Gynecology - Urogynecology and pelvic reconstruction
Repair of pelvic relaxation
Pelvic relaxation is a common condition in which there is weakness of the supporting structures of the female pelvis, thereby allowing descent (prolapse) of one or more of the pelvic organs through the vagina. These organs include the urethra, bladder, rectum, small intestine, uterus, and vagina (vaginal vault) itself.
Pelvic relaxation usually results from a combination of factors including multiple pregnancies and vaginal deliveries (especially deliveries of large babies), menopause, hysterectomy, aging, weight gain, and any condition associated with chronic wheezing, coughing, sneezing, or straining. Such conditions include asthma, bronchitis, seasonal allergies, or constipation. Vaginal birth is probably the single most important factor in the development of prolapse. Passage of a large infant head through the female pelvis causes tissue trauma, separation or weakness of connective tissue attachments, and alterations in the geometry of the pelvis. It is unusual for women who have not had children or who have delivered by caesarian section to develop significant pelvic relaxation.
The urethra and bladder are anatomically situated in front of the vagina, the cervix and uterus at the very deepest part of the vagina forming the top or the roof (the apex), and the rectum lies behind or below the vagina. Thus, when prolapse develops from failure of the supporting tissues to keep these structures in place, one or a combination of abnormalities may occur: the urethra and bladder may descend into the vaginal canal from the front wall (urethrocele or cystocele), the cervix and uterus may descend down the vaginal canal from the top (uterine prolapse), and the rectum may ascend into the vagina from the back wall (rectocele). Pelvic relaxation can vary from minimal descent, causing few if any symptoms, to major descent in which one or more of the pelvic organs literally fall outside of the vagina causing significant health and personal comfort problems. The degree of descent often varies with position and activity level, increasing with standing and with exertion, and decreasing with lying down and resting.
Because the female genital tract and urinary tract are intimately related (due to their anatomic proximity), pelvic relaxation can cause significant changes in normal urinary function. These range from stress urinary incontinence (a spurt-like leakage of urine from the urethra associated coughing or sneezing), to an inability to empty the bladder unless one manually pushes back the prolapsed bladder. It is important to know that such symptomatic pelvic relaxation can be surgically corrected. The goal of this pelvic reconstructive surgery is to restore normal anatomy and function. Non-operative treatment of pelvic relaxation is used when symptoms are minimal or when surgery cannot be performed because of the patient's state of health. Such conservative treatment options included change of activities, management of constipation and other conditions that increase abdominal pressure, pelvic floor muscle exercises (Kegel exercises), hormone replacement therapy, and pessaries. A pessary is essentially a large vinyl donut that is inserted into the vagina to act as a "strut" to help provide pelvic support.
For approximately 100 years, the repair of pelvic prolapse has relied on hysterectomy and the use of the patient's own tissues to create new support for the pelvic organs. This technique failed in up to 50% of the cases, because the tissues had already failed once and were likely to fail again. Today, gynecologic surgeons with experience in pelvic floor repair rely often on synthetic "mesh" material to reinforce a woman's normal supporting tissues. These meshes are made of various types of synthetic thread similar to fine fishing line, woven into fabric sheets and then sewn in place to repair the various types of pelvic floor support failures.
Uterine prolapse repair
Uterine prolapse results from descent of the uterus and cervix because of weakness of their supporting structures. This condition is frequently called a "dropped uterus," or "uterine hernia." Normally the cervix is located at the top of the vagina. As uterine prolapse progresses, the amount of descent into the vaginal canal will increase. Uterine prolapse is graded as follows:
Grade 1: mild descent of the cervix towards the vaginal opening with strain
Grade 2: the cervix reaches the vaginal opening with strain
Grade 3: the cervix reaches beyond the vaginal opening with strain
Grade 4: the cervix and uterus are outside the vaginal opening at all times (also called procedentia)
The symptoms of uterine prolapse are typically one or more of the following:
- a bulge or lump protruding from the vagina
- a sense of "dropping out" and lack of pelvic support
- an involuntary loss of urine or the need to "manually reduce" (push back) the uterus in order to initiate voiding
- kidney obstruction because of descent of bladder and ureters (tubes that drain urine from the kidney to the bladder)
- vaginal pain with sitting and walking
- painful intercourse
- frequent urinary tract infections
If lifestyle changes such as weight loss fail to provide relief from symptoms of uterine prolapse, or if you would prefer not to use a pessary, surgical repair is the best option. Surgical repair of uterine prolapse usually requires vaginal hysterectomy to remove your uterus and excess vaginal tissue. Increasingly, the uterus is not removed, and the uterus is re-supported using synthetic mesh. This field of gynecologic surgery is rapidly evolving, yielding exciting new ways to restore normal anatomy that is effective and long-lasting.
We generally prefer to perform uterine prolapse repair vaginally because vaginal procedures are associated with less pain after surgery, faster healing and a better cosmetic result. You would not be a good candidate for surgery to repair uterine prolapse if you plan to have more children. Pregnancy and delivery of a baby put strain on the supportive tissues of the uterus and can undo the benefits of surgical repair. Also, for women with major medical problems, anesthesia for surgery might pose too great a risk. Fortunately, most pelvic reconstructive surgery can be performed under spinal or epidural anesthesia, eliminating the risk of general anesthesia.
Vaginal prolapse repair
The two principle types of vaginal prolapse are cystocele, involving the bladder and front wall, and rectocele, involving the rectum and back wall of the vagina. The enterocele is a unique form of vaginal prolapse that involves a weakness near the roof or apex of the vagina that allows pressure from the small bowel above to create a bulge down into the vagina. Most often, these defects or bulges exist in combination, frequently at least two at a time.
Note in the diagram of normal female anatomy, the uterus is suspended at the top of the vagina, which is a relatively straight canal with no bulges from the bladder in front or the rectum behind. These other two pelvic structures are kept in their normal anatomic position by strong sheets of connective tissue called fascia.
- Cystocele
A cystocele occurs when the wall between a woman's bladder and her vagina weakens and allows the bladder to droop into the vagina. This condition may cause discomfort and problems with emptying the bladder. A bladder that has dropped from its normal position may cause two kinds of problems—unwanted urine leakage and incomplete emptying of the bladder. In some women, a fallen bladder stretches the opening into the urethra, causing urine leakage when the woman coughs, sneezes, laughs, or moves in any way that puts pressure on the bladder.
Cystoceles are graded as follows:
Grade 1: mild drooping of the bladder a short way into the vagina
Grade 2: the bladder sinks far enough to reach the opening of the vagina
Grade 3: the bladder bulges out through the opening of the vagina
Today, the surgical repair of cystoceles relies on the use of "biologic" or synthetic materials to provide strength and durability. These materials are used in place of a patient's own fascia. Biologics generally are derived from animal connective tissue that has been processed and sterilized and adapted for use in humans. One typical example is Pelvicol, derived from the tough skin of pigs.
More commonly used today are synthetic materials called mesh, woven from various types of nylon thread. Most of these meshes have bands that hold them in place, pulled through various incisions in the patient's groin. Perigee and Prolift are two such products but more advanced systems are now available.
The physicians of Women's Health Associates now use mesh delivery systems that do no require skin incisions in the groin. We use mesh that is fixated internally, leading to less post-operative pain and faster healing. Two of these systems are the Pinnacle and Elevate.
- Rectocele
A rectocele occurs when the fascia — a wall of fibrous tissue separating the rectum from the vagina — becomes weakened, allowing the front wall of the rectum to bulge into the vagina. Childbirth and other processes that put pressure on the fascia can lead to a rectocele. Generally, rectoceles occur after menopause, when estrogen — which helps keep your pelvic tissues strong — decreases.
A small rectocele may cause no signs or symptoms. If a rectocele is large, it may create a noticeable bulge of tissue through the vaginal opening. Though this bulge may be uncomfortable, it is rarely painful. Women may complain of a sense of vaginal "pressure" or a feeling that something is falling out of the vagina with increasingly sever cases of rectocele. A woman with a very large rectocele might not be unable to defecate without placing downward pressure on the posterior vaginal wall with her fingers.
The same principles of repair described for cystoceles also apply to rectocele repair. Beyond biologic materials available for repair, we also use synthetic mesh materials. The older systems with bands to anchor the mesh material in place include Prolift and Apogee. More recently, internal anchoring systems such as Pinnacle and Elevate have avoided the need for groin incisions. The physicians of Women's Health Associates are trained in the use of all the available mesh systems.
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Urogynecology and
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