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.
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)
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)
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)
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.
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.
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?
with a rectocele may experience:
• Vaginal pressure or
• Protrusion coming from the posterior vaginal wall
Difficulty evacuating rectum or ODS
• Dyspareunia (painful intercourse)
skin between the vagina and the anus (perineum) may also be deficient and need
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
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.
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
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
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)
is ODS??Obstructed defaecation syndrome is a common condition in which a person
is unable to evacuate their bowels properly.
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.
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.
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
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
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.
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
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.
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.
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.
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.