Pelvic floor problems and surgery

The pelvic floor can mean different things to different people, but in essence it represents a hammock or a trampoline of muscle, tendon and bone that acts to support the structures in the abdominal cavity above the pelvis. It also acts as a control mechanism of the structures that traverse through it. In men, that would be the waterworks and the bowel and in women, those two structures as well as the vagina. Mr Andrew Clarke, a leading surgeon and expert in pelvic floor surgery, discusses the different problems related to the pelvic floor and the treatment approaches taken.

What is pelvic floor surgery?

Pelvic floor surgeries are operative techniques that address damage or injury to the pelvic floor. These surgical procedures are directed at both the supportive abilities and the controlling function of the pelvic floor.

• Operations from above through the abdominal cavity to help lift and reconfigure any weakness and collapse that may have occurred.
• Operations to remove tissues that have slipped down and are causing a problem.
• Operations that reinforce and reconfigure bulges that have developed through the collapse and weakness of the pelvic floor. (e.g. a transvaginal repair of a rectocele which helps straighten the rectum and help you function better).
• Operations that improve the residual function that is already present in the pelvis. (e.g. sacral neuromodulation is a technique of placing a wire into the nerve root in the lower back which can be used to augment and improve the neurological function of the pelvic floor).

Why is pelvic floor surgery needed?

The pelvic floor can be injured through a variety of processes. The most common one is through child birth, but other factors include:

• Obesity
• Ageing
• An inherent weakness within the tissue that you might see in hypermobility syndromes.

These can all weaken the pelvic floor and contribute to it collapsing and descending and malfunctioning because of that.

What are the principles of treating pelvic floor problems?

There are important principles that we must adhere to whenever we see patients that presents to us with problems with their pelvic floor. Any patient that has symptoms of a change in bowel habits and especially if they tell us that there are other worrying symptoms associated with that. For example, if a patient complains of rectal bleeding, then it is incumbent on us to make sure that this is not a sign of a more serious underlying bowel pathology, such as cancer. We will often investigate and treat these patients first and foremost.

If cancer is ruled out then the next step of treatment is a conservative and non-operative approach. As the pelvic floor has muscles, tendons and bones, it is not dissimilar to a knee or hip. If you were to present with a painful knee or a poorly functioning hip, we would not expect surgery to be the first line of treatment, which is the same for problems with the pelvic floor.

The majority of our patients will see a pelvic floor physiotherapist or a nurse specialist that will help them improve their function, strength, and their coordination. These measures alone may improve function to a point where a patient needs nothing further doing. In fact, two-thirds of patients are happy with conservative measures in isolation. Only for patients that are resistant to conservative treatment do we consider ongoing investigation and possibly surgical remedies.

When patients have exhausted non-operative treatments for their pelvic floor disorder and if their symptoms are severe enough and life-changing enough to want treatment escalation, then we are in the realms of surgical therapies. What procedures we perform are very much dependent on clinical appraisal and on investigations. These will help point us to where the main problem is arising from and hence what form of surgery is needed

What is the recovery like after having pelvic floor surgery?

Recovery from pelvic floor surgery is dependent on the type of procedure that is performed. I think it is fair to say that even the larger reconstructive operations have a quick recovery associated with them and most of the procedures that we perform for the pelvic floor are either day case or overnight stay. The immediate result of the procedures can be a little variable especially if we have patients on laxatives to help the bowel open. Patients need to be warned that in the immediate post-operative period, how their bowel functions may not represent how it behaves longer term.

If you would like to find out more about pelvic floor problems, make an appointment with a specialist.