal head can also cause a stretch neuropathy and eventually muscle fibre atrophy.

- Finally the endopelvic connective tissue is generally torn by the same obstetric events, creating a group of "site specific" fascial defects.

Avulsing and stretch neuropathy injuries to the pelvic diaphragm result in a sagging concave levator plate and a widening of the urogenital hiatus.  Valsalva pressures are now deflected downwards and outwards, creating a sliding stress on the pelvic viscera;if the fascial mesentery is also torn, the pelvic organs align over this widened hiatus and become susceptible to descent and prolapse.

These injuries are generally compensated for years by the strong connective tissue of young women. Whether or not these events ever results in overt prolapse depends upon secondary factors e.g., nutritional deficiency, repeated abdominal straining, central obesity, surgery eg hysterectomy and the acquired collagen weakness that develops in a torn anterior or posterior suspensory hammock (see below)

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. 

(Figure 2)  The connective tissue of the postero-superior axis form a continuous strong band that runs from the sacral periostium (bone), through the uterosacral ligaments, into the pericervical ring and down through the rectovaginal septum to insert into the perineal body.  When this is intact bowel motions are guided smoothly through the pelvis and easily out of the anus. however, when it is torn, pelvic dragging discomfort and obstructed defecation becomes a problem.

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 fibro muscular 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 sidewall.

- The lower third blends into and merges with the fibro muscular tissue surrounding the opening of the vagina and anus.

The anatomical consequences of damage to the vaginal suspensory axis are shown in Figure 3 (below). Laceration of the uterosacral ligaments above the pericervical ring creates uterine descent, whilst avulsion of the rectovaginal septum below the pericervical ring leads to herniation of small bowel (enterocele), sigmoid colon (sigmoidocele) or rectum (rectocele) into the vaginal lumen.

In order to restore the vaginal depth and axis, all three levels of support must be attended at the time of surgery (see ventral mesh rectopexy)

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 (PCF in Figures above).  It is attached distally to the pubic bone area and proximally to the pericervical ring of the uterus if this 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 (shown here)

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 (shown above)

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 compartment prolapse (rectocele, enterocele, rectal intussusception, rectal prolapse)

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 an enterocoele.

cystocele & enteroceleTo simplify things, An enterocoele (or enterocele) occurs when the small bowel pushes down from within the abdominal cavity onto the back wall of the vagina through the gap between the rectum and vagina (the rectovaginal septum). When the sigmoid colon comes down, it is known as a sigmoidocoele. Enterocoeles and sigmoidocoeles cause similar symptoms and usually respond to identical treatments and so we will consider them together.

What causes them? 

These bulges will usually increase in size with bearing down (Valsalva maneuver) especially when having a bowel movement. 

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.

What symptoms do they cause?

Patients with a rectocele may experience:

• Vaginal pressure or discomfort 

• Protrusion coming from the posterior vaginal wall 

• Difficulty evacuating rectum or ODS 

• Dyspareunia (painful intercourse) 

The skin between the vagina and the anus (perineum) may also be deficient and need repair. 

How are they diagnosed? The surgeon seeing you will often be able to detect the presence of an enterocoele or sigmoidocoele by examining you. A defecatoing proctogram is useful, however, in confirming the diagnosis and establishing whether the enterocoele/sigmoidocoele is an isolated problem or is present in association with other abnormalities such as prolapse.

How can they be treated? In our opinion the best surgical treatment for an enterocoele, in patients with significant symptoms, is  a laparoscopic ventral mesh rectopexy (LVMR) which will also treat the rectocoele and rectal intussusception that often co-exists.

Rectal Intussusception / Internal or Occult Rectal Prolapse.


What is it? Rectal intussusception is known by a number of other terms including internal or occult rectal prolapse. It refers to when the rectum telescopes down either within the rectum see above (low grade internal prolapse) or down into the anal canal (high grade internal prolapse) [marked in red in the diagram] seen when the anaesthetised patient is examined with a CAD . When the rectum protrudes through the anal canal, this is described as an overt or external rectal prolapse and is different from intussusception.

What causes intussusception? Rectal intussusception is more common in women (90% of patients) because of damage to the pelvic floor from childbirth. In some subgroups (men and women not having given birth) there may be an underlying tendency to pelvic floor weakness. Rectal intussusception frequently co-exists with other pelvic floor abnormalities including rectocele and enterocele.

What symptoms does intussusception cause? The common symptoms are of obstructed defecation syndrome (ODS). Most strikingly, they often get the sensation of a blockage which is made worse by straining. Some patients get pelvic pain. Others may also suffer with a degree of incontinence.

How is it diagnosed? We often suspect the diagnosis on the basis of symptoms and examination in clinic. You will need tests and a proctogram is the one that usually confirms the diagnosis.

How is intussusception treated? About one third of patients will get significant or complete resolution of their symptoms with simple measures like dietary changes or biofeedback. In other patients, we may suggest a laparoscopic ventral mesh rectopexy (LVMR), which lifts the rectum out of the pelvis and restores it to its normal position. Intussusception rarely occurs in isolation but often in association with a rectocoele and/or enterocoele.

Obstructed Defaection Syndrome (ODS)

What is ODS??Obstructed defaecation syndrome is a common condition in which a person is unable to evacuate their bowels properly.

What causes ODS??Generally ODS is caused by the structural abnormalities associated with a weak pelvic floor or prolapse disease (intussusception or internal rectal prolapse or rectocele). Less commonly (about 5-10%), a tight pelvic floor (anismus) is the cause.

What symptoms do patients get??This syndrome is characterised by difficulty passing motions, multiple (often unsuccessful) visits to the toilet, a sensation of a blockage and incomplete emptying. Patients with ODS often use their finger to help them to empty, pushing on the perineum (the skin in front of the anal canal), on the back wall of the vagina or in the anal canal itself. Patients often have some symptoms of faecal incontinence, particularly after evacuation. 

Other symptoms include back pain, pelvic pressure or pain, or a sensation that something is bulging into/falling out of the vagina/rectum. As a result, patients often 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.

Which test will I need??After an examination in clinic, we may recommend a colonoscopy to rule out rare causes for ODS. Anorectal physiology and endoanal ultrasound will help distinguish a weak from a tight pelvic floor. A defecating proctogram looks at the co-ordination of the pelvic structures during defaecation. A transit study will check to see if the colon is sluggish and failing to propel its contents to the rectum for defaecation.

Which treatments might be offered??Often patients can be helped with changes in diet or stool softeners. Biofeedback retrains the muscle of the pelvic floor and co-ordinates the muscles better. For those failing to improve with these measures and evidence of a structural cause for ODS such as an intussusception or rectocoele, surgery such as llaparoscopic ventral mesh rectopexy (LVMR), STARR or rectocoele repair may be indicated.


Solitary Rectal Ulcer Syndrome (SRUS)

What is it? Solitary rectal ulcer syndrome is a condition in which a benign ulcer develops in the rectum in association with an internal prolapse or difficulty emptying the bowels (ODS). 

What causes SRUS? There are a number of theories as to how SRUS is caused. Many patients have a history of constipation and straining and some people believe that this causes the lining of the bowel to prolapse down. The ulcer then may occur from trauma to the bowel from it rubbing against itself. Some patients with SRUS have difficulty in opening their bowels and may insert a finger into the anal canal to aid defaecation and it is possible that the ulcer comes from the finger being inserted.

What symptoms does it cause? The typical symptoms are of pelvic pain, bleeding and mucus discharge. Patients often report a sensation of incomplete emptying and a persistent feeling of fullness in the pelvis.

How is SRUS diagnosed?
After an assessment in clinic, we may recommend a flexible sigmoidoscopy or colonoscopy to look at the bowel higher up and to biopsy the ulcer in order to rule out other causes of ulceration. We often recommend other tests including a proctogram which looks for evidence of rectal prolapse commonly seen in association with SRUS. This may direct future treatments.

How can SRUS be treated? Often people with SRUS can be treated with changes to their diet and laxatives. Biofeedback may retrain the voluntary and involuntary processes involved with opening your bowels, improving symptoms. In patients with persistent symptoms and bowel prolapse, operative treatment (STARR or laparoscopic ventral mesh rectopexy) of the underlying anatomical abnormality can give prolonged symptom relief.

Anismus

Anismus is known by a number of other names including pelvic floor dyssynergia and paradoxical puborectalis contraction. It refers to a condition in which the external anal sphincter and the puborectalis muscle contracts rather than relaxes during an attempted bowel motion. It is one of the causes of obstructed defecation syndrome (ODS) It is not completely clear why it occurs. It is probably a specific voluntary sphincter muscle abnormality.

What symptoms does anismus cause? Patients often report symptoms of constipation i.e., they have to strain when trying to pass a stool and that they get a sensation of a blockage or resistance to the passage of stool.

How is it diagnosed? The diagnosis of anismus is based on clinical examination, anorectal physiology and defecatory proctography. Probably the best diagnostic test for anismus is a positive response to botulinum toxin.  Often the apparent anismus seen on proctography and in physiology assessment is learnt behavior secondary to an underlying prolapse.

How is anismus treated? Some patients will report improvement in their symptoms with biofeedback or pelvic floor retraining, which retrains the muscles, helping the patient to relax the sphincter muscle during defaecation. We usually recommend an injection of botulinum toxin into the sphincter muscle after completing an examination under anaestheia to exclude an occult prolapse as the underlying problem.  If successful, the initial injection relieves symptoms for about 6 weeks then begins to wear off. The injection can be repeated and the second injection usually lasts longer and may be permanent.

External Rectal prolapse

External full thickness rectal prolapse occurs when the rectum, becomes stretched and protrudes out from the anus. Most commonly, this is caused by a weak pelvic floor from the ageing process, postmenopausal change, deficient collagen and childbirth even though it may only come to light many years later. Men and women with long term constipation and straining also seem to be at risk of the condition.  Most patients are aware of a lump protruding from the anal canal when they strain. In some patients, this is present all the time. The condition is often associated with a weak sphincter muscle and most patients suffer with incontinence, bleeding and/or ODS. Often the diagnosis is easily made as the lump is obvious on examination. At other times, we will examine you after you have strained on the toilet or commode in order to make the prolapse “come down”. Occasionally we will ask for you to undergo anorectal physiology studies and an ultrasound to assess your sphincter function. Occasionally a proctogram is helpful. The best treatment for almost all patients with rectal prolapse is a LVMR which provides effective long-term control in 98% with restoration of good function (ODS/incontinence) but without the risk of developing constipation.  Occasionally, in very unfit patients, the prolapse is excised and fixed through the anal canal (Delorme's rectal mucosectomy), though this approach tends to be less durable.

Bristol Laparoscopic Associates goals for patients with utero-vaginal, bladder and or rectal prolapse (both internal and external) 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, unlike gynaecologists that a hysterectomy should not be considered as an essential part of repair surgery for uterovaginal or vaginal prolapse and that a posterior repair should only be contemplated in women ho only complain of a bulge and have no evacuatory problems.  Finally vaginal vault prolapse should again not be treated in isolation as the majority of these types of patients will have a prolapse within the posterior compartment.




Laparoscopic pelvic floor repairs

Long-term results LVMR in male patients
Long-term results of LVMR for rectal prolapse
How to deal with complications post Lap ventral Mesh rectopexy
LVMR successfully treats solitary rectal ulcer
LVMR for combined uterine/vault & rectal prolapse
Vaginal sacrocolpopexy & LVMR for Vault Prolapse
Utero/vaginal vault prolapse repair
Laparoscopic Enterocele repair
Laparoscopic Rectocele Repair
Laparoscopic Rectal Prolapse Surgery
A patient view of laparoscopic rectopexy
BLAs development of Lap Ventral mesh rectopexy (LVMR)
What will happen if I ignore this problem?
What is a Lap ventral mesh rectopexy (LVMR) - what to expect
Is LVMR safe?
Recovering at home
Movicol after pelvic floor surgery
Pelvic Floor Exercises -0 Kegel Exercises
HALO or THD procedure
NICE guidance Lap Sacrocolpopexy
Urinary Stress Incontinence
NICE guidance stress incontinence

Investigations & results

Defecating proctogram
Anorectal Physiology tests
Biofeedback
Urodynamics

The traditional approach to the repair of prolapse and incontinence has involved a predominantly vaginal approach. This approach is approximately 150 years old. These procedures were refined 100 years ago and 50 years ago the first abdominal procedures were reported which appeared to show a quite marked improvement in the success rate compared to the time honoured vaginal approach.

The problem with the traditional abdominal approach was the associated morbidity of open surgery, the large unsightly scar and the longer postoperative recovery phase.  As the new techniques for abdominal surgery were evolving, so were the techniques for laparoscopic or keyhole surgery. The first laparoscopic incontinence operation was performed in l991 and since then the evolution of pelvic floor surgery has accelerated dramatically. 

Pelvic floor dysfunction may present as uterovaginal prolapse, urinary or faecal incontinence, voiding and defecation disorders and sexual problems etc. with this in mind it became very clear to us here @ Bristolsurgery.com that with the magnification offered by the laparoscope, pelvic floor anatomy could be extremely well visualised and the defects that were causing each of the various types of prolapse could be accurately identified and repaired. Most of these defects are completely invisible using the vaginal approach.

Bristolsurgery.com have developed for the first time, a holistic approach to the pelvic floor- laparoscopic ventral mesh rectopexy [posterior colporraphy, vaginal sacrocolpopexy]. First performed in 1996, we have now performed over 900 LVMRs and now offer national revisional service for failed surgeries and the correction of mesh related complications.

Each patient who presents with any of these symptoms needs to be assessed in terms of a site-specific anterior compartment defect, middle compartment defect and posterior compartment defect.  Surgery needs to be directed towards the site-specific repair of these defects restoring their normal function using the laparoscopic approach which reproduces the various abdominal approaches that have been used for many years and evolving some completely new techniques that would not be possible using the traditional approach. 

Bristol Laparoscopic Associates believe that this new approach to the problem is more anatomical and capable of restoring normal function without significantly distorting and fibrosing or scarring the vagina. Using these new techniques, the bladder neck can if necessary be anchored in a retropubic intra abdominal position. The bladder base can be reattached to the pelvic sidewall. The cervical ring of fascial tissue and ligaments can be reconstituted both with the uterus in position and after hysterectomy.

The fascial supports can be reproduced using polypropolene or polyester mesh and anchored to the ligaments around the cervix above the perineum below and the pelvic floor muscles laterally to try and restore normal anatomy.

So what are the benefits of laparoscopic pelvic floor repair?

• Excellent view of the pelvic floor from above
• Accurate identification of the pelvic floor defects
• Minimising the need and extent of vaginal repair, thus reducing the risk of painful internal scars and vaginal shortenibg/narrowing
• Hysterectomy for uterine prolapse may be avoided or deferred until childbearing is completed
• Restoration of normal pelvic anatomy is achievable
• Less invasive than the open procedure.

Risks and complications of pelvic floor repair:

Risks and complications are rare with laparoscopic pelvic floor repair and generally depend upon the complexity of the individual case. Back pain and constipation are fairly common in the first two to four weeks after surgery.  Movicol is sometimes needed for constipation.  Transient urinary retention can occur in the first few days.  Underlying preoperative urinary stress incontinence can deteriorate and indicate the need for "lifting up" the base of the bladder.  remember that in most women, urinary incontinence gets better. Infection, bleeding, and trauma to the repaired organs are very uncommon.  Occassionaly a small hole iis made in the bladder.  This will be repaired at the time; a catheter is left to drain the bladder for a week. Conversion to the open procedure may occur in case of unexpected complications.

What about the recovery?

• Resume normal activity level as you feel able remembering to rest as required.
• Gentle walking or swimming is allowed.

• Take analgesics to help back pain and laxatives until regular bowel movements.

• Avoid jarring activities such as jogging, jumping or heavy lifting.
• Postpone vigerous sexual intercourse for four weeks

What is the expected outcome of surgery?

A successful prolapse operation can be expected in over 98% of cases. This generally means restoration of normal pelvic anatomy and in the majority of cases improvement or return to normal of bladder, bowel and sexual function.

Remember.  Recto urogenital prolapse is very common. Although not life-threatening, it is a progressive condition which can cause physical discomfort and disfigurement and at times even personal and social embarrassment through loss of bowel and bladder control. It may also affect or restrict your sexual relationship. Prolapse is common but it is not necessary to suffer in silence.  Appropriate help can return you to a healthy and active lifestyle.




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Contact: Claire Trenberth - 0117 9804051
claire.TRENBERTH@spirehealthcare.com
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