Dr Bruce Farnsworth

Pelvic Reconstructive Surgeon

 

 

 

  

               Patient Information - Prolapse

 

What is a Prolapse?

Bladder, Bowel and Uterine Prolapse ?

Prolapse is best understood as a hernia of the bladder or bowel into the vagina. The hernia occurs because there is a defect in the anatomy of the fascia and ligaments that hold everything in place and prevent prolapse. Understanding the anatomy is the first step to understand the solution.

 

In 1990 Petros and Ulmsten published a comprehensive integrated work that proposed a musculo-elastic theory to explain pelvic function. The anatomy of the pelvis comprises an integrated system made up of sheets of muscle tissue interposed with various sheets of collagen and elastin. Since 1997 Dr Farnsworth has based his practice on what has become known as "The Integral Theory of Petros and Ulmsten".

 

Basic Anatomy of the Pelvis

 


 

This diagram shows the anatomy of the pelvic floor viewed from above. The ligaments of the pelvis support the vagina and pelvic organs These include the Midurethral or Pubourethral ligament (PUL), the Arcus Tendineous (ATFP) and the Cardinal (CL) Uterosacral (USL) complex. The bladder rests on the Mid vaginal hammock (MVH) . Clearly the uterus and cervix (CX) play a critical role in supporting the pelvic organs. Laxity of vaginal ligaments results in prolapse and also prevents muscles from contracting effectively to open and close the urethra and anus.  In the pelvis the muscles are not always attached directly to bone but transmit their forces  indirectly via these ligaments.

 

 

The lateral view shows how the vaginal tube is attached anteriorly to the pubic symphysis via the Pubourethral ligaments (PUL) and posteriorly to the sacrum via the uterosacral ligaments (USL).

 

Dr Farnsworth is a member of AAVIS (Australian Association of  Vaginal and Incontinence Surgeons). AAVIS members use a variety of surgical and non surgical methods to repair defects in the pelvic ligaments that can result in prolapse, incontinence or pain. 

 

The tension free anterior vaginal sling or intravaginal slingplasty was the first operation that was developed based on the Integral Theory. Techniques pioneered by AAVIS members since 1997 have increasingly become the gold standard in treatment of prolapse and incontinence around the world.



Click here to visit the AAVIS Website




 Causes of Prolapse
 

A number of factors are significant in the causation of Prolapse.

Genetic Weakness - This may explain why some young women and women who have never had children develop a prolapse.

Pregnancy and Childbirth - This is the most significant causal factor for prolapse. During pregnancy, hormonal changes and the extra weight and pressure of the baby can contribute to the weakening of the pelvic floor. A vaginal delivery can also result in the supporting pelvic structures being damaged. Damage to the pelvic floor occurs particularly in long second stages of labour, rapid deliveries, forceps or vacuum deliveries, and in the delivery of large infants. Often damage that occurs during pregnancy and childbirth goes unnoticed at the time, with symptoms only becoming evident following menopause. Recent research has revealed that the pelvic muscles are avulsed from their attachment at the actual time of delivery rather than later atrophy as a result of nerve damage. 

 Menopause - Oestrogen and progesterone are important i maintaining the pelvic floor. Significant deterioration follows the onset of Menopause.

Increased abdominal pressure  - this includes obesity, chronic coughing, chest disease, the lifting of heavy objects, constipation and straining, pelvic masses such as fibroids. Sustained pressures over a long period of time can weaken the pelvic floor.

Previous Pelvic Surgery - hysterectomy and previous repair surgery increases the risk of recurrent prolapse. A history of post operative complications and premature postoperative activity increases this risk.

Prevention of Prolapse

Common sense tells us that we should be able to do something to avoid prolapse. In reality genetic factors may be important and changes in lifestyle may have little impact.

Increasingly women are turning to caesarean section to avoid the damage attributed to natural birth but evidence suggests that pregnancy itself is a factor in subsequent pelvic floor dysfunction. Certainly the avoidance of interventional delivery and pelvic muscle trauma at the time of delivery should be a factor in preventing subsequent dysfunction. Damage may not become evident until the menopause when the loss of connective tissue that occurs at this time places more stress on already compromised ligaments.

Treatment of long term medical conditions and weight reduction can also help. Avoidance of activities such as heavy lifting and manual exertion in patients who have a predisposition to prolapse or other risk factors is also important, especially in the first few months after surgery.