Pelvic Floor Disease Treatments: Physiotherapy & Surgeries

The pelvic floor is a muscle and connective tissue structure, which carries the weight of our internal organs as well as acts together with the abdominal muscles to balance out our posture. The pelvic floor directly supports the urinary bladder, the uterus and the rectum, and their exit tubes – the urethra, the vagina and the anal canal – are crossing through the pelvic floor musculature to open on the perineum. Three different specialties deal with the pelvic floor in women, and two in men: Urology; Gynecology and Proctology. In most cases the diagnosis and treatment plan are discussed on a Pelvic Floor MDT (Multidisciplinary Team) meeting, before pelvic floor surgeries.

The diseases of the pelvic floor falling on proctological territory are Rectocele, Rectal prolapse, Internal Rectal Intussusception, Anismus, Non-relaxing Puborectalis Syndrome, Pelvic Floor Descent and some less frequent disorders. Most of these disorders come with the symptoms of Obstructed Defecation, which is difficulties of emptying the stool.

All pelvic floor disorders should be first treated by Pelvic Floor Physiotherapy (dietary and toilet habit guidance; teaching pelvic floor muscle awareness, exercise and relaxation; biofeedback). The reasons for this are many: most patients experience improvement after sorting out simple every day life habits; some patients do not require any further treatment after pelvic floor physiotherapy; even after the best performed surgery the improvement will be less if the diet and toilet habits are not optimised; even the best performed pelvic floor surgery only restores anatomy, but the patient needs to be taught of the function, of the use of the restored proper anatomy!

Unfortunately, often health insurance companies do not recognise the importance of pelvic floor physiotherapy in the treatment of these diseases and approve none or only one session of pelvic floor physiotherapy, which is barely enough to assess the problem, let alone provide any guidance for the patient. Ideally 6 to 10 sessions of physiotherapy is needed to achieve maximum benefit from conservative management. If surgery is planned, physiotherapy is still very important, few sessions before, to assess problem, teach muscle awareness and detrain wrong compensatory spasms, and a few sessions after surgery to teach patients the use of the new, reconstructed anatomy.

Rectocele Repair is aiming to restore the integrity of the wall between the front of the rectum (and anal canal) and the back of the vagina. When gynecologist performs this surgery, they enter through the back wall of the vagina. When proctologist then through the perineum.
The perineal approach allows for reconstruction of not only the recto-vaginal wall but also the perineal body. This reduces the pelvic floor descent as well. Through the perineum any anal sphincter muscle surgeries can be performed from the same cut. It is possible but not at all necessary to use meshes to strengthen the recto-vaginal reconstruction.

Rectal Prolapse, Rectal lining prolapse, Rectal mucosal prolapse

Rectal prolapse is when the rectum as a tube falls into itself and hanging out through the anus. In case of rectal lining prolapse not the full thickness of the rectal wall falls outwards, but only the redundant mucosal lining. Internal Rectal Intussusception is a milder form of rectal prolapse, when the rectum falls into itself but does not come out through the anus.

Rectal prolapse surgeries aim to either fix the rectal wall, so it can not fall into itself; or remove the fallen in segment to unblock the way.
Rectopexy (laparoscopic ventral mesh rectopexy) is an abdominal surgery using a mesh to fix the front wall of the rectum to the bony promontory of the pelvis inside, to prevent it from falling into itself during defecation.

STARR procedure or Stapled Trans-Anal Rectal Resection is a procedure performed via the anal opening with a stapling device to remove a segment of the rectum, to unblock the rectal tube.

When only the rectal mucosal lining is prolapsing, it is sufficient to treat it with hemorrhoidopexy/rectal mucopexy, via anus, either with sutures or with stapler.

Anismus and Non-relaxing Puborectalis

Anismus is the tightness of the anal ring and its failure to relax or paradox contraction during trials to defecate.

Non-relaxing puborectalis syndrome is the tightness of the puborectalis muscle and its failure to relax or paradox contraction during trials to defecate.

There is not much space for surgery in these purely functional disorders. They should be primarily addressed by physiotherapy. However, when physiotherapy fails, Botox injection can give temporary relief. Botox injection is not a surgery, but it requires at least sedation, to be able to target the injection into the correct muscle, so from patient’s perspective it is like a surgery.

What to expect when going for this procedure?

Pelvic Floor Surgeries are done under general anaesthesia (or at least deep sedation), so before the procedure you need to have a meeting with the anaesthetist. Because of the anaesthesia, a period of 6 hour fasting is required before surgery. There is no need for a full bowel preparation, unless you have very serious constipation. Most of the time two enemas are sufficient, which are prescribed by your doctor, and instructions are given by your nurse how to administer them to yourself in the evening before the procedure and in the morning on the day of the procedure.

Some of these surgeries can be done as a day case, so you can go home the same day, few hours after your surgery. Some of them require overnight stay in hospital.

After the surgery you will feel minimal pain, because your doctor will give you a numbing injection, during surgery, to the nerves of the anal area (pudendal nerve block). If you go home same day you will receive a detailed explanation about the medications prescribed, and how to take them: you will be given anti-inflammatory painkillers, local anaesthetic jelly and antibiotics if necessary. If you stay in hospital your nurse will give you the medications.

Once you are ready to go home, your doctor will give you a number to contact her in case of emergency as well as arrange a free follow-up visit for you within 2 to 5 days.