Pelvic Floor Repair - An Overview

Introduction:

Pelvic floor repairs are a group of surgeries done to reverse a condition known as pelvic floor prolapse (POP). POP is a gynecological condition in which the pelvic organs slip into the vagina due to the weakening of the supporting muscles and ligaments. POP can result in symptoms like urinary leakage or incontinence, constipation, and difficulty in intercourse.

POP can be treated with various minimally invasive surgical techniques, all grouped under pelvic floor repair. An individual's fertility goals and the prolapsed pelvic organ determines the technique. If the prolapse includes the uterus, it is treated with a hysterectomy (surgery that removes the uterus). In individuals who have already had a hysterectomy, POP can be treated by lifting and supporting the top of the vagina. Surgeons often carry out more than one procedure simultaneously.

What Are the Various Types of Pelvic Floor Repair?

Several types of surgeries can be performed to improve the pelvic floor anatomy; some of them are:

a. Apical Suspensions - Also known as a restorative procedure, this technique restores the support of the top of the vagina. If the POP of the individual also involves the uterus, then this surgery can be done at the same time as a hysterectomy. Sexual function is not affected by this technique; there are two types of therapeutic procedures:

1. Sacral Colpopexy - During this procedure, the surgeon places an abdominal incision and attaches a strip of mesh material from the vagina to a strong ligament on the coccyx (a bone near the tailbone). The procedure can be done laparoscopically (with a laparoscope) or robotically (with a robot).

2. Uterosacral or Sacrospinous Ligament Suspension - This procedure is done through the vagina without any abdominal incision or mesh. The surgeon will stitch the top of the vagina to a ligament in the pelvis.

b. Anterior Repair - It is a surgical procedure to repair or reinforce the weak layers between the bladder and the vagina without affecting sexual function. The procedure can be carried out under general anesthesia as well as under local anesthesia. During the procedure, the surgeon will place an incision along the center of the front wall of the vagina. After this, the weak layers are repaired using absorbable stitches and removing any redundant vaginal skin. In cases with extreme prolapse, the surgeon will use a mesh to strengthen the anterior vaginal wall.

c. Posterior Repair - The surgical procedure reinforces or repairs the weak layers between the vagina and the rectum without interfering with sexual function. After administering the anesthesia, the surgeon makes an incision along the center of the back wall of the vagina. The weak layers will then be repaired using absorbable stitches.

d. Obliterative Procedure - Also known as Lefort colpocleisis or total colpocleisis, it is a type of surgery that narrows or closes off the vagina to support the prolapsed organs. The surgeon will sew the inside of the vaginal walls leading to reduced relapse.

What Are the Complications Of Pelvic Floor Repair?

With any surgery, there is always a small risk of complications. The following are the general complications typically seen after surgery and apply to pelvic floor repair.

1. Anesthetic Problems - The possible complications that can occur due to anesthesia in a pelvic floor repair are bladder and vaginal perforation from the needle, which can be avoided using modern anesthetics and monitoring equipment.

2. Bleeding - Serious bleeding that requires blood transfusion is unusual in vaginal surgery and occurs in less than 1 % of individuals.

3. Postoperative Infection - Although antibiotics are often given just before surgery and all attempts are made to keep the surgery sterile, there is a slight possibility of infection, which can be treated with antibiotics.

4. Bladder Infections - Also known as cystitis, occurs in about 6 % of the women undergoing the procedure and is more common if a catheter is inserted for urine elimination during and post-surgery. Symptoms include burning or stinging while passing urine; sometimes the urine might contain blood. A course of antibiotics can easily treat cystitis.

The following symptoms are specific to pelvic floor repair.

1. Constipation - This is the most commonly seen postoperative complication and is typically treated with laxatives. But it can be avoided by maintaining a high-fiber diet and drinking plenty of water.

2. Dyspareunia - It is the term used to describe pain during intercourse and is seen in a few women after pelvic floor repair. If this happens, it is advisable to talk to the healthcare provider, who will prescribe the necessary treatment.

3. Damage to the Bladder - It is an uncommon complication that may happen during surgery, and if it does occur, it can be repaired during the surgery itself.

4. Incontinence - It is the inability to control the bladder and is observed in women who undergo a large anterior wall repair and happens due to the unlinking of the urethra (the tube from the bladder). This can be resolved by doing pelvic floor exercises taught by the physiotherapist or by surgery supporting the urethra.

5. Mesh Complications - This happens in cases where a prosthetic mesh was used for reinforcement. The most common complication is mesh extrusion (exposure or erosion), which can be managed by trimming, an office procedure. In a few individuals, the mesh may also cause pain and can be treated only by removing the mesh.

How to Recover From a Pelvic Floor Repair?

• In the early postoperative period, avoiding excess pressure is advised.

• Maximal strength and healing around the repair occur at three months, and any heavy lifting should be avoided until this time.

• It is advisable to take two to six weeks off work.

• Sexual intercourse should be delayed for five to six weeks post-surgery, and when participating, it is advisable to use a lubricant during the intercourse.

The individual should directly communicate with their healthcare provider regarding their apprehensions and discuss the benefits and risks ahead of the procedure to prevent complications.

Conclusion:

Pelvic floor repair is a surgical procedure to treat POP. The non-surgical options for treating POP include a wait-and-watch approach, pelvic floor exercises, and pessaries (artificial devices that can be placed in the vagina to prevent prolapse). The approach is customized per the patient's needs to maximize the outcome.