woensdag, augustus 24, 2005

Pelvic floor prolapse and U ( English)

The pelvis of the woman can be compared with the foundation of a wall: it give support to various organs. Sometimes this support is good, but at times, and without any warning, it can give way. This can happen over time, but sometimes overnight. The probable building blocks for the foundation are the fibrous tissue layers found in the so-called pelvic floor: this is not accepted by everyone in the world of pelvic floor gynaecology.
For the purpose of this discussion, though, I would like to suggest that we see the pelvic floor as a layered support system, with fibrous layers, or fascia, as the main support system. These fascia layers give support to the central tunnel, the vagina, which runs through the pelvic floor. This tunnel is the communication gap between the outside world and the abdomen. The traffic through this tunnel is of various sizes with sexual demands on the one side and the products of this traffic, the baby, on the other extreme!
If this surrounding fibrous support system fails, the surrounding organs will sags or fall or prolapse into the vaginal tunnel: this is pelvic organ prolapse (POP).
It is not too difficult to understand that damage done (by childbirth, for instance) to these layers could lead to a loss of support and then prolapse of organs into the vaginal tunnel. The story does not stay as simple as this. In some women prolapse happen without a history of childbirth or childbirth with big babies: it just happens without any pre warning! To simplify: they have chosen the wrong parents.
The backbone of tissue integrity is the in the genes. If mom, or aunts or sisters are having prolapse problems the chances are high that the siblings or daughters or nieces will have it too! These genetic factors play the biggest role in onset of prolapse. In the women who gave easily birth, especially when the second stage of labour had been quick, prolapse follows in later life, especially near or after the menopause when the oestrogen levels went down. These dropping in the oestrogen levels can be the last straw before the whole foundation comes down. This could be the reason why prolapse is more common in the older women.
Medically speaking the news is not so good. We know how frequent it occurs, we even knows why it happens. What I cannot put forward out of our working field is how to rectify the wrong! In the same vain: we do not even know exactly what the symptomatic or even the anatomical cut off points of intervention is!
To rectify the defective anatomy unfortunately will not always automatically lead to rectification of the functional abnormalities. In the extreme cases the rectification of the deviations from normal are easy. The lesser deviations are usually our problem.
An extra complicating factor is that some symptoms may be masked and became only apparent after surgery. Or new symptoms may appear after surgery (and not always due to the surgery). No wander there’s a lack of consensus in our medical world about the symptoms and signs of this problem, and more important, in the approach to this problem!

I do want to hold out a light at the end of the tunnel, though. The last few years a tremendous surge in our knowledge happened. The whole field of so called urogynaecology had a growth spurt, both in numbers of interested gynaecologists and with it also in newer approaches in diagnostic acumen and surgical techniques.

It is generally accepted that operative repair of the defective anatomy is needed, especially in the advanced cases. The type of operation is though not so clear. Different techniques are being tested. Even this is not so easy: the same technique in different hands can have different results – even in the same pair of hands one found at times different results: the pathology will dictate. The minefield of successes and failures of pelvic floor repairs will thus always stay with us. In a later article more will be said about the pelvic floor and surgery.

The pelvic floor and its problems had been associated to a large extent with the function of the bladder: bladder symptoms are the most dramatic and also the most worrisome to the patient. I would like to predict that with time the defective functions of the other pelvic organs (vagina and rectum) will more and more come to the fore in the whole context of pelvic floor prolapse. A new or better name for our subject field than “urogynaecology” must be put forward.

I would like to use this webpage as a starting point for women to be able to look through the window at the pelvic floor specialist. This will enable them to understand the dilemmas of diagnosing and treating this common defect of women.

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