Pelvic organ prolapse or Pelvic organ prolapse (POP) is the herniation of the pelvic organs (uterus, bladder, rectum) out of the vagina.
Pelvic floor surgery covers surgical interventions performed for the problem of gynecological diseases known among the public as pelvic organ prolapse or uterine prolapse.
In fact, pelvic organ prolapse may originate from the uterus, the bladder from the anterior vaginal wall, the rectum or rectum from the posterior vaginal wall. These prolapses may be seen isolated or together. We often witness that pelvic organ prolapses are defined as uterine prolapse because they cannot be distinguished from each other among the public.
In this article, you can find answers to your questions such as what is the pelvic floor, the function of the pelvic floor, pelvic organ prolapse, problems that occur in pelvic organ prolapse, complaints about pelvic floor prolapse and what is pelvic floor surgery.
The pelvic floor is a structure consisting of muscles and connective tissue that surrounds the bottom of the pelvic bone by forming a hammock-shaped diaphragm. This collection of muscles and connective tissue extends from the groin in the front to the coccyx in the back and to the protrusions of the pelvic bone on the sides.
The majority of the pelvic musculature is the levator Ani muscle, which consists of the puborectalis, pubococcygeus and iliococcygeus muscles. The puborectalis muscle wraps around the line where the anus and rectum meet like a sling, and contributes to defecation control by providing the angle between the anus and rectum during contraction.
The support provided to the pelvic organs is related to the pubococcygeus and iliococcygeus muscles. The pubococcygeus forms the inner part of the levator ani muscle and creates openings for the urethra, vagina, and anus.
The bulbospongiosus and ischiocavernosus muscles are the muscles that contribute to the superficial part of the pelvic floor in the anterior part of the pelvis. The more superficial musculature of the pelvic floor on the posterior side forms the external anal sphincter. The transverse perineal muscles form the middle part of the superficial part of the pelvic floor and join the bulbospongiosus muscles and external anal sphincter as the perineal body.
The nerve tissue of the pelvic floor muscles consists of the pudendal nerve, which originates from the sacral nerves called S3 and S4. The vascularization of the pelvic floor muscles comes from the branches of the internal iliac arteries.
The functions of the pelvic floor can be examined in 3 basic groups;
Pelvic organ prolapse or Pelvic organ prolapse (POP) is defined as the protrusion of the pelvic organs (uterus, bladder, rectum) out of the vagina when the pelvic floor no longer supports their proper position.
Prolapse of the pelvic floor tissues or pelvic organ prolapse is a common gynecological problem that is strongly associated with childbirth, aging and menopause. Women with pelvic organ prolapse show various complaints (vaginal, bladder, bowel and sexual) that greatly affect their daily activities and quality of life. These complaints create significant problems in patients' treatment and follow-up.
In most cases, although there are no complaints and the problem is not at an advanced level, follow-up with exercises and recommendations is recommended, surgery is required in up to 20% of patients.
The problems that occur in pelvic organ prolapse can be grouped as urological, gynecological, colorectal and general. If we list the causes of these problems;
Urological
Gynecological
Colorectal
General
There are more than one cause of pelvic organ prolapse. Among these, pregnancy is the most important factor that causes pelvic organ prolapseThe second most important reason after pregnancy is normal birth. The probability of levator ani muscle injury in normal birth varies between 21 and 36%.
If we briefly list the reasons that increase the frequency of pelvic organ prolapse;
Most patients with pelvic organ prolapse do not have any specific complaints. Seeing or feeling a bulge coming out of the vaginal opening is the most obvious complaint. When taking a history before the examination, "Do you see or feel a swelling in your vagina?" is a general question to be asked for pelvic organ prolapse.
Standing up, lifting heavy objects, coughing, and physical exercise increase the feeling of swelling and discomfort in a patient with pelvic floor prolapse, even if it is not the cause.
All surgeries performed in pelvic organ prolapse and aiming to correct the cause are collectively called pelvic floor surgery. Our aim in the surgeries we perform in pelvic organ prolapse is to eliminate the patient's complaints and increase their quality of life. The only point we focus on in pelvic organ prolapse surgeries is not the anatomical correction of the prolapse.
Our main goal is to reduce complaints, increase satisfaction, and increase the quality of life in the patient we perform pelvic floor surgery. In these surgeries, anatomical correction alone may not ensure complete disappearance of complaints. For this reason, we evaluate the patients we will take for surgery in terms of gynecology, colorectal, and urology and plan a surgical solution targeting the cause.
In patients for whom we plan to have pelvic floor surgery, sometimes more than one prolapse is detected at the same time in preoperative evaluations. In this case, prolapse surgeries targeting more than one area are performed in the same surgery session.
If we briefly list the surgeries we perform on patients for whom we plan to have pelvic floor surgery;
There are various treatment options for cystocele or anterior vaginal wall prolapse, including follow-up, pessaries or surgical correction. There is no standard surgical treatment for anterior vaginal wall prolapse. It is important to discuss the risks and benefits of different surgical options with each patient.
In general, anterior vaginal wall correction surgery is performed by placing sutures that support the weakened tissues. This procedure is called anterior colporrhaphy in the medical literature. Natural techniques have been introduced to further strengthen the tissue and increase its durability. Although natural tissue repair provides lower success rates compared to artificial patch-reinforced repair, it is a preferred method due to its fewer complications. Natural tissue repair is effective in alleviating vaginal swelling complaints and reducing sagging in the vagina.
Cystocele repair surgery success varies between 19% and 97% depending on the definition of success. We define success in our surgeries as relieving our patients' complaints of vaginal bloating and reducing the sagging inside the vagina. The aim of the surgery we perform is to maximize patient satisfaction and return the pelvic organs to their original positions.
Rectocele (posterior vaginal wall bowel prolapse) can cause a feeling of bloating in the vagina and complaints of difficulty in defecation. The frequency of posterior vaginal wall bowel prolapse alone is not definite, because it is usually accompanied by anterior vaginal wall (cystocele) or vaginal vault prolapse (apical prolapse).
Up to 80% of rectoceles can be observed without causing any complaints. Rectocele surgical treatment can be performed transvaginal, transperineal or transanal approach. vaginal posterior wall bowel prolapse can be repaired using natural tissue or a patch. The use of a patch has become less preferred due to the high complication rates.
In our patients, we prefer the transvaginal approach and natural tissue repair in the repair of Rectocele (vaginal posterior wall bowel prolapse).
In rectocele repair, the traditional aim is to compress and support the rectovaginal connective tissue with sutures. This procedure is called posterior colporrhaphy in the medical literature.
Identification and correction of apical prolapse is critical to reduce the recurrence of the problem after pelvic floor repair surgery. In cases with both vaginal anterior and posterior wall prolapse, clinically significant apical prolapse is almost always present. In our pre-surgical evaluations of our patients, we always evaluate whether vaginal anterior or posterior wall prolapse accompanies vaginal dome prolapse or uterine prolapse.
In patients with a uterus, apical prolapse manifests itself as the uterus prolapses out of the vagina, while in patients who have had their uterus removed by hysterectomy, it manifests itself as the blind vaginal vault herniating out of the vagina.
The surgical treatment of apical prolapse (uterine prolapse) or vaginal vault prolapse is performed by surgically closing or correcting the vagina. The technique recommended for closing apical prolapse (uterine prolapse) or vaginal vault prolapse is Colpocleisis. Today, this technique is not as popular as it used to be.
Surgeries to be performed to correct uterine prolapse from the vagina are divided into two.
Vaginal and laparoscopic approaches to pelvic floor surgery have now become complementary techniques. Laparoscopic sacrocolpopexy is an example of advanced closed surgical approaches and therefore requires advanced laparoscopic surgical experience in the performing team. Our advanced laparoscopic surgical experience and experience in pelvic floor surgery allow us to make the right surgical choice for our patients.
Abdominal sacrocolpopexy or sacrohysteropexy is the hanging of the vaginal dome or uterus to the promontory by incising the abdomen from the midline with an open surgical technique. Today, it is not performed by clinics with laparoscopy experience.
Removal of the uterus may cause the ligaments between the uterus and the sacrum bone, the cardinal ligaments that connect the uterus to the hip bone, to deteriorate and further weaken vaginal support. If there is no obstacle to protecting the uterus, such as tumor development or precancerous lesions, sacrohysteropexy may be beneficial. However, patients who have undergone sacrohysteropexy should have their cervix and endometrium continuously monitored.
If it is decided to remove the uterus, a technique called supracervical hysterectomy, in which the cervix is left and the remaining uterus is removed, may be applied. The cervix is hung to the promontory with a patch. Since the patch is not sewn directly to the vagina, the possibility of a reaction in the vagina decreases and a safer surgery is possible. This technique can also be performed laparoscopically, or with a closed method.
Pelvic floor surgery prices vary depending on the type of surgery, whether a laparoscopic approach is used, and the hospital where the surgery is performed.
