Damage to the pelvic floor can occur during pregnancy or delivery, and possibly as a consequence of a hysterectomy. Other causes of damage to the pelvic floor are also pelvic surgery between the coccyx and anus (the perineal approach), and the removal of the coccyx (coccygectomy). Amongst female high-level athletes, perineal trauma is rare and only certain sports such as bicycle racing, water-skiing, and equestrian sports are associated with it.
A repercussion of pelvic floor damage is not only urinary incontinence, but pelvic organ prolapse, which is when the pelvic organs displace into or outside of the vagina. Physical factors that contribute to pelvic organ prolapse include asymmetries caused by physical damage to the pelvis and disproportionate, excessive, or insufficient muscle tone. Other factors such as age, hormonal status, pregnancy, and family history can all contribute to developing pelvic organ prolapse.
Kegel exercises may be performed to strengthen pelvic floor muscles and their function, however surgery may be necessary to repair significant damage to the pelvic floor.
Specific methods aside, the general technique used for laparoscopic surgery to treat pelvic organ prolapse is as follows:
Preparation for the surgery is undertaken, which involves shaving the area of operation, an enema, and a fasting of six hours. General anaesthetic is applied, the laparoscope and assistive instruments are inserted, and the appropriate areas (uterus, pelvic structures) are checked and visualised. The vagina and bowel are separated and a column support is created with a series of sutures in the ligaments and back wall of the vagina. If necessary, the lateral pelvic muscles are sutured by opening the side areas of the vagina. To amend severe tissue damage, native tissue (from the patient), animal tissue, or animal-augmented tissue may be used to strengthen the pelvic floor. Synthetic mesh is an option, too, but must be considered carefully due to possible side-effects such as mesh erosion and rejection. Often a bladder neck suspension is performed before the wounds are sealed appropriately.
There are several forms of pelvic organ prolapse and the techniques of laparoscopic surgery varies depending on the type of prolapse and location:
- Enterocoele (Vault prolapse): Found at the top of the vagina and repaired using Laparoscopy.
- Sacrospinous fixation surgery: the vagina is attached to the tailbone and possibly supported by synthetic mesh.
- Alternatively vault suspensions may be performed.
- Rectocoele: Found in the rectum through the back wall of the vagina and repaired using Laparoscopy.
- Connective tissue between the vagina and rectum are secured to reduce the bulge size, and excess tissue is removed.
- Urethrocoele: Found in the urethra at the lower front wall of the vagina and repaired using Laparoscopy with bladder neck suspension.
- Cystocele: Found in the bladder through the front all of the vagina and repaired using Laparoscopy.
- The bladder is moved upwards and secured by connective tissue, which is fixed in place. Excess tissue is removed. If urinary incontinence is present, bladder neck suspension is recommended to support the urethra.
Recovery time is relatively short. Post-surgery recovery requires several days in hospital. A catheter will be required and general pain-killers such as paracetamol are optional. Patients are often in a light working condition within 6 weeks. No heavy lifting for the rest of life.