So the pelvic floor can mean different things to different people. But in essence, it
represents a hammock or a trampoline if you like of muscle, a tendon and bone that acts
to support the structures in the abdominal cavity above the pelvis. And also acts as
a gatekeeper as a control mechanism of the structures that traverse through it. In men,
that would be the waterworks in the bowel and in ladies, those two structures as well
as the vagina. And so treatment and therapies towards the
pelvic floor have a great impact on functionality because of the control of the pelvic floor
has on these structures. Pelvic floor surgeries are operative techniques
that address damage or injury to the pelvic floor. We talked moments ago about the role
of the pelvic floor which is one of support and one of a controlling function. And so
surgical procedures are directed at both those areas. For example, if we are re-supporting
the pelvic floor, we may consider operations from above through the abdominal cavity to
help lift and reconfigure any weakness and collapse that may have occurred.
We may think of operations to remove tissues that is slipped down and is causing a problem.
Operations through the tail end to remove tissue which may involve a stapling technique
might be an example of the same. We might think of operations to reinforce
bulges that have developed through the collapse through the weakness and reconfigure the pelvic
floor architecture in that way. For example, a transvaginal repair of a rectocele which helps
straighten the rectum and help it function better.
The last category of surgery may be one to augment or to improve residual function that’s
already present in the pelvis. For example, sacral neuromodulation which is a technique
of placing a wire into the nerve root in the lower back may be used to augment and improve
how the neurological function of the pelvic floor can be improved. You might consider
bulking agents to help improve closure of the tail end and again augment the residual
structures present. Pelvic floor can be injured through a variety
of processes. The most common one is through child birth but other factors such as obesity,
such as ages, such an inherent weakness within the tissue that you might see in hypermobility
syndromes can all weaken the pelvic floor and contribute to it collapsing and descending
and malfunctioning because of that. 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 volunteered symptoms of a change in bowel habits, change in patterns
in going to the toilet, and especially if they tell us that there are other worrying
symptoms associated with that. For example, rectal bleeding, then it’s incumbent on
us to make sure that that presentation isn’t one of some serious underlying bowel pathologies
such as a cancer. And we’ll often investigate and treat the patients along those lines first
and foremost. In the absence of such a diagnosis, then the
next part of treatment is a conservative and non-operative approach. We’ve already talked
about the pelvic floor containing muscle and bone and tendons and have movement and function,
in that way, it’s not dissimilar to a knee or a hip. And if we were to present with a
painful knee or a poorly functioning hip, we wouldn’t expect surgeries first line
therapy and so is the case in 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 to the pelvic floor and these measures alone may improve
function to a point where a patient needs nothing further doing. And in fact, two-thirds
of patients are happy with conservative measures in isolation. Only those patients whom 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’re in the realms of surgical therapies.
What procedures we perform are very much dependent on clinical appraisal and on investigations.
And they’ll help us define and point to us where the main problem is arising from.
And that is what it takes what sort of surgery may be available to us. For example, if a
patient has a prolapse and has a very weakened pelvic floor, we may consider options to re-support
it from above and regain alignment in that way. And keyhole surgery might fall into that
category. We may consider removing tissue that is herniating
down into the pelvis and getting in the way and blocking bowel function and operations
through the tail end to remove that redundant tissue may be considered.
And finally, we may think of therapies to reinforce, improve the structures that we
already have in place. And so for example, if we have an incontinent patient, has a weakened
sphincter, if there’s no prolapse, we may consider operations to either rebuild that
sphincter through an operation to overlap the residual muscle or we may consider nerve
stimulating techniques or bulking agents to try and reinforce the tail end.
The recovery from pelvic floor surgery is dependent on the type of procedure that’s
performed. But I think it’s fair to say that even the larger operation, the reconstructive
keyhole procedures 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. And patients need to be warned that in the immediate post-operative
period, how their bowel function may well not represent how it behaves longer term.