Treatment

Introduction >
Problems of bladder and pelvic floor >
How the pelvic floor works >
The way to help you >
The advantages of the Petros/Goeschen techniques >
Questions and answers >



Our Uro-Gynaecological Center is for

Diagnosis and Treatment of Incontinence
Problems of the bladder and the pelvic floor
Urine and faecal incontinence
Vaginal and uterus prolapse
Pelvic floor pain
Organic sexual dysfunction

Dear patient,
 
with the following information about our Uro-Gynaecological Centre for Diagnosis and Treatment of Female Bladder- and Pelvic Floor Problems (KVINNO Centre Germany/Spain) we would like to introduce ourselves. We want to offer you a new concept to help with problems of the bladder and the pelvic floor, e.g. urinary and faecal incontinence, vaginal and uterus prolapse, pelvic floor pain, and organic related sexual problems. The original concept comes from the Royal Perth Hospital in Perth, Australia (www.integraltheory.org).

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Problems of bladder and pelvic floor

One in four women in Europe know the problem of uncontrolled loss of urine under stress i.e. coughing or standing up, feeling always damp, having emptying problems or a dragging feeling in the vagina, getting up at night to pass urine, faecal soiling and pain (lower abdomen, coccyx) on deep penetration during intercourse. No one wants to speak about it, neither with their partner nor with their doctor. It is a taboo.

We want to break this silence. It is our aim to help woman with these problems to enjoy a better and untroubled life by using new medical procedures.

We use new procedures which were developed by Prof. Dr. P. Petros in the Royal Perth Hospital, Australia and further developed by Prof. Dr. K. Goeschen in Germany.

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How the pelvic floor works

It is important to keep in mind that the pelvic floor is one functional unit (integral theory) working like the elastic membrane of a trampoline. It consists of a fibro-muscular membrane through which pass the rectum, the vagina, and the urethra. It also consists of ligaments working like shock absorbers. The muscular membrane and the shock absorbers are suspended from the pelvis at the front, the middle, and the back. Forward forces stretch the vagina to close off the urethra. Backward forces stretch the vagina to close off the bladder neck. The uterus and the bladder lie on the pelvic floor.

Fig.1 left: Simplified diagram of the normal pelvic floor with vaginal membrane (red), ligaments at the front, middle and back (red lines), pelvic bone griddle (black).

Right: Muscle membrane and ligaments are overstretched. The trampoline cannot work. The nerve endings at the bottom of the bladder (blue) are signalling permanently to the brain that the bladder is full. This makes you feel you have to pass urine, or you feel urge symptoms.

The vagina works like an elastic membrane. Its tissue can become lax with age and after childbirth. If the vaginal tissue is lax the muscles cannot close off the urethral tube. Thus, when you cough, you can loose urine (stress incontinence). The same laxity fails to support the filling bladder. The nerve endings at the bottom of the bladder are stimulated prematurely and overcome the brain's inhibition at a lower bladder volume (bladder instability). This may be expressed as a sensation of urgency, wanting to pass urine frequently, or getting up at night to pass urine (nocturia).

The following diagram can be used as a guide to understand what the connections between your symptoms and the site of the anatomical damages (front, middle, back) are.



Frequency, getting up at night, and passing urine before arriving at the toilet may occur in all zones. Not all criteria may be present for a particular zone. Requirement for help is always a precise and individual method of diagnosis according to the symptoms.
 
If you are interested in the diagnosis and treatment of your special problems concerning the bladder and pelvic floor please make an appointment. During this appointment we will carry out a gynaecological and special examinations to localize your problem. We will explain you the results and the recommended treatment.

- Deliveries

Childbirth is often the reason for future incontinence or prolapse problems. Deliveries can result in laxity and stretching of the vagina, the ligaments, nerves and the pelvic floor muscles. Consequently many women suffer from discomfort, pain or loss of urine during sex. After giving birth many women have the feeling that the vagina is too lax and too big. As a consequence they may not feel attractive anymore as a sexual partner.


- Operations

Occasionally previous operations in the lower abdomen, e.g. hysterectomy, are responsible for bladder and pelvic floor problems. Prolapse operations may result in partial or even total loss of smoothness of the vagina because of scar-tissue formation. This leads to severe incontinence and even to discomfort during intercourse and pain.

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The way to help you

After the exact location of the damaged part of the pelvic floor we can offer you a schedule for your individual problems of bladder, pelvic floor or organic sexual dysfunction. The decision on what is to be done depends on the results of the examination. Help is available either in form of a non-surgical approach (Petros concept) or as an operative procedure (Petros/Goeschen concept).

- The non-surgical treatment

You will remember that the pelvic floor contains muscles and ligaments. Using the non-surgical approach, the damaged tissue is strengthened with electrotherapy for the fast and slow twitch muscles with additional help for the fast twitch muscles by performing special exercises. The daily treatment programme with special exercises and electrostimulation generally lasts for three months.

However, in case of severe pelvic floor damage an operation is necessary.



Fig.2  If the attachment between muscle and vagina is loose the muscles cannot pull the vagina backwards to support the bladder base.
This leads to frequency, urge, nocturia and bladder emptying problems. Pelvic floor exercise is insufficient.






Fig.3  In these cases only an
operation can restore the connection
between muscle and vaginal wall using
a posterior sling.






- The surgical treatment, the "keyhole" surgery

Prof. Goeschen has been the first surgeon in Europe who performed these new minimal invasive operations for pelvic floor reconstruction. In cooperation with Prof. Petros he created new techniques.
 
The new keyhole techniques reinforce damaged tissue. The principles are:

1. The vagina must have better support for bladder opening and closing. A prolapsed vagina is conceptually like an invagination. Its side walls need to be secured to prevent a further prolapse.
2. A severely damaged ligament cannot be repaired. New natural ligaments can be created by using precisely positioned artificial tapes. The Intra-Vaginal-Sling plasty (IVS) uses the body’s own wound repair mechanism to create new natural collagenous ligaments at the site of lost or weakened ligaments. The problem of weak and thin vaginal tissue is addressed by avoiding vaginal excision. Excess width is refashioned as length. Double layer "bridge" repairs weakened structures.
 
Although the positive outcome of an operation can never be guaranteed the long-term results of IVS show an overall success-rate of 80 % up to 90 %.

After Prof. Petros in Australia and, in cooperation with him, Prof Goeschen in Germany have developed this new "vaginal keyhole surgery" which sees and repairs the pelvic floor as a functional unit (integral concept), women now have a new hope for improvement of their situation. It is not necessary any longer to accept problems with bladder, pelvic floor and organic related sexual disturbances as beyond repair if they are caused by damaged tissue in the genital tract.

There are further advantages of the Petros/Goeschen method: no vaginal shortening and only small vaginal scars (minimal invasive vaginal surgery). The vagina remains in its normal anatomical position. The attempt to operate all the damaged tissue in one operation did not prove successful. Overcorrections are a possibility. Sometimes it is better to operate in two steps.

The 2-year and the 4-year follow-up overall cure rate of the Petros/Goeschen procedure is 80 % to 90 %. After 2-year follow-up: for stress incontinence, 88 %, for urinary frequency, 85 %, for nocturia, 80 %, for urge incontinence, 86 %, and for emptying problems, 50 %. Pre- and post-operative urodynamics indicate that detrusor instability is not associated with surgical failure. After 4-year follow-up urine incontinence is cured in 80 % of all patients, the cure-rate for faecal incontinence is 90 %.


Another advantage of the keyhole surgery (Petros/Goeschen concept) lies in the drastic reduction in post-operative in-patient and out-patient recovery. Using standard traditional operating techniques (either through the abdominal wall or through fairly large vaginal incisions) post-operative in-patient recovery may take up to 10 to 14 days. With the keyhole surgery, post-operative recovery is reduced to 2 to 7 days, depending on general health of the patient.

All Petros/Goeschen techniques are performed entirely through the vagina, either under general anaesthesia, spinal anaesthesia or local anaesthesia. The type of anaesthetic used is decided after consultation between the specialists and yourself.

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The advantages of the Petros/Goeschen techniques
 
- High, until now unheard-of healing rates, also helps patients who have already   been operated using different techniques
- Minimal post-operative pain
- Urinary catheter after surgery only for some hours
- Small vaginal incisions and wounds
- Short post-operative stay in hospital (2-7 days)
- Quick return to daily life
- Operation is suitable for women of any age
 
Surgical treatment in the anterior Zone

The Anterior Zone extends between the external urethral meatus and bladder neck. The urethral tube lies entirely within the anterior zone. Inability to close off the tube will result in involuntary urine loss. The aims of anterior zone defect repair are to reinforce the ligament and its supporting structures by implanting a tape without constricting the midpart of urethra. This can be done in three ways:


Fig.4 ‘Tension-free’ midurethral sling to reinforce the anterior ligament. The ends are placed suprapubically through the abdominal wall. There is a little chance to perforate the bladder or great blood vessels

Fig.5 ‘Tension-free’ midurethral sling to reinforce the anterior ligament. The ends are placed laterally through obturator fossa. This reduces the chance to perforate the bladder or great blood vessels







 

Fig.6 ‘Tension-free’ midurethral sling to reinforce the anterior ligament. The ends are placed into the tissue close to the pubic bone. There is nearly no chance to perforate the bladder and great blood vessels





Surgical treatment in the Middle Zone

The middle zone extends between bladder neck and the cervix or hysterectomy scar. The anterior vaginal wall in the middle zone is supported by a thin fascia. The bladder base sits on this membrane. Herniations caused by lax or ruptured connective tissue in this thin membrane lead to a cystocoele (Fig.7)) or laterally to a paravaginal defect (Fig.8)). Many patients were found to have both defects. These defects are not easy to repair using traditional techniques, as up to one third may recur.

Direct repair cannot adequately restore stretched damaged tissue. Thus the vaginal wall needs to be supported by slings or meshes. The “U-sling” (Fig.9),  “transverse sling” (Fig.10) or “mesh support” (Fig.11) operation reinforces both the lateral and midline defects simultaneously using tapes or a meshes.



Fig.7 Midline Defect = Cystocoele                                                    














Fig.8  Lateral Defect










  Fig.9 strong repair with U-sling or         











Fig.10 transverse slings or             











Fig.11 mesh-support











Surgical treatment of Scar tissue in the Middle Zone = Tethered Vagina

The ‘tethered vagina syndrome’ is an entirely iatrogenic condition that is caused by scar-induced tightness in the area of the urethral tube and the bladder neck due to multiple previous vaginal operations. The classical symptom is commencement of uncontrolled urine leakage as soon as the patient’s foot touches the floor, indeed, often commencing as the patient rolls over to get out of bed.

Due to multiple previous vaginal operations the bladder acts like a watering can: In the supine position  urine is stored in the bladder. While standing up the patient presents an uncontrolled bladder emptying immediately on getting out of bed.  

Fig.12 Resting in supine position
The bladder acts like a storage











Fig.13 Standing up causes a massive urine loss.



In these cases it is essential to dissect the vagina from the bladder neck and urethra, and then to free all scar tissue from urethra and bladder neck to restore the elasticity. In order to prevent a recurrence fresh vaginal tissue must be brought to the bladder neck area of vagina.


Fig.14 Restoration of elasticity after removing the scar tissue
and covering the defect with a muscle-skin-flap












Surgical treatment in the posterior Zone

Weakened ligaments in the posterior Zone causes the uterus or after hysterectomy the upper vagina to descend into the vaginal cavity with the result of an uterine/vaginal prolapse. It is clear that as well as a posterior sling, approximation of the sidewall is also needed to support the apical repair as well as lengthen the vagina.

Fig.15  strong posterior repair with sling or                  










Fig.16  mesh








- The importance of preserving the uterus

The uterus is located in the centre of the pelvic floor. It is surrounded by important nerves, blood vessels, connective tissue, and muscles. Within the complex architecture of the pelvic floor the uterus acts like the keystone of an arch, being an important insertion point for posterior ligaments and the downward muscle. Removal of the uterus may cause a point of weakness in the posterior ligaments predisposing to prolapse of the vagina. This, in turn, may cause bladder problems in 18 % of patients who have had a hysterectomy.

Fig.17 a+b The uterus, the central anchoring point of the pelvic floor, acts like the keystone of a roof

For the above reasons we try to conserve a healthy uterus whenever possible. A hysterectomy using the procedure of Petros/Goeschen is rarely necessary. Pregnancy after keyhole approach is still possible. However, we recommend then that delivery should take place by Caesarean section.

Fig.18 Hysterectomy may weaken the fascial side-wall support and the ligaments by removing a major part of its blood supply. Conservation of the uterus is important in the long-term prevention of vaginal prolapse and incontinence

Back to your daily life

Keyhole surgery is designed for patients to return to home, work, and normal activities as soon as possible. On day after discharge from hospital, you can usually drive your car, cook, go shopping and look after your children. However, in some patients, recovery may take longer.


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Questions and Answers

What symptoms can be improved by the Petros/Goeschen techniques?

Urine loss due to stress, feeling of urgency, urinary frequency, having to get up at night to pass urine, inability to empty the bladder properly, deep pelvic pain during sexual intercourse or pain of otherwise unknown origin in the lower spinal column or the sacral bone, faecal incontinence and other bowel problems.


What is the basic difference between the Petros/Goeschen method and other traditional methods?

Traditional methods are based on three different theories: muscular weakness, abnormal function of the bladder and wrong position of the bladder neck.
The Petros/Goeschen method is holistic. Whether surgical or non surgical, the method is based on the same universal principle (the integral theory): to identify damaged vaginal tissue and ligaments of the pelvic floor (front, middle, back). The damaged muscles and the inserting points of the ligaments are strengthened with electrotherapy and pelvic floor exercises or reinforced using the Petros/Goeschen "keyhole" surgery.


What is the difference between the Petros method and traditional testing methods for urinary incontinence?
Traditional testing methods can only diagnose that something is wrong, but they cannot diagnose which part of the vagina is damaged. The Petros procedure uses a whole series of parameters including symptoms, pad test, natural bladder volume and special gynaecological examination to arrive at the conclusion as to which part of vagina may be causing the bladder symptoms.


What is the difference between Petros/Goeschen "keyhole" surgery and traditional incontinence surgery?

Traditional bladder neck elevation operations need large skin incisions of about 10 cm, are painful, require catheterisation, and require up to two weeks post-operative recovery in hospital. They claim to cure only stress incontinence. The patient cannot return to normal life for at least six weeks after the operation.
 
“Keyhole" surgery requires only 2 to 7 days of in-patient stay in hospital after the operation. The operation techniques precisely reconstruct ligament weakness in the front, middle, or back parts of the vagina. They cause very little pain, and require catheterisation only for some hours after the operation. Patients return rapidly to normal daily activities, like shopping, house duties, driving a car, etc., after discharge. The "keyhole" surgery of the Petros/Goeschen method, which interprets the pelvic floor as an integral compartment, gives those patients who were operated upon unsuccessfully with TVT a new hope for success.
Many other symptoms such as urgency, having to pass urine frequently, getting up frequently at night to the toilet, inability to empty the bladder properly, pelvic pain of otherwise unknown origin, faecal incontinence and other bowel problems in the pelvic area can be cured.


What are the results of "keyhole" surgery?

Recent results were published several times in the International Journal of Urogynaecology and in other scientific journals (Der Frauenarzt). The results are as detailed below:

Symptoms Reported = Improvement

stress incontinence = 88 %
frequency = 85 %
nocturia = 80 %
urge incontinence = 80 %
emptying symptoms = 50 %

The mean value is 77,8 %


What is the difference between the Petros/Goeschen "keyhole" surgery and traditional prolapse surgery?

Traditional vaginal surgery requires approximately 10 to 14 days of post-operative stay in hospital, urinary catheterisation after the operation and is painful. Keyhole" surgery requires an urinary catheter only for some hours after operation and does not require a painful vaginal tamponade, means only 2 to 7 days of post-operative recovery in hospital and is nearly painless.


What can be done should the operation fail?

Because the vagina is not excised, there is no point of no return. Since the operation is so minimally invasive it can quite easily be repeated. Most post-operative failures occur within a few weeks after surgery.


Does it mean that my operation has failed if symptoms return?