Treatment of descensus genitalia

Descensus genitalis (pelvic organ descent) describes the descent of the bladder ((cystocele) rectum (recto cele) small and / or large bowel (enterocele), vagina (vaginal prolapse) or uterus (uterine prolapse) – usually due to weakened connective tissue. 

Connective tissue weakness can occur as a result of vaginal births, genetic predisposition or can, for example, be related to age. Heavy physical work, obesity, smoking or chronic constipation also increase the risk of prolapse.                                                                      

Therapeutic goal: more quality of life                                                                                              

Genital prolapse usually has a considerable impact on the quality of life of the women affected: it often affects the function of the bladder and bowel. Their sexuality as well as physical and social activity can also suffer. Typical symptoms also include a sensation of a bulge, pulling in the womb area and a sagging feeling.                                                  

The goal of treatment is therefore not only to reconstruct the physiological anatomy,  but also in particular to restore quality of life for those affected.

  • Possible treatment
  • How do you choose a treatment
  • Surgical treatment with synthetic mesh implants In the anterior compartment
  • Advantages of Multi-armed meshes

Possible treatments                                                                                                      

Genital prolapse can be treated with different conservative and surgical methods. Surgical procedures, however, are not usually the first choice for genital prolapse. Conservative options first must be exhausted.                                                                                           

Conservative 

  • Clinical observation
  • Reduction of known risk factors such as obesity, nicotine abuse and chronic constipation
  • Pelvic floor training
  • Local oestrogen replacement therapy
  • Pessary treatment                                                                                                                    

Surgical therapy should only be considered if none of these treatments work or if the psychological stress of those affected is too great.                                                                    

Surgical

  • Colporrhaphy/vaginoplasty
  • Surgery with synthetic or biological materials
  • Paravaginal defect repair (anterior compartment)
  • Apical fixation (middle compartment), laparoscopy or open abdominal Lateran fixation
  • Sacrospinous fixation (middle compartment)
  • Incontinens tapes – retropubic/retrosympheseal(TVT) and transobturator (TVT-O)
  • other surgical treatments

How do you choose a treatment?                                          

As a first step, a comprehensive diagnostic work-up and accurate indication are crucial for choosing the appropriate treatment for genital prolapse. Detailed observation of the individual needs of the patient is also vital – the patient must be questioned in detail (condition and circumstances) and given advice. The appropriate treatment method should always be chosen in close coordination with the patient personally and with the referring doctor. If surgical treatment is indicated, the appropriate surgical procedure should be chosen after carefully explaining to the patient all possible surgical procedures with their approaches, benefits and risks, and after considering the success rates and medical skills available.          

The best possible materials are just as important for successful surgery as pre- and postoperative complication management. In certain circumstances, it may be useful to perform the surgery in collaboration with a centre of excellence.

Surgical treatment with synthetic mesh implants in the anterior compartment                                                                

Surgical treatment with mesh implants in the anterior compartment can be discussed if your patients have:

  • Severe prolapse
  • Recurrent prolapse
  • Comorbidity
  • Levator avulsion
  • High demand for anatomically stable rep air                                                          

Variations of synthetic meches                                                                              

There are essentially three different groups of mesh implants. 

  • Multi-armed meshes: these are inserted transvaginally. The arms are drawn in through suitable structures (tendinous arch of pelvic fascia or the sacrospinous ligament, for example) using appropriately shaped instruments and fixed securely. 
  • Single-incision meshes: these are also inserted transvaginally and anchored to suitable structures with anchors or sutures as needed.  
  • Armless meshes: these are usually inserted laparoscopically, e.g. for sacrocolpopexy.

Common to all variations is that modern type 1 meshes (monofilament, macroporous,  low-weight) are superior to multifilament meshes due to the lower rates of complications with the meshes.

Advantages of multi-armed meches                              

Compared with single- incision – meshes, the use of multi-armed meshes is associated with more complex surgical procedures. However, these bring many advantages, particularly in the case of severe or recurrent prolapses and in the case of a high requirement for patient safety in respect of anatomical repair.

  • They can permanently improve quality of life.
  • They can achieve an anatomically stable result.
  • They can reduce urge incontinence.
  • They can have a very low risk of relapse.