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Query: UMLS:C0033377 (prolapse)
 11,717 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Posterior pelvic floor compartment disorders generally refer to functional anorectal disturbances that by definition are symptom-based rather than anatomical defect-based and have a significant impact on quality of life. Symptoms attributed to the posterior compartment are often non-specific and associated with structural, neuromuscular and functional defects giving rise to symptoms of prolapse, pelvic pressure, faecal incontinence, stool trapping and constipation. They may range from mild to incapacitating and occur in varying combinations. While symptoms of constipation and incontinence may conceptually represent the opposing extremes of normal anorectal function, the dynamic interrelationships between the different pathophysiological mechanisms involved in the development of these disorders suggest a more complex explanation. Faecal continence and defecation are dependent on several neurological and anatomical factors that involve coordinated physiological processes, including intestinal transit and absorption, colonic transit, rectal compliance, anorectal sensation and continence mechanism. However, it is well recognized that pelvic floor symptoms originating from one compartment do not imply absent pathology in another compartment. Furthermore, symptoms associated with one disorder (such as constipation related to functional obstructed defecation) can be causative in the sequential development of other pelvic floor disorders, such as a urogenital prolapse syndrome, that may further exacerbate symptoms. In addition, it has been found that treatment that corrects one problem may improve, worsen or even predispose to other symptoms from another compartment. Consequently, while the concept of global pelvic floor dysfunction has emerged, the traditional single speciality referral and evaluation of pelvic floor problems continues to foster potentially segregated management strategies that can overlook the relevance of concomitant symptomatology. The evaluation and treatment of posterior pelvic compartment disorders needs to assume an individualized but multidisciplinary therapeutic approach. Given the variation in surgical approaches described to correct anatomical integrity of posterior pelvic compartment deficits, the consensus on optimal management has yet to be achieved. Therefore, it is critical that outcome measures following surgery are clearly defined. Treatment is to a great extent dictated to by functional severity and the impact that symptoms have on quality of life. Long-term follow-up should ensure that the potential for complications is minimized and satisfactory bowel, bladder and sexual function is maintained.
Best Pract Res Clin Obstet Gynaecol 2005 Dec
PMID:Posterior pelvic floor compartment disorders. 1619 48

The surgeon who faces a patient with vaginal vault prolapse is dealing with a complex and intriguing challenge. Part of the complexity is due to the lack of standardization and routine application of tools to assess pre- and postoperative anatomical and functional outcomes. Patient satisfaction is a major endpoint for surgical success; thus all aspects of the prolapse pathology and the patient's lifestyle should be considered. The surgeon needs to be well versed and flexible in order to choose the most appropriate operative approach to achieve optimal results for an individual patient. In this chapter we present the vaginal and abdominal approaches for the correction of vaginal vault prolapse, with discussion of the surgical outcomes and complications for each technique. A comprehensive comparison of the various techniques is offered on the basis of current published literature. In addition, we focus on various controversies, including the prevention of vault prolapse at the time of hysterectomy, issues regarding uterine preservation, the management of overt or occult concomitant stress incontinence, and the place-if any-for combined anti-incontinence procedures at the time of prolapse surgery. New minimally invasive techniques for vault prolapse are also reviewed. We emphasize areas that call for further research and for standardized outcome criteria.
Best Pract Res Clin Obstet Gynaecol 2005 Dec
PMID:Vaginal vault prolapse: choice of operation. 1622 73

Incontinence and defecatory difficulties are commonly reported among women and are often ascribed to traumas sustained during childbirth. Specifically, injuries to the anal sphincters (tears) and conformational changes in the various structures that comprise the pelvic floor (prolapse and perineal descent) have been considered as important contributors to the development of anal incontinence, or difficult defaecation (straining, incomplete evacuation), in later life. An understanding of both the effects of pregnancy and parturition on these structures and the natural history of any traumas sustained are, therefore, of key importance. Unfortunately, the literature on these issues, though vast, is far from complete. While it is evident that pregnancy, per se, imposes changes, primarily through hormonal influences, on colonic, ano-rectal and pelvic floor physiology, the long-term impact of such effects is far from clear. Risk factors for the occurrence of significant, though often occult, anal sphincter injuries during birth have been identified and the role of these tears in the etiology of post-partum incontinence has been well delineated. In contrast, the contribution of such intra-partum events to the later onset of incontinence is far from clear and may well have been over-estimated.
Best Pract Res Clin Gastroenterol 2007
PMID:Impact of pregnancy and parturition on the anal sphincters and pelvic floor. 1788 13

Pelvic floor function and structure are complex, and imaging (integrated with an understanding of physiology) is central to guiding the clinician in managing patients with incontinence, constipation, difficult rectal evacuation and pelvic organ prolapse. Multimodal imaging techniques such as static and dynamic imaging techniques (sometimes combined in a single sitting) have revolutionised our understanding of functional anatomy. The advent of endo-luminal imaging has increased our spatial resolution by its closer proximity to the area of interest. Dynamic imaging gives us a near physiological data set which helps us to simulate what is likely to happen in real life and gives us a better understanding of the multifactorial causes, and consequences, of pelvic floor dysfunction.
Best Pract Res Clin Gastroenterol 2009
PMID:Imaging pelvic floor dysfunction. 1964 85

The pelvic floor is a highly complex structure made up of skeletal and striated muscles, support and suspensory ligaments, fascial coverings and an intricate neural network. Its dual role is to provide support for the pelvic viscera (bladder, bowel and uterus) and maintain functional integrity of these organs. In order to maintain good pelvic floor function, this elaborate system must work in a highly integrated manner. When this system if damaged, pelvic floor failure ensues. The aetiology is inevitably multi-factorial, and seldom as a consequence of a single aetiological factor. It can affect one or all the three compartments of the pelvic floor, often resulting in prolapse and functional disturbance of the bladder (urinary incontinence and voiding dysfunction), rectum (faecal incontinence), vagina and/or uterus (sexual dysfunction). This compartmentalisation of the pelvic floor has resulted in the partitioning of patients into urology, colo-rectal surgery or gynaecology, respectively, depending on the patients presenting symptoms. In complete pelvic floor failure, all three compartments are inevitably damaged resulting in apical prolapse, with associated organ dysfunction. It is clear that in this state, the patient needs the clinical input of at least two of the three pelvic floor clinical specialities. Whilst the primary clinical aim is to correct the anatomy, it must also be to preserve or restore pelvic floor function. As a consequence, these patients need careful clinical assessment, appropriate investigations, and counselling before embarking on a well-defined management pathway. The latter includes behavioural and lifestyle changes, conservative treatments (pelvic support pessaries, physiotherapy and biofeedback), pharmacotherapy, minimally invasive surgery (intravaginal slingoplasty, sacrospinous fixation and mid-urethral tapes) and radical specialised surgery (open or laparoscopic sacrocolpopexy). It is not surprising that in this complex group of patients, a multi-disciplinary approach is not only essential, but also critical, if good clinical care and governance is to be ensured.
Best Pract Res Clin Gastroenterol 2009
PMID:Complex pelvic floor failure and associated problems. 1964 90

The evolution of the multidisciplinary approach to the management of chronic conditions is a reflection of how medicine has evolved from a singular to a plural effort recognising the complex causations and consequences of such disorders. This thinking should not be confined to tertiary centres alone and should be adapted where local expertise is available. Such an approach is especially important in pelvic floor disorders, where the correlation between structure and function is not always straightforward. There is a need to avoid over-investigation by accurate clinical assessment allied to tailored investigation, leading to a step-wise approach to treatment (which may include behavioural, physiotherapy, medical or surgical management). The algorithms here on faecal incontinence, obstetric trauma, pelvic floor prolapse and chronic pelvic pain attempt to provide such a logical approach to patients.
Best Pract Res Clin Gastroenterol 2009
PMID:Organising a clinical service for patients with pelvic floor disorders. 1964 93

Current studies do not support any benefit of supracervical hysterectomy in reducing perioperative morbidity and adverse effects on pelvic support, sexual and urinary function. Prolapse, pelvic mass and bleeding were the most common indications for trachelectomy after supracervical hysterectomy. Vaginal trachelectomy was the preferred approach to the procedure involving the least complications.
Best Pract Res Clin Obstet Gynaecol 2011 Apr
PMID:Removal of the retained cervical stump after supracervical hysterectomy. 2107 97

Contemporary understanding of the dynamic anatomy of pelvic floor support has lead us to new conservative surgery for the management uterine prolapse. The uterus itself does not play any role in the pathogenesis of uterine prolapse. Therefore, hysterectomy should not be the prime treatment, and fixing of the cervix to strong ligament such as sacrospinous ligament could give a more successful result and conservation of the uterus in young women. Other techniques, such as abdominal mesh hysteropexy or posterior intravaginal slingoplasty with conservation of the uterus, are alternative surgical options.
Best Pract Res Clin Obstet Gynaecol 2011 Apr
PMID:Uterine prolapse in young women. 2116 9

Pelvic-organ-prolapse repair presents unique challenges to the pelvic surgeon. Historically, the unacceptable failure rates with traditional procedures have instigated the many conceptual and technique changes. Critical analysis of the biomechanics of normal and altered anatomy has shifted the primary focus of surgeries from the midline of the distal vagina to the interspinous diameter. In addition, just as surgeons in other fields have begun to incorporate bolsters into various types of repairs, the field of prolapse repair has seen a proliferation of materials that are available to help strengthen repairs. Much effort, time and significant resources have been invested in improving these repairs, but much remains to be learned. The rapid pace of change has prevented the development of the type of evidence-based data that are needed to analyse accurately the specific risks and benefits of the various available approaches. Conceptual changes in the aetiology of pelvic organ prolapse, pelvic biodynamics and the specific nature of connective tissue damage have helped to fuel the rapid pace of change.
Best Pract Res Clin Obstet Gynaecol 2011 Apr
PMID:Anterior, posterior and apical vaginal reconstruction with and without bolsters. 2118 88

In this review, I aim to establish the place of vaginal pelvic organ prolapse surgery with mesh, drawing on personal experience. Physiopathologic justifications for the use of synthetic implants are described, and reasonable indications are highlighted. Major recommendations for the insertion are made. Possible complications, such as erosion, retraction, pain, failure and dysfunction are explained, and treatments, including secondary surgery are reviewed. The need for specific training is emphasised, including indications, standard techniques of insertion, follow up, and mesh-related symptoms of complications, their management, including indications, and techniques of revision or excision. Mesh surgery in pelvic organ prolapse aims to replace defective ligaments and fascias by a synthetic implant that provokes a foreign body reaction and fibrosis around it, recreating new connective support. Women indicated for this type of surgery include those at high risk of recurrence after autologous surgery resulting from defective connective tissue. Insertion techniques and the management of complications need specific training before using mesh in pelvic organ prolapse surgery. Revision and removal should be carried out in referral centres.
Best Pract Res Clin Obstet Gynaecol 2011 Apr
PMID:Place of mesh in vaginal surgery, including its removal and revision. 2124 10


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