The pelvic floor is a complex anatomical and functional system involving the muscles, fascia, ligaments and organs of the pelvis. Changes in this system can present with very different symptoms:
An accurate diagnosis therefore requires distinguishing the anatomical problem from the functional one and assessing the rectum, anal canal, urinary tract and pelvic compartments together.
Anatomy
What is the pelvic floor?
The pelvic floor is the group of muscles, ligaments, fascia and connective structures that closes the pelvis from below and supports the pelvic organs.
In women, it mainly supports:
The pelvic floor also contributes to urinary and faecal continence, defecation, sexual function and the management of intra-abdominal pressure.
The three compartments of the pelvic floor
Clinically, the pelvic floor can be divided into three compartments:
Anterior compartment
- bladder
- anterior vaginal wall
Weakness may cause
Apical or central compartment
- uterus
- cervix
- vaginal vault after hysterectomy
Weakness may cause
Posterior compartment
- posterior vaginal wall
- the rectum
Weakness may cause
The condition
What is pelvic organ prolapse?
Pelvic organ prolapse occurs when the supporting tissues can no longer hold one or more organs in their normal position.
It may involve one or more compartments at the same time and cause descent of the:
It is a benign condition, but when it becomes symptomatic it can significantly impair quality of life, causing heaviness, urinary difficulties, defecation disorders and changes in sexual function.
Three-compartment prolapse
The term three-compartment prolapse is used when the anterior, central and posterior compartments are involved at the same time.
In these cases it is particularly important to avoid an assessment limited to a single organ and to study the overall balance of the pelvic floor.
Why prolapse develops
The most frequently associated factors include:
Symptoms
What symptoms can pelvic organ prolapse cause?
Mild prolapse may be completely asymptomatic.
When it becomes clinically relevant, it may cause:
Sensation of heaviness or bulging
- pelvic or perineal pressure;
- a feeling that something is “coming down”;
- a vaginal bulge;
- worsening after many hours standing or after exertion.
Urinary symptoms
- difficulty emptying the bladder;
- increased urinary frequency;
- urgency;
- urinary incontinence at rest or on exertion;
- recurrent urinary tract infections.
Defecation disorders
- constipation;
- evacuation difficulty;
- need to strain heavily;
- sensation of incomplete evacuation;
- need for manual manoeuvres;
- alternating evacuation difficulty and incontinence.
Posterior compartment
Rectal prolapse and posterior compartment disorders
The posterior compartment deserves specific assessment because different abnormalities can cause very similar symptoms.
Rectal prolapse
In rectal prolapse, the rectal wall progressively descends towards the anal canal and, in complete cases, may protrude externally.
It may be associated with:
Rectal intussusception
Rectal intussusception is an infolding of the rectal wall that may remain internal and therefore not be visible externally.
It can be one of the anatomical causes of obstructed defecation.
Rectocele
A rectocele is a bulging of the anterior rectal wall towards the vagina.
It may cause:
- incomplete evacuation;
- need for vaginal or perineal digitation;
- obstructive constipation;
- pelvic heaviness.
A rectocele may be present without symptoms: treatment therefore depends on the correlation between the anatomical finding and the reported symptoms.
ODS
Obstructed defecation and constipation due to pelvic floor dysfunction
Obstructed defecation syndrome (ODS) is not a single disease but a group of disorders characterised by difficulty expelling stool.
Anatomical and functional problems may coexist, including:
- 01rectocele;
- 02rectal intussusception;
- 03rectal prolapse;
- 04pelvic floor dyssynergia;
- 05altered bowel motility.
Typical symptoms of obstructed defecation
Proctology
Most common proctological problems
Proctology covers many conditions of the anal canal and rectum. Some may coexist with pelvic floor disorders and should therefore be assessed within the same clinical pathway.
01Haemorrhoids and haemorrhoidal prolapse
Haemorrhoids are vascular structures normally present in the anal canal. Haemorrhoidal disease develops when these structures become symptomatic or prolapse.
The most common symptoms are:
- bright red bleeding;
- prolapse during defecation;
- itching;
- discharge;
- a sense of fullness.
Treatment ranges from lifestyle changes and medical therapy to outpatient or surgical procedures, depending on grade and symptoms.
02Anal fissure
An anal fissure is a small tear in the lining of the anal canal.
The characteristic symptom is very severe pain during and after defecation, sometimes associated with minor bleeding.
03Anal abscesses and fistulas
A perianal abscess is an infection causing a collection of pus in the tissues around the anal canal.
An anal fistula, by contrast, is a persistent abnormal tract between the anal canal and the skin that forms to drain the pus.
Diagnosis and treatment depend on the location and complexity of the tract.
Diagnosis
Diagnosis of pelvic floor and proctological disorders
Proctological examination and pelvic floor assessment
During the consultation, the following are assessed:
Defecography MRI
Defecography MRI allows evacuation to be studied dynamically and may show:
- rectocele;
- intussusception;
- rectal prolapse;
- enterocele;
- pelvic floor descent;
- associated abnormalities of the other compartments.
Proctoscopy and colonoscopy
Endoscopic examinations may be indicated in the presence of bleeding, changes in bowel habit or other symptoms requiring assessment of the colorectal lining.
First-line approach
Conservative pelvic floor treatment
Not all patients with prolapse or evacuation disorders need surgery.
Conservative treatment may include:
When surgery is needed
Surgery for pelvic and rectal prolapse
Surgery is considered when the anatomical defect is significant, symptoms affect quality of life and conservative treatment is not sufficient.
Minimally invasive access
Laparoscopic and robotic prolapse surgery
Some procedures can be performed laparoscopically or robotically, allowing work deep in the pelvis through minimally invasive access.
Techniques that may be used in selected cases include:
sacrocolpopexy
lateral suspension
POPS
rectopexy
combined procedures on the pelvic compartments
Selection criteria
The choice depends on the compartment involved, age, symptoms, previous surgery and functional goals.
Transanal surgery
Some rectal conditions can be treated through a transanal approach.
The choice between a transanal and a transabdominal approach depends on the type of prolapse, anorectal function and the patient's general condition.
- 1type of prolapse
- 2anorectal function
- 3general condition
Abdominal-pelvic system
Pelvic floor and abdominal wall
The abdominal wall, diaphragm and pelvic floor work together to manage intra-abdominal pressure.
In the presence of rectus diastasis, hernias or abdominal wall changes, it can be useful to assess the abdominal-pelvic system as a whole, especially when the following coexist:
Book an assessment
Specialist pelvic floor and proctological assessment in Rome
Evacuation disorders, rectal prolapse, haemorrhoids and pelvic floor changes can have different and often coexisting causes.
A specialist consultation identifies the anatomical and functional problem and defines the most appropriate pathway, from conservative therapy to minimally invasive surgery when indicated.
FAQ
Frequently asked questions about pelvic organ prolapse and proctology
What is the pelvic floor?
It is the group of muscles, fascia and ligaments that supports the pelvic organs and contributes to continence, urination and defecation.
Which organs can be involved in prolapse?
The bladder, vaginal walls, uterus or vaginal vault, rectum and, in some cases, the small bowel may be involved.
What is the difference between a rectocele and rectal prolapse?
A rectocele is a bulging of the rectal wall towards the vagina; in rectal prolapse the rectum descends towards the anal canal and may protrude externally.
Can constipation be caused by the pelvic floor?
Yes. Some patients have evacuation difficulty caused by anatomical changes, muscular dyssynergia or both.
Does obstructed defecation always require surgery?
No. Initial treatment is often conservative and rehabilitative; surgery is considered in selected patients with significant anatomical abnormalities and persistent symptoms.
Does pelvic organ prolapse always require surgery?
No. Treatment depends on the severity of symptoms and their impact on quality of life. Some forms can be monitored or treated conservatively.
Can rectal prolapse cause incontinence?
Yes. Rectal prolapse may be associated with reduced continence, mucus discharge and evacuation difficulty.
Which tests may be needed?
Depending on symptoms, defecography MRI, anorectal manometry, endoanal ultrasound, proctoscopy or colonoscopy may be indicated.
Can prolapse be treated with minimally invasive surgery?
In many selected cases, yes. Some suspension procedures can be performed laparoscopically or robotically.
Are haemorrhoids and rectal prolapse the same thing?
No. They can cause similar symptoms, but they are different anatomical conditions and require an accurate diagnosis.