Pelvic Floor Dysfunction

Abstract

Pelvic floor disorders (PFDs) refer to a group of conditions comprising pelvic organ prolapse (POP), urinary incontinence, and urination or defecation abnormalities caused by weakened or damaged pelvic floor muscles, nerves, and connective tissues. The pelvic muscles, fascia, or ligaments around the pelvic organs, present an anatomical hammock across the pelvic floor. They play a vital role in supporting the normal function of pelvic organs. Once these muscles or connective tissues are damaged due to some reasons, the PFDs will consequently occur. Up to now, the diagnosis and treatment of PFDs are still filled with challenges due to the various etiology and symptoms of PFDs. In this chapter, we focus on urinary incontinence and POP, the two common conditions of PFDs, besides general introduction to PFDs. Not only is the latest evidence reviewed but also our viewpoint is presented. In general, PFDs involve urology, gynecology, anorectal department, and other fields, and the disciplines are usually associated with each other. Therefore, a multidisciplinary approach is usually necessary. With a developed understanding of the anatomy and function of the pelvic floor, pelvic floor reconstruction has received much attention and more new technologies are also constantly emerging, developed to improve the traditional methods.

1. Introduction

Pelvic floor dysfunctions (PFDs) are a common global health problem, which refers to highly prevalent conditions in women in which the pelvic floor muscles, nerves, fascia, or ligaments around the bladder, rectum, and vagina work abnormally. Pelvic floor dysfunction comprises pelvic organ prolapse (POP), urinary incontinence, urination or defecation abnormalities (e.g., overactive bladder or fecal incontinence), chronic pelvic pain, urogenital fistula, and female sexual disorders, which are widely concerned around the world. It involves urology, gynecology, anorectal department, and other fields, and the disciplines are usually associated with each other. The overall incidence of PFDs is difficult to evaluate precisely due to the wide range of disciplines involved. PFDs could affect up to 50% of women of childbearing years [1]. Approximately a quarter of American adult women have been reported suffering from at least one of these diseases, while 16% of men were diagnosed with PFDs [2, 3]. Many studies showed that about 11% of women had received one or more surgical treatments for urinary incontinence or POP by the age of 80 years [4, 5, 6]. The risk for women who undergo surgical intervention related to stress urinary incontinence in their lifetime was 20.5% [7]. Pelvic floor dysfunction has a profound and long-term impact on patients, which not only increases the personal psychological burden and has a significant negative impact on the quality of life, but also seriously interferes with individual daily activities in social and professional fields. The comprehensive diagnosis and treatment of pelvic floor disorders are of rising interest and need due to an increasing age and the obesity epidemic, and the number of women affected by these conditions may continue to rise.

Breakthroughs have been made in anatomy and pathophysiology theory on pelvic floor dysfunction since 1990. Petros and Ulmsten proposed an Integral Theory (IT), which states that POP and abnormal pelvic symptoms (e.g., urinary stress and urge symptoms) mainly arise from lax connective tissues in the vagina or its supporting suspensory ligaments of the anatomic structures on the pelvic floor. Three organ groups, including bladder and urethra, vagina and uterus, rectum, and anus, are linked together by surrounding muscles and supporting ligaments. The normal opening and closure mechanism of these organs are able to be guaranteed by four important muscle groups (pubococcygeal muscle, levator plate, longitudinal muscle of the anus, and the puborectalis muscle) only when the suspensory ligaments are intact [8]. Functionally, these pelvic floor tissues were under the control of the same central nervous system, so the functional and dysfunction performance of any group of these organs are not isolated but correlated. As a result, muscles, ligaments, and nerves are used as links to integrate multiple disciplines such as urology, obstetrics and gynecology, and anorectal surgery into pelvic floor surgery. Functional urology is a subspecialty of urology that can solve a variety of common diseases, including urinary incontinence, POPs, sensory and voiding changes, defecation dysfunction, female sexual dysfunction, chronic pelvic pain syndrome, and fecal incontinence. Female urology, with a focus on the diagnosis and treatment of female pelvic floor dysfunction, has gradually sprung up and become a new subspecialty of urology. Much experience has also long been accumulated by obstetrician-gynecologists for the management practice of PFDs. However, PFDs have traditionally been conducted in a separate treatment by each relevant discipline, resulting in delays in health care, repeated counseling, the resultant significant public health burden, economic costs, and unsatisfactory efficacy [9]. Therefore, complete independence between disciplines is not conducive to the overall recovery for patients. It is gratifying to note that in recent years, urologists, anorectal physicians, and gynecologists have become increasingly aware of the need for closer communication and cooperation in treating PFDs, providing more support to each other to solve this troublesome problem. With the emergence of new technologies for pelvic floor reconstruction and rehabilitation, the mutual integration and cooperation of urology, gynecology, anorectal, pain, rehabilitation, and other departments in the treatment of PFDs are becoming more frequent. The causes and etiology of conditions related to PFDs are manifold but not fully unclear. The Integral Theory shows that the pelvic floor exists as an organic whole with interrelated anatomy and function rather than a simple superposition of every component, which is composed of supporting axes of different compartments, maintaining its internal stability and balance. When this balance is broken by any damage, other structures in the system can compensate for the function of the damaged structure to keep the system stable, but if the persistent injury exceeds a certain compensatory range, it will cause PFDs.

1.1 Risk factors of pelvic floor dysfunction

There are several risk factors that may be associated with an increasing prevalence of pelvic floor disorders over time. The risks higher with any of the characteristics are shown in Box 1.

Modifiable risk factors An increasing body mass index (BMI) over 25 kg/m^2 Smoking habits Lack of exercise Constipation (a condition that causes an increase in abdominal pressure) Low estrogen status Diabetes ; Non-modifiable risk factors Age (increased risk with aging) Race Related to gene Family history of urinary incontinence, overactive bladder, or fecal incontinence. Gynecological cancer and any treatment for PFDs before Gynecological surgery (e.g., a hysterectomy) Fibromyalgia Chronic respiratory disease and cough that lead to an increased abdominal pressure (e.g., chronic cough may result in an increasing risk of fecal incontinence and flatus incontinence). Innate dysplasia and acquired damage of the spinal cord. Menopause in women. Prostatectomy in men. Related to drug (such as inappropriate use of muscle relaxation drugs). Sexual abuse ; Related to pregnancy: Maternal age (being over 30 years) Having delivered one or more babies before their current pregnancy. Having diabetes in the period of pregnancy. Multiparity ; Related to childbirth: (pelvic floor muscle and nerve were damaged) Previous vaginal deliveries (forceps or vacuum). A vaginal birth when the baby is lying face up (occipital posterior). An active second stage of childbirth takes more than 1 hour. Injury to the anal sphincter during birth.

Box 1.

Risk factors for pelvic floor dysfunction.

1.2 Anatomy and physiology of pelvic floor and control mechanism of urine

The pelvic floor structure, a hammock-like shape, is composed of tough muscles, ligaments, and fascia. The levels between muscle, ligament, and fascia are complex, and the bladder, uterus, and rectum are close to each other. They cooperate and interact with each other, affecting the overall function of the pelvic floor system. The pelvic bone encircles the lower part of the abdominal-pelvic cavity, and the soft tissues seal the gap between the pelvic walls, thus forming the primary bottom tissue of the pelvic cavity. Bladder, urethra, uterus, rectum, and anus are involved in the pelvic floor. The support of the pelvic floor is vital for the urinary control mechanism of the lower urinary tract. The pelvic floor is a three-dimensional structure, which is viewed as a functional unit by more and more scholars in recent years, and the purpose of surgery should not be limited to the removal of lesions or the implantation of sling and other supports. In the field of urology, the target is to restore the normal anatomical relationships as much as possible, reconstructing the function of micturition and defecation. The characteristics of the anatomy and physiology of the pelvic floor differ between women and men (see Figures 1 and 2). In the following section, the mechanisms of urine control will be penetrated from different sex aspects, starting with anatomical and physiologic considerations.

Figure 1.

Muscles of the male pelvic floor and digital palpation of deep pelvic floor muscles. M presents muscle. Adapted from Faubion et al. [10] and Rehder et al. [11].

Figure 2.

Muscles of the female pelvic floor and digital palpation of deep pelvic floor muscles. M presents muscle. Adapted from Faubion et al. [10].

1.2.1 Control mechanism of urine in female

Urinary control in women is a consequence of the combination of various factors, and the bladder, urethra, related nervous system, the surrounding suspensory ligaments, and supporting tissues play an essential role in urine control. The urethra is a flexible sealed pipe and mainly covered involved three anatomical tissues: the urethral mucosa, internal urethral sphincter, and external urethral sphincter, while the surrounding structures that support the bladder and urethra are the anal levator muscle and the intrapelvic fascia. Urine control in women is mainly caused by the tension forced along the proximal urethra and/or the middle urethra. In addition, the distal urethral muscle also plays a certain role. Female urethral mucosa consists of loose connective tissue, a transitional epithelial tissue, which is associated with the urethral opening and closure. The urethral mucosa is abundant and often performs a formation of urethral mucosal ruffles. It allows for its expansion (opening during micturition) and helps to form the mucosal hermetic seal, which leads to an enhanced urethral closure reflex during bladder filling. The mucosa-submucosa of the urethra represents a spongy-shaped tissue and is abundant in elastic fibers and venous plexus. This property promotes a tension of the urethral mucosa and expansion of the urethral cavity, contributing to forming an effective water-tight seal. In addition, the urethral mucosa is sensitive to estrogen, which can increase the blood flow in the urethra and the vasodilation of blood vessels of the urethral submucosa. It may be one of the reasons why estrogen is able to improve the symptoms of patients with stress urinary incontinence. The periphery of the urethral submucosa is surrounded by the periurethral fascia. The effective function of the bladder neck originates from specific urethral mucosal properties, including internal sphincter (inherent characteristics of bladder neck/proximal urethra and distal (striated muscle) sphincter. The internal urethral sphincter is responsible for maintaining the closure of the bladder neck while the external urethral sphincter keeps the urethral closure pressure closed at rest. In cases of increased abdominal pressure, such as coughing and sneezing, the external urethral sphincter will contract to prevent the occurrence of urinary incontinence. At the same time, the levator anal muscle also contracts to support the bladder neck under the abdominal pressure. When the anal levator muscle is relaxed, the position of the bladder neck relative to the pubic bone is subsequently changed to voiding smoothly. In terms of the pelvic fascia, it can assist the levator anus in supporting and limiting the downward movement of the bladder neck.

1.2.2 Supporting structures of the female urethra

The supporting tissue of the urethra encompasses random muscle and connective tissue components. The full-length urethra is separated from the vagina by only one layer of fascia, and it is closely related to the anterior vaginal wall with a similar origin that both differentiates and develops from the urogenital canal. Strong muscle support (anterior vaginal wall) provides posterior support and middle urethral pressure. Relaxation of vaginal support can lead to anterior vaginal wall prolapse and adversely affect the urine control area. The musculature and fascia of the pelvic floor maintain a certain tension, further supporting the urinary control mechanism of women. The relaxation of pelvic floor caused by various factors may change the position and function of the bladder neck and urethra.

1.2.3 Structure and function of the female urethral sphincter

The smooth muscle sphincter and striated muscle sphincter are the major urethral sphincters that play a major role in the female urinary control mechanism. The circular striated muscle, localized in the proximal urethra and (or) the middle urethra, is responsible for the sphincter control. The smooth muscle of the posterior urethra can be divided into two layers: the inner layer is the longitudinal muscle and the outer layer is the circular muscle.

They are derived from the internal and external longitudinal muscles of the bladder to the urethra, respectively. The smooth muscle sphincter is a physiological rather than an anatomical sphincter that is innervated by autonomic nerves and is under nonconscious control, keeping the bladder neck and proximal urethra closed during the entire storage period of urine. There is no complete and separate anatomical structure of the internal sphincter. The urinary control mechanism of the internal sphincter is not located at a certain site or level but involves the full length of the female urethra. External urethral sphincter muscle (EUS) refers to the muscle fibers of the urethral striated muscle sphincter being in circular permutation around the membranous urethra, which starts from deep transverse perineal muscle. Part of the muscle fibers fold into the proximal urethra, go up on the outside of the longitudinal muscle in the urethra, then stop at the middle part of the proximal urethra, and finally are connected to the outer circular muscle of the urethra. These fibers are called the striated sphincter muscle in the wall of the urethra, composed of slow-response muscle fibers. They can produce almost complete circular compression in the middle urethra under the influence of the pudendal nerves and maintain a certain tension for a long time without fatigue [12]. However, the sphincter muscle around the urethra contains not only many slow-response muscle fibers but also fast-twitch muscle fibers in which the fast-twitch muscle fibers are innervated to quickly contract and close the urethra, but they cannot maintain the closed state of the urethra for a long time. In most cases, the above additional forces, the inherent characteristics of the urethra and muscle elements that promote urine control led to urinary incontinence in women under a combined action of alone or a combination.

1.2.4 Anatomy of the pelvic floor and control mechanism of urine in male

The structures that contribute to male urinary continence include the bladder neck (preprostatic sphincter), prostate, striated urethral sphincter, and levator ani muscle. A comprehensive understanding of periprostatic anatomy is crucial to the successful performance of urological pelvic surgery.

1.2.5 Urethral sphincter

The urethral sphincter consists of internal sphincter and external sphincter (i.e., the smooth muscle urethral sphincter, the rhabdosphincter, preprostatic sphincter, and levator ani muscle). The internal sphincter encompasses smooth muscle fibers and elastic tissues, which may be irreparably damaged during the prostatectomy. There are unmyelinated nerve fibers filtering the smooth muscle aspect of the proximal urinary tract and the bladder neck at 5 and 7 o’clock. The external urethral sphincter is regarded anatomically as intrinsic striated urethral sphincter (rhabdosphincter), as well as striated slow-twitch fibers. It presents a close bond to the anatomy and function of the pelvic floor, which is responsible for urinary continence during prostatectomy. It encircles the sphincteric part of the urethra in a round shape or omega shape. The anterior inserts on the distal ventral layer of the prostate and the perineal fascia, form a dorsal midline raphe. Then, the midline raphe fuses with the posterior layer of the prostatic apex and Denonvilliers fascia and with the central perineal tendon. The muscle fibers are controlled by the inferior hypogastric plexus, which covers both sympathetic and parasympathetic fibers. The neurovascular bundle (NVB) is visible running with part of these fibers. There are myelinated nerve fibers penetrating the striated sphincter on either posterolateral side at 3 and 9 o’clock [13, 14, 15].

1.2.6 Levator ani and puboperinealis muscles

The levator ani is the innermost muscle of the pelvic floor, having abundant type II fast-twitch and slow-twitch fibers. Levator ani encircles the urogenital hiatus at its extreme near-striated urethral sphincter. At the hiatus, it links to the striated urethral sphincter and thickens. When an increased pressure in the intra-abdominal suddenly presents, contraction of this thickened levator sling at the urogenital hiatus may show a crucial contribution to urinary continence. The striated sphincter at the perineal body originates from puboperinealis and runs along the lateral aspect of the prostate and the sphincteric part of the urethra, then meets on the dorsal aspect of the perineal body. These mainly are fast-twitch muscle fibers that contribute to quitting urine flow by angulating the urethra. The anteromedial fibers of the levator ani muscle are involved in the continence mechanism due to their strong connection with the rhabdosphincter and the prostate. Prostate apical dissection and urethrovesical anastomosis may result in the damage of these structures with the resultant urinary incontinence [15].

1.2.7 Supporting structures of the male urethra

The anterior urethral attachments are composed of pubovesical and puboprostatic ligaments, as well as the tendinous arch of the pelvic fascia. It can stabilize the urethra behind the pubis. The posterior support of the sphincteric urethra depends on a complex combination of Denonvillier’s fascia, the rectourethralis muscle, the perineal body, and the levator ani [13].

1.2.8 Bladder neck and prostatic urethra

The effective bladder neck is derived from specific urethral mucosal properties, containing the internal sphincter (the inherent characteristics of the bladder neck / proximal urethra) and the distal (striated muscle) sphincter, the male bladder neck has the internal sphincter passing through and extending to the distal seminal caruncle. The tension produced by the bladder neck is an important contribution to keep the body from incontinence. Without disease or injury, urine can usually be maintained above the bladder neck, not falling to the external sphincter level. On the one hand, the adrenergic in smooth muscle from the bladder neck and prostate urethra is activated. On the other hand, the sympathetic nerve distributed in this area as well as the prostate itself, further increases bladder neck resistance. Therefore, the complete loss of sphincter function may not lead to urinary continence in men.

1.3 History

A general history should be taken of current and past symptoms or disorders related to pelvic floor dysfunction, such as

• Urologic: urinary hesitancy/frequency/urgency, dysuria, bladder pain, urinary incontinence, and emptying disorders of the bladder

• Gynecologic: dyspareunia (during/after intercourse), sexual dysfunction, bulging from the vagina, and uterus/vaginal prolapse.

• Colorectal: constipation, fecal incontinence/leaking, rectal/anus prolapse, emptying disorders of the bowel, and bloating.

• Chronic pelvic pain/pressure: for female patients, abnormal work in pregnancy and childbirth is associated with potential symptoms of pelvic floor dysfunction. Ask women about the number of their previous pregnancies and giving birth, who have recently given birth (natural childbirth/cesarean derivation)about symptoms of PFDs during routine postnatal. For men, when asking them, pay attention to their potential prostate or urethral problems. Information on past history is also required to be detailed, such as the patient’s previous history of pelvic floor surgery, gynecology and obstetrics, trauma and drug therapy, radiotherapy, and family history of POP, all of which may provide important information for clinical diagnosis and treatment [16]. A focused medical history should be interrogated around the symptoms described above, clinical examination and investigations to exclude other causes, such as pelvic masses, neurological diseases, urinary tract infections, diabetes, inflammatory bowel or bladder conditions, and fistula. Also, the history of symptoms should be carried out around the nature, severity, duration, and frequency of urinary incontinence, POPs, as well as other symptoms related to pelvic floor dysfunction. Besides, we should pay attention to the patient’s quality of life affected by PFDs.

1.4 Physical examination

Physical examination of patients with PFDs encompasses general situation, abdominal and pelvic examination.

1.4.1 General condition

Age, body size, gait, and physical fitness are the factors that can reflect the mental state, neurological, and physical state of patients.

1.4.2 Abdominal exam

Combined with medical history, the abdominal exam can help to understand the patients’ history of abdominal surgery and make an adequate evaluation of the incision, hernia, abnormally enlarged organs, and abdominal morphology.

1.4.3 Pelvic exam

At least seven key items are included for female pelvic examination: Digital rectal examination (DRE), external genitalia, urethral orifice, urethra, bladder, vagina, cervix, uterus and its appendages and para-uterine tissues, anus, and perineum.

• Digital rectal examination (DRE): to assess the anal sphincter tone, rule out malignancy, and locate the origins of pain, hemorrhoids, anal fissures, and anorectal abscesses. In men, the size, nodularity, and tenderness of the prostate can be evaluated.

• External genitalia, perineum: inspect general appearance, color of the external genitalia, labia for size and adhesion, and vulva and vagina for atrophy; to evaluate female estrogen level. For example, the vulva is pink and wrinkled under normal estrogen levels. In contrast, the vulva is pale, flat, dry, and unwrinkled at estrogen-deficient level.

• Urethra: cotton swab test for localizing vulvodynia and assessing the position and mobility of urethra; excessive mobility of the urethra refers to the angle of cotton swab changes exceeds 30°C [17, 18].

• Vagina, cervix: speculum exam for atrophy or inflammation of the vaginal mucosa and visualization of the cervix.

• Anal: sensation, response to touch and pinprick.

• Perineum: graves speculum for the degree of the perineal relaxation in the lithotomy and standing position.

• The pelvic organs and floor muscles: bimanual exam/digital muscle testing for the strength of pelvic function muscle (PFM) and pain; palpation of the urogenital triangle encompasses ischiocavernosus, bulbospongiosus, and transverse perineal muscles and perineal body, evaluating dyspareunia.

In men, the assessment of penile and urethral orifice for stenosis is included in the exam, especially for men with urinary incontinence, following prostatectomy. The examination of urinary incontinence is best performed in a standing position. In addition, a neurological exam is important for patients with known or suspected neurological diseases. Make an evaluation of the patients’ mind, speech, cognitive function and gait, deep and superficial sensations in the lower extremities, perineum and perianal areas, nerve reflexes, and tension on vaginal and pelvic floor muscle, which is helpful for the diagnosis and treatment of PFDs. The bulbocavernosus reflex (BCR) and anal sphincter tension represent the neural function in S2–4 segments. A positive BCR means that when the glans or clitoris is squeezed, the anus and pelvic floor will contract.

1.5 Evaluation

In addition to the above-detailed history and physical examinations, there are various other supplementary measures used to evaluate the pelvic floor function, symptoms, and quality of life of patients, such as

• Questionnaire: Urinary diaries, UDI-6 and ICIQ-UI (widely used to assess the related pelvic floor symptoms of urinary incontinence and non-incontinence), pelvic floor dysfunction-related quality of life scale.

• Pad test/weights: An accurate evaluation of urinary incontinence and quantifies urinary loss.

• Urine analysis: The guidelines in the Society of Urodynamics, the American Urological Association (AUA), and Female Pelvic Medicine and Urogenital Reconstruction (SUFU) mentioned that urine analysis should be performed in patients with urinary incontinence to exclude infection, micro-hematuria, proteinuria, and glucosuria [19, 20].

• Urodynamics: To measure the functional aspects of the distal urinary tract, including urine storage and voiding.

• Cystoscopy: Visual inspection of the bladder and urethra to exclude suspected bladder or urethral pathology.

• Ultrasonography: To measure the postvoid residual volume (PVR); if necessary, endoanal ultrasonography can be performed to evaluate the detection of sphincter defects, infectious process, or neoplastic diseases of the anal canal, excluding a traumatic defect related to fecal incontinence; pelvic ultrasound to assess the uterus and adnexa; dynamic transperineal ultrasound is focused on exploring some functional diseases of the pelvic floor.

• CT scan MRI of the abdomen and pelvis: To evaluate structural anatomy.

• Electromyography (EMG): Electrodes (needle or surface) measure external sphincter activity during contraction and relaxation.

• Endoscopy: (Anoscopy, sigmoidoscopy, colonoscopy), incorporated as indicated to evaluate for other sources of pelvic pain (colorectal, gynecologic, neurologic, orthopedic, and urologic).

• X-ray/MR defecography: Defecography allows the evaluation of the defecation process in the physiological sitting position with the advantage of detailed morphological and dynamic evaluation of the pelvic floor structures and pelvic organs in a noninvasive way. It can provide an evaluation for rectal prolapse, rectocele, enterocele, and perineal descent.

Besides, uroflowmetry, excretory urography or cystourethrography, anorectal manometry, and balloon expulsion can be considered in specific cases. An integrated test approach is needed in the assessment of these patients, adequate to understand the complex anatomy and function of the pelvic floor.

1.6 Management

With initial assessment in primary care, therapeutic management for patients with PFDs should be planned to accommodate their specific needs. A multidisciplinary team approach for the management of pelvic floor dysfunction is often necessary. The common therapies are performed in Box 2.

Conservative management of pelvic floor dysfunction Lifestyle changes Weight loss: advise for patients with a body mass index (BMI) over 30 kg/m^2 Diet: appropriate intake of alcohol and caffeine (cola, tea, and coffee) for overactive bladder or urinary incontinence; reduction or avoidance of cigarettes, acidic foods/beverages, including citrus and tomatoes, concentrated sugar, artificial sweeteners, and spicy foods [23]. Physical activity: walking, swimming, and yoga. Pelvic floor muscle training (PFM): pelvic floor exercises (Kegel) for strengthening the pelvic floor. For patients who cannot finish an effective pelvic floor muscle contraction, consider biofeedback techniques, electrical stimulation, or vaginal cones as supplementing pelvic floor muscle training. Behavioral approaches: bladder retraining, toileting, and habit training. Psychological interventions. Medicines: Topical vaginal estrogen for overactive bladder, vaginal thinning, and dyspareunia; anticholinergics (fesoterodine, tolterodine), beta3 agonists (mirabegron) for overactive bladder. Manipulation: Pessaries for symptomatic POP and urinary incontinence, biofeedback, physical therapy (trigger point massage, myofascial release, strain-counterstain, joint mobilization) Invasive procedures: Botulinum toxin A injections to the pelvic floor, electric neuromodulation (sacral neuromodulation (SNM) /percutaneous tibial nerve stimulation (PTNS)), and trigger point injections or acupuncture for pain [24]. ; Surgical management of pelvic floor dysfunction A surgical approach is necessary if patients do not have satisfactory symptom relief with nonsurgical treatments. Urinary incontinence: mid-urethral sling (MUS) surgery (e.g., tension-free vaginal obturator route tape (TVT-O), transobturator tape (TOT), tension-free vaginal tape (TVT)); (open or laparoscopic) colposuspension; urethral injections; autologous fascial sling the pubovaginal sling (PVS); artificial urinary sphincter (AUS). Pelvic organ prolapse (POP): Anterior vaginal wall prolapse (i.e., cystocele, urethrocele, and paravaginal defect): anterior vaginal wall repair, transvaginal paravaginal repair, colposuspension. Posterior vaginal wall prolapse Enterocele: Repair of the rectovaginal fascia and obliteration of the cul-de-sac. Rectocele: Posterior vaginal wall repair or transanal repair, rectopexy (posterior or anterior), or perineal resection (Altemeier).

Box 2.

Management of pelvic floor dysfunction [21, 22].

Regarding invasive procedures, botulinum toxin A(BoNT-A) and urethral bulking agents (UBAs) are normally performed as outpatient procedures to save costs. Growing evidence has shown that BoNT-A is a promising alternative option for treating UUI/OAB/CPP and UBAs have benefits for SUI in certain specific cases, such as patients who are fragile, have severe comorbidities or high anesthetic risk, are unwilling to undergo more invasive procedure, or have limited surgical options (postoperatively, after irradiation) [23, 25].

Besides, the health care model of PFDs has drawn growing attention. There have been a number of different models available for the management of PFDs, but the most effective one has not yet been determined. Nurse-led primary healthcare has become a topic gradually gaining attention in female PFDs. Traditionally, primary health care nurses and general practitioners are typically tasked with diagnosing and managing elderly patients with urinary incontinence, OAB, prolapse, and other chronic illnesses. Nurse-led care services in primary health care for community-dwelling people are in high demand, especially for frail patients, post-stroke survivors, and dementia individuals. Nurses play a crucial role on the health care team in evaluating and treating PFDs. Not only is the patients’ health status monitored but also advice about the treatment and referrals is offered, which may support the patients in achieving the agreed-upon care and analyzing the results of the care. The findings of a study indicated that a nurse-led care protocol (SICP) based on the star model can significantly decrease incontinence episodes and urine leakage and improve the quality of life in women with SUI [24]. Oliver and his colleagues assessed the effectiveness of a healthcare service model called a nurse-led urology triage clinic (UTC) and they found that the UTC could result in a decrease in clinic visits and patient journey time. Furthermore, 59% of patients can be adequately managed by a specialist nurse [26]. Additionally, a RCT has revealed that a nurse-led telephone-based intervention before the initial urogynecology appointment shortened the duration of the appointment and enhanced the satisfaction of both patients and physicians [27]. A Dutch study showed that the implementation of a new nurse-led service for urinary incontinence led to better health outcomes in elderly community dwellers (2592–2618 QALYs gained in 2030) and lower cost-savings (€32.4 -€72.5 million in health care perspective; €182.0–€250.6 million in societal perspective) [28].

Because urinary incontinence and POP are two of the most common PFDs, this chapter focuses on urinary incontinence and POP.

Apical pelvic organ prolapse (i.e., uterus, vaginal vault): laparoscopic/robotic sacrocolpopexy; hysterectomy and uterosacral ligament suspension (apical repair), sacrospinous ligament fixation (SSLF), colpocleisis, and vaginal fornix suspension.

2. Urinary incontinence

2.1 Introduction

Urinary incontinence is defined as any involuntary loss of urine by the International Continence Society (ICS). It is a common severe health problem that impacts the quality of life and even economic consequences for millions of people. At present, the symptoms related to urinary incontinence are named by the International Continence Society (ICS)/ International Urogynecological Association (IUGA), including stress urinary incontinence, urge urinary incontinence, mixed urinary incontinence, persistent urinary incontinence, positional urinary incontinence, undetected urinary incontinence, coital incontinence, urgency, and nocturnal enuresis. The occurrence of urinary incontinence is closely associated with advanced age, pregnancy, delivery of babies, high-impact physical activities, hormone levels, body mass index (BMI), immobility, urinary tract infections, diabetes mellitus (DM), depression, smoking, prostate-related surgery, and other identifying well-established factors. Urinary incontinence (UI) affects up to 32% of men and at least 1/4 of women in their lifetime, but it presents more often in women [29, 30, 31, 32]. Major causes of urinary incontinence in men are usually associated with following radical prostatectomy (RP), prostate irradiation, and transurethral resection of the prostate (TURP), affecting up to 69% of men [33]. It may damage the nerves, blood supply, and/or structures around the pelvic floor, resulting in weakening urethral sphincter function and urethral bulb [11].

2.2 Management of urinary incontinence

The treatment of urinary incontinence should be tailored to the patients for different causes and physiological and pathological changes. At first, based on a detailed examination, the clinician must determine whether the cause of the symptoms is the bladder itself or the bladder outlet problem or both. Then provide counseling advice and develop personalized programs for patients according to patients’ needs, goals and expectations, risk-benefit ratio, and cost-benefit ratio. It is very important to provide patients with treatment goals that meet their expectations and achievability. Treatment of urinary incontinence contains nonsurgical and surgical treatments, and it is important to differentiate between different pathophysiological forms.

2.2.1 Conservative therapy of urinary incontinence

2.2.1.1 Lifestyle changing

Examples of lifestyle factors related to urinary incontinence encompass obesity, smoking, physical activity, and inadequate nutrition. Changing these lifestyles (i.e., weight loss, quitting smoking, reducing caffeine/fluid intake, dietary/behavioral modification, and reducing unnecessary medication) may help to improve urinary continence.

2.2.1.2 Pads usage

Patients with cognitive impairment or temporary urinary incontinence after a comprehensive assessment can be offered urinal pads.

2.2.1.3 Constipation improvement

Some studies have shown that constipation is strongly close to urinary incontinence and overactive bladder. Improving constipation through behavior, diet, and medication can contribute to treat urinary incontinence.

2.2.1.4 Behavioral therapy, physiotherapy, and electrophysiological stimulation of the pelvic floor

Bladder training is the first-choice treatment for female patients with urge incontinence or mixed incontinence. The European Society of Urology (EAU) and American Association of Urology (AUA) guidelines recommend pelvic floor muscle therapy (PFMT) as first-line therapy for female patients with stress urinary incontinence and mixed urinary incontinence, as well as men after prostatectomy [34]. Pelvic floor strength should be monitored and pelvic floor training should be continued for at least three months [35]. Besides, if the symptom improvement is not obvious after receiving anticholinergic drugs, female patients with urge incontinence may be considered to accept transcutaneous tibial nerve electrical stimulation (TTNS). In addition to pelvic floor training, electrostimulation (skin, vaginal, anal) may be provided to treat urinary incontinence. However, female patients with stress urinary incontinence or overactive bladder syndrome are not recommended to use electrostimulation alone. A systematic review indicated that PFMT combined with EMG-BF achieves better outcomes than PFMT alone in treating stress urinary incontinence or pelvic floor dysfunction [36]. Moreover, vaginal pessary therapy or the insertion of urethral plugs is an alternative conservative option for female patients with stress urinary incontinence. Women who are pregnant should be provided with prepartum physiotherapy that may decrease the risk of developing urinary incontinence.

2.2.2 Drug therapy for urinary incontinence

The appropriate drugs should be selected according to the type of urinary incontinence.

2.2.2.1 Antimuscarinic agents

If conservative non-pharmacological interventions fail to improve the symptoms of adults with overactive bladder or urge incontinence, then antimuscarinic agents must be additionally used. Antimuscarinic agents of extended-release formulations are an effective oral therapy option for female patients with urge incontinence. The common antimuscarinic agent contains solifenacin, tolterodin, oxybutynin, among others. If treatment with an antimuscarinic agent is not satisfactory, an increasing dose or the combination of anticholinergic agents with different components or mirabegron may be considered. Besides, changing the medication within the same group of medications or the form of delivery may be an effective option. Antimuscarinic agents, except for oxybutynin, are safe in the treatment of older patients. Oral oxybutynin has an obvious negative impact on cognitive functioning. Increasing awareness is needed to review the (total) anticholinergic burden, potential interactions with other medications, and possible intolerances.

2.2.2.2 β3-adrenergic agonists

β3-adrenergic agonists (mirabegron) are suitable for overactive bladder, urge incontinence, or mixed urinary incontinence. In terms of female patients who did not have any effective improvement or cannot tolerate antimuscarinic agents or in whom antimuscarinic agents are contraindicated, β3-adrenergic agonists (mirabegron) should be provided to them. Mirabegron has an equivalent effect of administration compared with antimuscarinic agents regarding the improvement of the symptoms of overactive bladder but without an increased risk of postvoid residual urine. It is important to have an awareness that one negative side effect of β3-adrenergic agonists (mirabegron) can be the risk of increasing blood pressure. β3-adrenergic agonists (mirabegron) combined with antimuscarinic agents may receive more benefits than escalating the dose of the antimuscarinic agent in female patients with an unsatisfactory treatment.

2.2.2.3 Duloxetine

If conservative therapy has not led to the desired success in patients with stress urinary incontinence, urge urinary incontinence, or in whom surgery is inappropriate, then duloxetine can be offered to patients. However, it should be noted that duloxetine has a high side effect.

2.2.2.4 Estrogens

Vaginal estriol administration should be considered in postmenopausal women with mixed urinary incontinence and vulvovaginal atrophy [37, 38]. The treatment of estrogens must be continued over long time periods.

2.2.2.5 Desmopressin

Desmopressin is currently not approved for use in urinary incontinence. Although it can relieve the symptoms in patients with urinary incontinence within a short period, long-term use is not recommended. It is essential to be aware that patients should be followed for the risk of hyponatremia before and during desmopressin therapy.

2.2.3 Surgical intervention for urinary incontinence

The choice of surgical intervention should be individualized based on the patient’s symptoms, the severity of the patient’s distress, the impact on quality of life, the patient’s goals and expectations, the surgeon’s experience, the medical and surgical history of patients, the availability of materials, and the potential for adverse events.

2.2.3.1 Surgical treatment of stress urinary incontinence

Surgical therapy should only be offered if patients with stress urinary incontinence have been treated with exhausted conservative therapies.

2.2.3.2 Surgical treatment of uncomplicated stress urinary incontinence

The characteristics of uncomplicated stress urinary incontinence contain no history of incontinence or prolapse surgery, no neurological symptoms, no concomitant symptomatic genital prolapse, or no wish to continue fertility. Slings have gradually become the standard therapy for women with stress urinary incontinence due to their various materials, implantation methods, and anchoring techniques. Several different surgical procedures have been reported for SUI, including mid-urethral sling (MUS), (Burch) colposuspension, autologous fascial sling, and the pubovaginal sling (PVS). Nowadays, MUS is considered as the surgical gold standard of stress urinary incontinence [39]. The MUS can be conducted through retropubic or transobturator routes with three types: retropubic MUS, such as retropubic tension-free vagina tape (TVT); transobturator MUS, such as transobturator inside-out tape (TVT-O) and outside-in tape (TOT); single incision sling (SIS), creating a dynamic mid-urethral support with synthetic material tapes. Compared with retropubic MUS, the benefits of transobturator MUS include a lower occurrence of bladder or vaginal perforation in the operation, major subsequent vascular complications and pelvic hematoma, a lower rate of supra-pubic pain, urinary tract infection, dysfunctional voiding, and lower urinary tract symptoms (LUTS) [40]. However, another study has shown that transobturator MUS presents a higher rate of recurrent procedures and a higher risk of groin pain than retropubic MUS [41]. Compared with retropubic or transobturator MUS, SIS can shorten operative time, have less intense postoperative, intraoperative bleeding, and a lower risk of postoperative voiding dysfunction. The currently available SIS may be appropriately offered to elderly women with anxiety of operative pain or postoperative voiding dysfunction [42]. If female patients wish to avoid surgical morbidity, UBAs are feasible, but the benefits must be balanced against recurrent injections and long-term results remain inadequate.

2.2.3.3 Surgical treatment of complicated stress urinary incontinence

Complicated stress incontinence is characterized by a prior history of failed anti-incontinence surgery, pelvic irradiation, neurogenic bladder, and concomitant POP. Recurrent urinary incontinence may be considered for reoperation with an artificial material mid-urethral sling, colposuspension, or autologous fascial sling. Compared with the first surgery, reoperation may have a higher risk of complications and a lower improvement. In general, the artificial urinary sphincter (AUS) and adjustable continence therapy (ACT®) balloons implantation are used for complicated stress urinary incontinence, but they have a high risk of complications, device failure, or the need for removal. As an alternative treatment, UBAs are a minimally invasive approach for select females with recurrent or persistent SUI after failed MUS procedures [25]. As a well-established treatment option, the usage of UBAs is increasing over the past few years [43, 44, 45]. Recently, a number of UBAs have been released, which include Bulkamid®, Macroplastiue®, Durasphere®, Coaptite®, or Urolastic® [46]. In general, UBAs can be performed as an office-based procedure under local anesthesia, which presents an encouraging short-term and acceptable medium-term efficacy, excellent safety profile, and few adverse events [46, 47]. The common adverse events include injection site rupture, urethral prolapse, urethral erosion, particle migration, and periurethral abscess. Unfortunately, there have been no studies comparing UBAs with other procedures for female SUI. In contrast to mid-urethral sling, the efficacy of UBAs seems to be less but can be balanced by a lower complication rate [48].

2.2.3.4 Surgical treatment of urge urinary incontinence

Onabotulinum toxin A (Botox) injection may be a minimally invasive option when conservative and drug treatment has failed in patients. It was approved for the treatment of adult refractory overactive bladder in 2020 [23]. Several studies have demonstrated that Botox is typically given in doses of 100 to 300 IU every 6 to 12 months and has been effective for 19 to 24 weeks after each injection. In clinical practice, it should be focused on the efficacy of onabotulinum toxin A for a limited time, as well as the risk of urinary tract infections and residual urine, and the possible need for intermittent self-catheterization. Generally, it is performed as an office-based procedure under local anesthesia, which avoids unnecessary costs associated with hospitalization. Sacral neuromodulation (SNM) should be considered if antimuscarinic agents have not led to the desired success in female patients with urge urinary incontinence. The option to offer augmentation cystoplasty should be considered in selected cases if the above methods are ineffective. Besides, urinary diversion should only be considered in patients when who have failed to respond to minimally invasive treatment, accept an artificial stoma, and with a low tumor risk. Detrusor myectomy to treat urinary incontinence is not recommended to patients.

2.2.3.5 Surgical intervention for male urinary incontinence

The artificial urinary sphincter (AUS) is defined as the gold standard therapy for postprostatectomy stress urinary incontinence. If male patients do not benefit from prior male urethral sling placement and gradually present with persistent or worsening stress urinary incontinence, the artificial urinary sphincter is better offered than a secondary sling [49]. Patients with severe postoperative urinary incontinence may be served with fixed slings. BTX-A injection is an excellent option for patients with small prostates and low prostate-specific antigen (PSA) levels, presenting better effects and tolerability. Although BTX-A injection has a positive effect on overactive bladder in men, evidence-based guidelines are still scarce [50].

2.2.3.6 Surgical treatment of mixed urinary incontinence

In patients with MUI, it is essential to identify whether urge or stress incontinence is the predominant symptom. The most troubling symptoms should be treated first. It is demonstrated that the overall cure rate with surgery is higher in patients with predominant symptoms of stress urinary incontinence than those with urgency-predominant symptoms of mixed urinary incontinence [51, 52]. Compared with a mid-urethral sling alone, a combined treatment with a mid-urethral sling and pelvic floor muscle therapy may result in slightly better outcomes [53].

2.2.3.7 Additional surgery for urinary incontinence

In recent years, various types of mesenchymal stem cells (MSCs) have been used to treat stress urinary incontinence due to their paracrine function, which contributes to tissue repair. There is some data supporting the feasibility and the safety of MCS therapy [54]. Besides, nerve growth factor (NGF) can contribute to nerve and muscle regeneration, and the study has investigated that a combination of stem cells and nerve growth factor (NGF) is more effective in relieving stress urinary incontinence than stem cell therapy alone [55]. Combination therapy is becoming an emerging and promising method for the treatment of urinary incontinence with a restoration of sphincter function. However, this stem cell therapy has limitations for clinical use due to the unclear potential mechanisms of action of stem cell therapy for SUI. And the extraction process as well as ex vivo expansion is still difficult. In addition, laser therapy may now be an option recommended to some women with stress incontinence. In the last two years, there has been an amount of data supporting a huge improvement about the use of laser therapy for stress incontinence. However, the current insufficient efficacy and safety of laser therapy limits the general recommendations.

3. Pelvic organ prolapse

3.1 Introduction

Pelvic organ prolapse (POP) is a highly prevalent problem in women, defined as the descent of the pelvic organs (i.e., vagina, uterus, bladder, and/or rectum) from their normal anatomical locations into or through the vagina. The prevalence of pelvic organ prolapse is thought to be as high as 30 to 60% of parous women (all stages of prolapse) [56, 57] and will present an increase due to the aging population, as well as the increase prevalence of undergoing future surgical procedures. Most cases of pelvic organ prolapse are asymptomatic. For those with symptomatic prolapse, around 3–6% are reported with a POP-related decisive lower quality of life, including bladder and bowel issues as well as coital dysfunction [58, 59]. In the general female population, the lifetime risk of undergoing a single operation for prolapse is about 12–19%, and by age 80 was 11.1% [4, 6, 60, 61].

3.2 The etiology and risk factors for pelvic organ prolapse

The pelvic organs are supported by the fibromuscular connective tissue in the vaginal wall, pelvic ligaments, and levator ani muscles. Tears in the pelvic floor muscles, fascial tissues, and/or weakness of the ligaments lead to prolapse. Causes of pelvic organ prolapse are complex and multi-factorial. Many risk factors are correlated with POP, including pregnancy, ethnicity or race, operative vaginal childbirth, higher parity, forceps delivery, aging, previous hysterectomy, menopause, connective tissue disorders, chronic constipation, weakness of the pelvic floor, increasing body mass index, and family history of prolapse.

3.3 Clinical manifestation of pelvic organ prolapse

Pelvic organ prolapse encompasses several prevalent clinical conditions, including vaginal bulging symptoms, urinary and fecal incontinence, obstructed defecation, sexual dysfunction, and female pelvic organ prolapse (FPOP). These are closely associated with the site of prolapse (the anterior vaginal wall, posterior vaginal wall, and apical prolapse). A feeling or visibility of vaginal bulging is the most frequently reported and specific symptom of pelvic organ prolapse [62]. Pelvic organ prolapse does not always present any symptoms and is discovered incidentally on physical examination [63]. If the prolapse reaches roughly the level of the hymenal remnant, women can present with vaginal symptoms of prolapse.

The symptoms of pelvic organ prolapse vary by the extent of prolapse and whether the prolapse involves the anterior, posterior, or apical segments of the vagina (see Box 3).

Vaginal symptoms Sensation or visibility of vaginal bulging or protrusion. Pelvic or vaginal pressure/heaviness. ; Urinary symptoms Symptoms related to bladder storage (urinary incontinence, urgency, frequency) Voiding symptoms (hesitancy, intermittency, prolonged urinary steam, and insufficient emptying) Splinting (pressing on the prolapse to help empty bladder) Position-dependent voiding ; Anorectal symptoms Incontinence of stool. Sensation of anorectal blockage or incomplete emptying. Hard straining/urgency to defecate. Splinting vagina or perineum for complete evacuation. ; Coital symptoms Dyspareunia Vaginal dryness Arousal or orgasm reduction Obstructed intercourse ; Pain Pain in vagina, bladder, low back, or rectum.

Box 3.

The symptoms of pelvic organ prolapse are performed.

3.4 Diagnosis and evaluation of pelvic organ prolapse

Pelvic organ prolapse can be confirmed according to the patient’s clinical symptoms and physical examination.

3.4.1 History

A detailed history should be offered. It contains the severity of prolapse-related symptoms, duration, aggravating factors, evaluation of voiding or defecation function, and accompanying coital dysfunction. In addition, based on the including risk factors for prolapse, a complete history of medical, obstetric, and surgical should be conducted [63]. Of note, some of bladder, bowel, and sexual symptoms may not be caused by prolapse but coexist with pelvic organ prolapse, such as overactive bladder, recurrent urinary tract infections, chronic constipation as well as urinary incontinence [64]. The site of prolapse is characterized as the anterior vaginal wall, posterior vaginal wall, and apical prolapse. The most common type of pelvic organ prolapse is the prolapse of the anterior vaginal wall, or cystocele, discovered 2-fold more common than posterior vaginal prolapse (the rectocele), and 3-fold as often as apical prolapse [65, 66]. Anterior-predominant prolapse presents an almost three times more apical descent below normal than posterior-predominant vaginal prolapse [67]. Among them, anterior pelvic prolapse is closely related to urinary system diseases, including cystocele (bladder bulge from the vagina) and urethral prolapse (urethral overactivity). Symptoms related to urinary symptoms include voiding dysfunction, incontinence, urgency, and frequency, and symptoms like outlet obstruction are commonly reported in cases of symptomatic POP [62]. Posterior pelvic prolapse (rectal prolapse) refers to a herniation of the rectal tissue into the vaginal lumen, resulting in a vaginal bulge along the posterior vaginal wall on examination, while apical prolapse is related to a uterine bulge and/or a hernia of the small intestine into the vagina(enterocele).

3.4.2 Physical examination

The commonly used method is the pelvic organ prolapse quantification (POP-Q) system proposed by the International Continence Society in 1996 (Figure 3) [68]. The hymen was defined as the fixed anatomic point of reference throughout this descriptive system of quantitative prolapse. There are six defined points above or proximal to the hymen (negative centimeters number) or centimeters below or distal to the hymen (positive centimeters number) and the plane of the hymen is defined as zero. Ordinal stages of pelvic organ prolapse can be assigned into five stages (0 through IV), in accordance with the most severe and distal portion of the prolapse by using specific letter qualifiers, as follows in Table 1 and Figure 4. Besides, there are three different types of prolapse are shown in Figure 5.

Figure 3.

The sites of defined points: Aa = a mid-point on the anterior vaginal wall, 3 cm proximal to the external urethral meatus, Ba = represents the most distal position of any part of the upper anterior vaginal wall from the vaginal cuff or anterior vaginal fornix to point Aa, C = the most distal edge of the cervix or cuff (vaginal apex (upper vagina)), D = the site of the posterior fornix (or pouch of Douglas) in a woman, Bp = the most distal site of any part of the upper posterior vaginal wall from the vaginal cuff or posterior vaginal fornix to point Ap, Ap = in the midline of the posterior vaginal wall 3 cm proximal to the hymen. a = anterior vaginal wall, p = posterior vaginal wall, Cx = cervix, gh = genital hiatus, pb = perineal body, tvl = total vaginal length (adapted from Bump et al. [68]).

POP-Q staging	Measurements are in centimeters and measured from the hymen
Stage 0	No prolapse. Point C or D is within 2 cm of TVL. Aa, Ba, Ap, and Bp are all 3 cm above the hymen (i.e., −3).
Stage 1	The vaginal apex is lower than 2 cm from TVL. Aa, Ba, Ap, and Bp are higher than −3 cm but less than −1 cm from the hymen (above the hymen).
Stage 2	Prolapse is within 1 cm of the plane of the hymen (1 ≤ hymen≥ − 1 cm).
Stage 3	The most distal prolapse is greater than 1 cm below the hymen but less than stage 4 ( + (TVL-2 cm).
Stage 4	complete vaginal eversion the maximum prolapse is outside of the body to within 2 cm of the TVL (TVL-2 cm) (e.g., if the TVL is 9 cm, the maximal prolapse is +7).

Table 1.

Stages of pelvic organ prolapse by pelvic organ prolapse quantification examination.

POP-Q = pelvic organ prolapse quantification; TVL = total vaginal length. Data from Bump et al. [68].

Figure 4.

Stages of prolapse are performed in accordance with the pelvic organ prolapse quantification system (POP-Q) (adapted from Haylen [69]).

Figure 5.

Different types of pelvic floor prolapse. A = anterior vaginal prolapse, B = posterior vaginal wall prolapse, C = uterine prolapse, D = vaginal vault prolapse (posthysterectomy) (adapted from Haylen [69]).

A speculum is performed to assess the extent of prolapse. It should be noted that more commonly prolapse involves multiple compartments of the vagina in most cases of symptomatic POP [64]. Attention should be paid in evaluating all three compartments during examination. A bivalve speculum combined with a single blade can be performed to assess the anterior and posterior vaginal walls during a Valsalva maneuver, respectively. Once apical prolapse has been visualized, an assessment of occult stress urinary incontinence is allowed during a Valsalva maneuver or cough.

3.5 Management of pelvic organ prolapse

Prolapse is a benign disease. If women with a mild degree of asymptomatic prolapse, observation is commonly recommended. Some women with advanced POP (stage 3 or 4) can also have few symptoms, little or no bother as well. In these cases, observation is considered first [70]. The assessment and treatment are offered to women with POP only if they develop bothersome symptoms due to the prolapse. In brief, treatment selection for women with POP contains observation, conservative measures, pessary use, and surgery.

3.5.1 Conservative management

Generally, the purpose of nonsurgical treatment is to alleviate symptoms, and increase the strength, endurance, and support of pelvic floor muscles. Conservative or mechanical treatments are considered for women with a mild degree of symptomatic prolapse, or those who wish to preserve fertility but are unwilling to accept or cannot tolerate surgery. Pelvic floor muscle training and pessary use are the demonstrated conservative treatment options for patients with POP. Lifestyle modifications with little risk, including weight loss, minimizing straining or constipation, and avoidance of heavy lifting, coughing, or high-impact exercise, are commonly offered.

3.5.1.1 Pelvic floor muscle training

Pelvic floor muscle training, recommended as first-line therapy for POP, refers to systematic contraction of the levator ani muscles with the goal of improving pelvic floor function and symptoms. It is demonstrated pelvic floor muscle training is effective in improving symptoms in women with mild-to-moderate POP [71, 72].

3.5.1.2 Pessary usage

Pessaries are intravaginal mechanical devices inserted into the vagina canal. They can be offered as short- or long-term therapy or hold over the need for surgery, through helping support the prolapsed organs inside the vagina and related pelvic structures, as well as relieving pressure on the bladder and bowel. Pessaries are indicated in patients who wish to childbearing, do not desire surgery, are frail, or have comorbidities that are not medically fit for surgery intervention. Pessaries are available in various shapes and sizes, helping to adapt to differences vaginal diameter and length in anatomy. The most commonly used pessaries are the ring, ring with support, Gellhorn, and doughnut pessaries. A ring pessary or ring with support is the first option for most patients due to an easy insertion and removement. Ring pessaries present a more effective improvement at an early stage of prolapse, and Gellhorn pessaries are usually conducted for patients with more advanced degrees of prolapse. Pessaries are a relatively simple and effective method for patients with POP but not perfect, and as high as 92% of patients among them can be successfully placed with a pessary [73]. A systematic review, including 89 articles, reported that more than 50% of women continued pessary use and had an obvious improvement in their quality of life, sexual function, and body perception [74]. Complications from pessaries insertion include discontinuation, local infection, vaginal bleeding, the risk of developing vaginal erosions or discharge, and new bowel and bladder symptoms [75, 76]. Although these are typically minor, an appropriate short-term removal or vaginal estrogen therapy should be considered. Moreover, a recent Cochrane review found that pessary use with pelvic floor muscle exercises probably improves prolapse-specific symptoms and quality of life compared with exercises alone [77].

3.5.2 Surgical treatments

Surgery is generally indicated in patients with bothersome symptomatic POP who have at least stage 2 prolapse on examination and have failed or declined nonsurgical therapy [78]. The objective of POP repair is to restore normal anatomy and function of the vagina, lower urinary tract, and pelvic organs, and thus eliminate POP-related symptoms. The option for the approach is based on several factors: the patient’s expectations, desires, and needs, degree of prolapse, comorbidities, and surgeon preference and capability. Surgical approaches include reconstructive and obliterative procedures. The former preserves the vagina while the latter closes the vagina. A wide variety of operations can be conducted via vaginal, laparoscopy, robot-assisted, or laparotomy for the treatment of patients with prolapse, each of which has an individual risk-benefit profile. The most common and traditional technique is the anterior repair (colporrhaphy) in terms of anterior vaginal wall prolapse, which is frequently offered to combine with other interventions to treat prolapse and/or urinary stress incontinence. The repair procedures of anterior and posterior defects comprised more than 90% of all prolapse operations [4].

3.5.2.1 Vaginal approach

Transvaginal approaches include vaginal hysterectomy, anterior or posterior vaginal wall repair (colporrhaphy), McCall culdoplasty, Manchester repair (amputation of the cervix with uterus suspension to the cardinal ligaments), prespinous and sacrospinous colpopexy, Le Fortes procedure, colpocleisis, sacrospinous ligament fixation (SSLF), uterosacral ligament suspension (ULS), and perineal reconstruction. They can be used for anterior, apical, or posterior prolapse of any stage. It is reported that 80–90% of approaches are implemented through the vaginal approach [79].

3.5.2.2 Laparoscopic, robotic, or abdominal approach (Sacrocolpopexy)

Transabdominal approaches include sacrocolpopexy, hysterectomy, vault suspending and uterosacral ligament plication, and enterocele ligation. Abdominal surgery can be performed through an open incision or a minimally invasive via the laparoscope or robot.

3.5.2.3 Apical pelvic organ prolapse

Apical prolapse is sometimes referred to as uterine or cervical prolapse. Uterine preservation (hysteropexy) was a feasible option for well-selected patients with apical pelvic organ prolapse, who may prefer preserve fertility, concern about the risks of hysterectomy, or a negative impact on coital satisfaction and a sense of identity. Hysterectomy has been usually employed for treating women with uterine defects and vaginal fornix suspension should be used to prevent recurrent prolapse as well. If the apical pelvic prolapse women are still present in women after hysterectomy, a uterosacral ligament suspension (ULS) or sacrospinous ligament fixation (SSLF) with transvaginal procedures can be considered. Some contemporary devices have been applied in clinical practice to reduce severe prolapse, but the data on effectiveness remain to be observed. When a hysterectomy is performed and an enterocele is present, iliococcygeus fascia suspension may be used [80]. In addition, after a total hysterectomy, the prolapse of the vaginal cuff may be present, which is also called vaginal vault prolapse (VVP). Sacrocolpopexy(SC) is regarded as the standard treatment for the management of vaginal vault prolapse, which is available for open operation (OSC), as well as minimally invasive approach assisted by laparoscopy (LSC) and robots (RSC) [81]. An updated network meta-analysis comparing efficacy and safety of open, laparoscopic, and robotic-assisted sacrocolpopexy approaches simultaneously indicated a superiority of robot-assisted and laparoscopic sacrocolpopexy over the open procedures with better anatomic outcomes, less estimated blood loss and overall postoperative complications [82]. In elderly and fragile patients with vaginal vault or severe uterine prolapse, colpocleisis is an appropriately recommended option with the benefit of a high success rate (91–100%), an effective improvement, and low risk [83]. It encompasses a uterine-sparing procedure, the LeFort colpocleisis, colpocleisis with hysterectomy, and posthysterectomy vaginal vault colpocleisis. The goal of the colpocleisis procedure is a well-approximated, obliterated vagina, approximately 3 cm in depth and 1 cm in width, which may help to gain well treated results [84].

3.5.2.4 Anterior pelvic organ prolapse

Materials used in surgery of anterior pelvic prolapse repair include native tissue, synthetic mesh, and biological xenograft material. If a patient has anterior vaginal wall prolapse, an anterior vaginal with native tissue repair can be offered. A recent study enrolling 102 patients with over five years of follow-up indicated that hysteropexy with anterior vaginal native tissue repair may be a suitable surgical treatment for anterior compartment prolapse and concomitant stage II uterine prolapse, and the cure rates of subject and object could achieve up to 88% and 86%, respectively [85]. In addition, Y-shaped synthetic polypropylene (PP) mesh was introduced in the middle of the twentieth century. It can be performed in sacrocolpopexy, fixed to the anterior, apical, and posterior aspects of the vagina as well as the anterior longitudinal ligament overlying the sacrum, restoring the normal axial position of the vagina. However, the use of polypropylene mesh has become highly controversial due to reported serious complications involving chronic pain and mesh erosion or exposure [86]. In patients with cystocele prolapse, the use of a standardized, trocar-guided mesh kit led to success in higher short-term rates but accompanied higher rates of complications and postoperative adverse events compared to anterior colporrhaphy [87]. Besides, if patients with vaginal wall prolapse caused by lateral and central defects, anterior colporrhaphy combinates with paravaginal repair can be considered. For patients with severe anterior prolapse, an assessment is recommended to be conducted to determine the risk of concomitant potential SUI before prolapse surgery, which is helpful in formulating surgical plans. In brief, although most materials used in the repair of anterior prolapse may lead to some complications, mesh has potential benefits in some well-selected patients. If surgeons and patients can understand the potential risks and benefits, then vaginal mesh implantation can be considered.

3.5.2.5 Posterior pelvic organ prolapses

The posterior wall prolapse encompasses a variety of bothersome symptoms, including a herniation of the anterior rectal wall (rectocele), a vaginal bulge, constipation, and coital disorder. If the defect extends to the proximal posterior vaginal wall, prolapse could manifest in the form of a herniation of small bowel or an enterocele. Patients with posterior vaginal prolapse sometimes mainly manifested the need for using vaginal splints or fingers to facilitate defecation. The best type of posterior vaginal wall repair lack of enough evidence. Repair procedures should be performed according to the extent of prolapse symptoms and patients’ quality of life. Also, the main goal of rectocele repair is to moderate bothersome symptoms, build up anatomic support, and recover defecation and coital function. Rectocele repair can be offered via a transvaginal, transanal, abdominal, laparoscopic, and transperineal route. Transvaginal rectocele native tissue repairs contain midline plication and site-specific defect repairs. Some studies indicated that the transvaginal surgical approach was probably superior to the transperineal or transanal route [88, 89].

3.5.2.6 Patients with POP and concurrent SUI

It is reported that POP is often correlated with symptomatic or occult stress urinary incontinence, approximately 55% of women with stage 2 POP have concomitant SUI, and only 33% of women with stage 4 POP have SUI, maybe as the result of kinking of the urethra if the prolapse advances [90]. The occult SUI is discovered only with the use of a speculum or pessary during physical examination. Patients with occult SUI may develop SUI symptoms following POP surgery. In addition, women with POP and no concomitant SUI may be at the risk of developing stress urinary incontinence (De nova SUI) symptoms after POP repair procedures. Therefore, a prolapse reduction cough stress exam should be conducted for preoperative women with POP and the POP operations combined with contemporaneous or delayed continence procedures should be offered to women with POP and SUI (symptomatic or occult). Adding an MUS during vaginal POP repair is recommended to reduce the postoperative SUI. However, the risk of short-term postoperative difficulty in urination void and other lower urinary tract symptoms needs to be considered [91]. It is indicated that the retropubic MUS is associated with greater morbidity than transobturator MUS [42].

3.6 Treatment of pelvic floor reconstruction

The treatment interventions for patients with pelvic floor dysfunction should be adjusted according to their specific needs. A multidisciplinary approach is usually necessary. In the past decade, the use of grafts (absorbable and permanent mesh, biological grafts) repair has been a controversial approach to treat POP, but the use of synthetic and biological transplant materials to improve the integrity and durability of POP repair has gradually become popular in selected cases. Based on current evidence, using vaginal mesh in the pelvic floor is associated with a well-established risk of complications, which has become a debated issue on a global level. Although the majority of females report treatment success and satisfaction, mesh-related complications after pelvic floor reconstruction are an advancing condition with various clinical manifestations, including mesh extrusion/exposure (vaginal/ urinary tract), mesh degradation, urinary tract perforation, vascular injury, de novo voiding LUTS and storage LUTS, vaginal exposure, vaginal infection, dyspareunia, and the need for a second procedure to remove or revise the mesh. In terms of psychological trauma, strained intimate relationships were also affected, with reduced sexual functioning and intimacy, as well as emotional suffering, which included anxiety and fears related to suicidal thoughts [92, 93, 94, 95]. The mesh problem, extrusion or erosion location, pelvic floor defect extent, severity, and probable recurrence should all be taken into consideration when choosing the appropriate treatment plan. With a developed understanding of the anatomy and function of the pelvic floor, pelvic floor reconstruction has received much attention and more new technologies are also constantly emerging, developed to improve the traditional methods. Robotic surgery has gained popularity for the reconstruction of pelvic floor defects. Compared with traditional transvaginal or transperineal procedures, robotic surgery is a probable safe and effective indication for pelvic floor reconstructive surgery in terms of better functional outcomes and long-term successful rates for the treatment of advanced or multicompartmental prolapses. The ultimate target of pelvic floor reconstruction is to restore the normal anatomical structure and function of the vagina, bladder, and surrounding tissues. A correct evaluation of the anatomical structure and function of the pelvic floor is crucial for the development of new therapeutics and optimization on prognosis. In addition, as people increasingly value the quality of life, the cost of healthcare is also increasing. Therefore, people are still making continuous efforts to explore methods for quantifying symptoms and evaluating outcomes, and some safe and more effective new technologies are still emerging to correct pelvic floor disorders, alleviate symptoms, and improve quality of life.