Pelvic Floor and incontinence
Pelvic Floor anatomy |
Essential concepts to understand pelvic floor anatomy are the support mechanism
anterior, middle and posterior compartment
the upper vagina is horizontal and rests upon the levator plate
the anatomy of the levator ani muscles
the role of the muscles, innervation and of the ligaments
Pathology, etiology and treatment
Pelvic floor descent and/or urinary incontinence is a frequent pathology occurring in over 10% of women older than 80 years. It is caused by muscular and of the support mechanism. The causes are
damage during delivery including an innervation damage
Innervation datmage will weaken the muscle and cause extra stress to the ligament support system.
damage of the support system ie rupture of ligaments or attachments (repair := site specific repair)
weakening of the support system by age or collagen decrease by menopause or congenital because of collagen pathology.
Prevention is hormone replacement therapy.
Therapy consist of a combination of muscle training, and of replacing /repairing the support system, which can be done by vaginal or laparoscopic surgery, and by site specific repair or mesh repair.
Surgical therapy |
Until 10-15 years ago repair was performed by vaginal surgery. Laparoscopic surgery has revolutionised this therapy and actually a spectrum of therapeutic posssibilities exist with specific pro’s and con’s.
Vaginal Surgery consisted of , vaginal Hysterectomy with if necessary Colporaphia anterior and/or Colporaphia posterior and repair of perineal body.
This is the traditional approach with unfortunately 20-30% recurrence rate.
Laparoscopic surgery has taken advantage of the newer concepts of anatomy and introduced the site specific repair such as high McCall, paravaginal defect etc. In parallel mesh repair was introduced ie mainly the promontofixation.
Vaginal mesh repair as initally TVT and then replaced by TOT revlolutionised stress urinary incontinence surgery.
Surgical strategy
Surgical strategy is a difficult discussion since few randomised studies exist . Unfortunately however, choices are often base upon the surgical skills of the surgeon instead of upon emergine evidences. Indeed those are equally skilled in all types or surgery are rare, vaginal surgery being basi training whereas promotofixation already is level 2 endoscopy.
General principles which seem solidly established.
Vaginal surgery is associated with a higher recurrence rate up to 30%
Vaginal meshes are associated with 5 to 10% mesh erosions, which is a disturbing complications.
In order to perfrom a subtotal vaginal hysterectomy together with a promotofixation a skilled and fast surgeon is required. Still few surgeons are able to do this in less than 2.5 hours.
The discussion between ’site specific repair’ popular in the USA and mesh surgery, mainly developed in France, is partially subjective. It is clear that long term results of meshes are better, but it is equally clear that meshes are a problem in case of complications (eg an infection ) or during subsequent surgery.
Our strategic choices
For pure stress incontinence.
if associated with an anterior vaginal prolaps : we start with a paravaginal repair en een Burch . In case of insufficient results in 10% a TOT is performed .
Without descent we start with a TOT. In case of insufficient results in 10% a laparoscopic Burch is performed
For pelvic descent without incontinence
If pregnancies are anticipated : laparoscopic repair eventually with a mes reinforcemnt of the uterosacrals and pubovesical fascia
If the family is completed : either vaginal surgery and in the 30% recurrences a promontofication. Or a subtoal hysterectomy with a promontofixation. Choices are discussed individually.
Preoperative exams ?
Urodynamic tests ? Although popular, they have littele impact upon the choice of surgical technique.
Imaging : as ultrasound and dynamic MRI. We do consider this as research instruments with today little proven clinical value.