Pelvic Floor Medicine – What's New?

Pelvic floor disorders are a common cause for diminished quality of life for many women of all age groups. The most frequent problems attributed to pelvic floor disorders include pelvic organ prolapse, stress urinary incontinence (leaking) (when sneezing, coughing, laughing, lifting, etc.), urinary urgency (inability to reach the bathroom on time) or a combination of the two, overactive bladder syndrome, bladder voiding problems, chronic pelvic and bladder pain, fecal incontinence and flatulence, etc.

For a large majority of the problems, initial treatment involves behavioral changes, dietary adjustments, physical therapy and drug therapy. In more serious cases, or if conservative treatment has failed, more invasive therapeutic methods are available to doctors. The following review discusses innovations in the treatment of pelvic floor disorders.

Pelvic Organ Prolapse

We see several marked trends in surgeries to repair pelvic organ prolapse:

One trend involves the increased use of implants to replace damaged natural tissue that is incapable of supporting the pelvic organs (bladder, uterus and/or rectum). Designed in particular for these surgeries, the implants are made of a synthetic mesh that is inserted underneath the skin and fixed into place with anchoring arms that are injected through the tissue on the sides of the pelvis. International research has proved the advantage of implants in reducing the recurrence of prolapse, particularly in prolapse of the anterior vaginal wall (cystocoele). We have recently witnessed a series of developments in this field, particularly in surgeries and fixation of the mesh through only one vaginal incision, without requiring anchoring arms, something that had previously required the use of special devices through additional incisions in the sides of the pelvis. In addition, the mesh itself has changed, becoming flexible and softer than the meshes that were used several years ago. These developments have both simplified surgery and minimized complications such as chronic pain and discomfort during sexual relations that had been observed in a certain percentage of patients who had undergone the surgery using older generation meshes.

Another global trend that is growing is laparascopic prolapse surgery (surgery performed through tiny incisions in the abdominal wall) that has achieved phenomenal anatomical and subjective results (according to quality of life and satisfaction surveys completed by the women, similar to surgeries that had been performed through a large incision in the abdominal wall. One advantage of the laparoscopic approach is that it lowers the high "cost" involved in opening the stomach, i.e. significantly reduces hospitalization time and level of post-operative pain in addition to preventing complications related to abdominal incisions (infection in the scar, etc.), as well as improved cosmetic results.

Urinary Incontinence

As with the prolapse surgery trend, surgeries to repair stress urinary incontinence is increasingly becoming "minimally invasive." Until the beginning of the 1990s, the preferred method for repairing urinary incontinence (Burch surgery) required the abdomen to be opened and the bladder neck to be lifted with stitches. A laparoscopic version was later developed that was, and still is, being performed in several centers around the world. Since the mid-1990s, the dominant technique  involves implantation of a synthetic band underneath the urethra (the tube connected to the bladder that removes fluids from the body) to support the structure and prevent urine from passing through when coughing, sneezing, laughing or lifting heavy weights, all of which are characterized by increased intra-abdominal pressure.

Faster to perform than abdominal surgery, this technique is carried out through small openings, one in the vagina and two additional openings in the lower stomach (the original method) or knee (in the second generation, in which the band is drawn from the vagina to the sides of the pelvis and not towards the lower stomach in order to minimize the risk of bladder injury).  The cure rates achieved with band surgeries is very good, similar to the rates for abdominal surgery, and the complication rate is lower. The newest generation of these surgeries, which are already being performed, is based on a shorter synthetic band that is implanted through a single 1.5cm long incision in the vaginal wall. Surgery can even be performed under local anesthesia. Large-scale studies in major centers around the world are currently examining the long-term efficacy of these small bands.

Women suffering from stress urinary incontinence, but who do not want or who are unable for medical reasons to undergo surgery, have another option – injection of special substances into the tissue surrounding the urethra to restrict the space and make the passage of urine difficult, thereby indirectly, improving urinary control.

Overactive Bladder Syndrome

There is also good new for women suffering from Overactive Bladder Syndrome (symptoms include high frequency of urination per day, nocturnia or frequent urination at night and strong, sudden urgency to void bladder, with or without loss of urine due to urine urgency). In persistent cases that do not respond to standard drug treatment or when drugs cannot be taken for medical reasons, there is an option of injecting botox (botulism toxin) into the bladder walls, thereby reducing the frequency and intensity of involuntary contractions of the muscle located in the bladder wall. These contractions cause the sense of frequency and urgency in urination, as well as nocturnia. The efficacy of the treatment is high, but injections occasionally need to be repeated after 6-12 months.

Another method used to cope with overactive bladder syndrome is implantation of a sacral nerve stimulation device in the lower back, above the buttocks. Miniature electrodes are inserted underneath the skin in the coccyx area to emit electrical pulses whose frequency and intensity can be controlled through remote control held by the patient to achieve significant improvement in bladder function. This treatment is expensive, and an effort is currently being made to include it in the Ministry of Health's basket of services.

One other method used to improve bladder function involves electrical stimulus of the nerve that passes near the ankle (the tibial nerve) with a thin needle (similar to the needles used in acupuncture) that is connected to an electrical pulse generator. The 30-minute treatments are carried out at a clinic and must be repeated once a week for 6-8 weeks and then less frequently, as needed.

In conclusion, the treatment of pelvic floor disorders is evolving with implementation of state-of-the-art technologies. At the same time, just as in any sector of medicine, to achieve optimal results, the type of treatment must be adapted to the specific patient as well as to the nature and severity of the problem.

The Urogynecology Clinic at Hillel Yaffe Medical Center offers a comprehensive solution for pelvic floor disorders that includes diagnosis and treatment provided by a gynecologist and the team from the Physical Therapy Institute.

Telephone number to schedule an appointment at the clinic: 04-6304322

To the Department of Obstetrics, Gynecology and Reproductive Sciences» 

To the Gynecological Surgery Forum – Pelvic Floor Surgeries»