Treatment Options

Prevention First: Does Caesarian section prevent prolapse and symptoms?

The short answer is only partly. The uterus has to prepare for labour. A hormone called “Relaxin” loosens the bonds which bind the collagen rods inside the ligaments and the vagina, so these stretch months before labour begins. This explains why pregnant women may develop bladder, bowel and pain symptoms well before labour starts. However, the process of labour creates even more stretching and more damage. Fortunately, most incontinence and pain symptoms which develop during pregnancy improve or disappear after delivery.

Pessaries

Historically, sufficiently large rubber rings called vaginal pessaries have been inserted into the vagina to prevent the prolapse coming out of the vagina. This is the oldest treatment for prolapse, and it is still an option today, especially for women who are very ill or who wish to delay or avoid surgery. Pessary fitting is an art, as pessaries frequently fall out and may cause ulceration of the vagina with long-term usage. 

In our experience, pessaries are not welcome in the young sexually active woman.

New Pelvic Floor Exercises based on the Integral System work differently

The “squatting culture” on which they are based strengthens the natural muscles and ligaments, so no conscious effort to close the urethra before a cough is required. Other symptoms such as pelvic pain, urgency and bladder emptying problems are also improved. For younger women, up to a 60% improvement
is possible in 60% of women using these methods.

“Squatting culture”-a simple time efficient method Rather than bending, the woman should train herself, as a daily routine, to squat down to pick up things. 

Examples are: using a dust pan, playing with a child, etc. An excellent adjunct is to use a rubber fitball instead of a chair at work. These are not so much exercises, as a better usage of muscles. They are very time efficient, as they become part of the daily routine. They can be reasonably effective in younger women but are not so helpful in older patients.

Vaginal Mesh Reinforcement Surgery for Prolapse

In the past 10 years, many surgeons have implanted large polypropylene mesh sheets below the vaginal wall. The meshes do not repair damaged ligaments. They work by blocking the bladder and bowel from protruding into the vagina. The problem with implanting a large sheet of foreign plastic material is that the body may react against it with varying degrees of intensity, ranging from nothing to swelling, redness, pain and scar tissue. The process is very similar to what happens with a splinter. 

Though mesh improves the surgical cure rate with prolapse surgery, it has, in some patients, caused pain with intercourse, smelly vaginal discharge, bladder and bowel perforations (fistulas) and other complications. This method has become sufficiently controversial to provoke warnings from the FDA, the American control agency. These mesh methods do not repair specific ligaments, so they cannot reliably cure symptoms.

The Next Step - Use of Minislings for Prolapse and Incontinence

Minisling operations insert very small strips of tape to reinforce damaged tissues. They are being increasingly used for the treatment of urinary stress incontinence. Tensioned minislings appear to be more effective than the non-tensioned variety. 

The TFS (Tissue Fixation System), a tensioned minisling technique, was the first minisling, and was performed in 2003 in patients from the Kvinno Centre. It became commercially available in 2009, having undergone rigorous testing for safety and efficacy over a period of 5 years before commercial release. It is the only minisling which can repair prolapses. It uses an identical philosophy to the TVT: small strips of tape support cystocoele, rectocoele and prolapse of the uterus, in the manner of ceiling joists. 

What is revolutionary about the TFS is that it also tightens loose ligaments, thereby restoring muscle strength. It is this dual action which cures or improves many symptoms which were not previously considered as being curable, urgency, nocturia, frequency, pelvic pain, abnormal emptying, bowel incontinence and  constipation. It also cures urinary stress incontinence equivalent to the TVT in the longer term. 

Though minimally invasive and significantly safer than previous operations, minislings are not complication free.

Further information on surgical and non surgical treatments is available at www.integraltheory.org or in Chapters 4&5 of the medical textbook.  The Female Pelvic Floor, Function, Dysfunction and Management According to the Integral System, PEP Petros, 3rd Edition, Springer Heidelberg 2010.