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The term “Pelvic Floor Disorder” encompasses a number of conditions recognised and named by colorectal surgeons, urologists and gynaecologists. Confusingly certain conditions may have unusual sounding names, names may be used interchangeably and conditions are commonly found in combination.
Most doctors are not familiar with their true meaning. They are most usually identified in women because generally the pelvis in females is wider and shallower than that of males. The presence of the vagina, an open stretchable organ that is not firmly fixed in position, may allow other abdominal and pelvic structures to descend, bulge into and deform it.
The pelvic floor is a combination of muscles and ligaments suspended from the ring of pelvic bones which support the abdominal and pelvic organs above and below. It is incomplete in several areas to allow the rectum, urethra (connected to the bladder) and vagina, in women, to pass through.
The presence of an enlarged uterus during pregnancy and the delivery of a child through the birth canal puts strain on the pelvic floor and may injure structures of the pelvis and perineum particularly the recto-vaginal septum (tissue between the vagina and rectum), pelvic nerves and the anal sphincter muscles. Other causes of injury are difficult (and particularly assisted- forceps, episiotomy) deliveries as well as previous hysterectomy and long-standing constipation.
Pelvic floor disorders of all kinds originate from weakness or poor function of the connective tissues of the pelvis and the pelvic muscles or nerves that supply them.
- Prolapse: The rectum, vagina or uterus may be deflected downwards towards the skin of the perineum even emerging from the anal canal or introitus (of the vagina).
- Rectocoele: The front wall of the rectum is pushed forward bulging into the back of the vagina
- Cystocoele: The back wall of the bladder is deflected backwards bulging into the front wall of the vagina
- Urethrocoele: The urethra is deflected backwards bulging into the front wall of the vagina.
- Enterocoele: The small intestine is deflected downward bulging into the back wall of the vagina.
- Intersusception: The upper bowel is deflected downwards from above pushing through the lower bowel with which it is in continuity. Like pulling the sleeve of a jumper inside out through the cuff.
- Pelvic floor dysfunction: Impaired coordination of the muscles of the pelvic floor, which have to relax during the process of defaecation, results in straining (using abdominal muscles) against an unyielding muscular barrier with multiple futile attempts to evacuate.
Most conditions (similar to hernias) give symptoms because an organ has moved from its normal anatomical position to an abnormal one. The symptoms are either those of discomfort or loss of function of the organ or organs involved; they may be multiple and may difficult to ascribe to a particular anatomical abnormality.
Discomfort is usually described as a deep dragging discomfort felt in the lower abdomen or pelvis worse after standing for prolonged periods.
- Prolapse results in disordered function and pain, bleeding and even ulceration or the structure that emerges from either the anal canal or vagina.
- Difficulty opening the bowels or “a feeling of incomplete evacuation” that often results in straining, repeated visits to, and prolonged periods sitting on, the lavatory. This may be part of the condition known as “Obstructed Defaecation Syndrome”
- Faecal incontinence, usually slow seepage into the underclothes of which the individual is usually unaware.
- Difficulty fully emptying the bladder.
- Urinary incontinence, often when coughing, sneezing or bending down
- Discomfort during sexual intercourse
Your surgeon will take a detailed history from you which will include the symptoms experienced with particular reference to both bowel and bladder function. Past surgical and obstetric history is especially important. A rectal examination is performed while relaxed and whilst squeezing the anal canal closed. A vaginal examination may also be carried out.
- Bowel imaging either with an endoscope or with x-rays.
- Ultrasound scan of the anal sphincters. A probe is placed within the anal canal to perform the scan and reported by a radiologist.
- MRI (magnetic) scan of the pelvic organs.
- Defaecating proctogram. X-ray opaque material is introduced into the anal canal and then the patient is asked to expel it whilst x-rays are taken.
The conditions listed above arise for a variety of different reasons and often occur in combination with a number of different but related symptoms. The majority of patients find great relief with reasonably simple measures, others require detailed evaluation and surgical treatment by colorectal surgeons, gynaecologists and urologists.
High Fibre Diet
Bulking and softening the stool with increased dietary fibre and ensuring to drink plenty of water can improve symptoms of prolapse and rectocoele as straining to evacuate is reduced.
Specialist physiotherapists can instruct patients in techniques to improve the function of the pelvic floor muscles
Finger pressure within the vagina either at the front, to assist with bladder emptying or at the back to assist with opening the bowels may correct the features of cystocoele and rectocoele respectively.
Small balloons or special electrodes are placed within the vagina or rectum or on the skin of the perineum. They are able to detect contraction in the muscles of the pelvic floor and when stimulated display this activity in the form of illuminating lights. This visual feedback to muscle contraction facilitates improved muscle coordination to assist with defaecation.
A variety of surgical procedures are carried out for pelvic floor disorders. They may be carried out by colorectal, gynaecological and urological surgeons. Operations may be carried out through the perineum (skin of the pelvic floor), the rectum, vagina or abdomen.