**7.1 Conservative therapy**

Without wanting to diminish the suffering of patients, pelvic floor disorders are of course not life-threatening conditions. Therefore, conservative therapy measures should first be offered and tried by the patient before surgical therapy. Depending on which symptom is the most prominent, various conservative methods are available. When a patient is suffering from stress urinary incontinence, pelvic floor training can improve functionality. The pelvic floor training should be supervised by a physiotherapist specialized in this field and can be supported by biofeedback or electrostimulation. Patients suffering from an overactive bladder and urge incontinence can benefit from bladder conditioning through behavioral training (toilet training) and anticholinergic therapy [9]. Anticholinergic medication should be tried for at least 3 months and the patient should be informed about possible side effects such as dry mouth or constipation. Other pharmacotherapy options are alpha-adrenoreceptor blockers for bladder voiding dysfunction and beta3-adrenoreceptor agonists like Mirabegron for overavtive bladder syndrome. A micturition diary can help to objectify whether medication is working or not. After menopause, incontinence symptoms can be improved by the use of local vaginal estrogens. All conservative measures should always be accompanied by lifestyle modifications like weight loss, nicotine abstinence and reducing caffeine intake, which can also optimize surgical outcome, if surgical therapy is planned next. Use of different types of pessaries can be useful to treat uterus prolapse and cystoceles, if tolerated by the patient, while treatment of rectoceles with a pessary is more complicated. There are different sizes and types of pessaries available, which can be individually customized. Often, sieve bowl pessaries are more effective in a cystocele and cube pessaries are better in descensus uteri or rectocele. It is necessary to try different pessaries to find which one gives the patient the most relief and holds best under movement without dislocating. The patient should be trained to change the pessary independently to lower the risk for infections and injuries. Especially in younger patients whose family planning has not yet been completed, pessary therapy should be preferred to surgical therapy. This also applies to older, multimorbid patients [8]. Regarding anal incontinence, stool thickening by appropriate nutrition or by medication (e.g. loperamide) can improve quality of life. Defecation disorder can be treated with dietary options or through laxatives. Conservative therapy should always be performed in consultation with the patient and reviewed regularly. If

necessary, a change to surgical therapy may be required if there is insufficient improvement or compliance. Moreover, there may be some patients who are not willing to try conservative therapy and immediately demand a permanent solution, which can only be achieved by surgery [9].

#### **7.2 Surgical therapy**

The therapy should be individually optimized to provide an optimal solution for each individual patient. Generally, the indication for pelvic floor surgery is elective. Therefore, the degree of suffering of the affected person is always decisive for the indication of a surgical intervention. Asymptomatic findings of descensus should not be operated on. If surgery is indicated, the goal is usually reconstruction of the anatomic situation. However, the patient desires a restitution of function and thus an elimination of symptoms. Unfortunately, even a successful anatomical reconstruction cannot always guarantee a cure of the symptoms. It is imperative to inform the patients about this. In particular, the occurrence of de novo incontinence should be mentioned. Positional changes can often be corrected effectively, in contrast to muscle or nerve damage. However, since the often weak connective tissue remains unchanged, there is a considerable risk of recurrence. This should also be discussed with the patient. In addition, it should be clarified with the patient what degree of stability she expects and needs from the operation [9].

The spectrum of surgical possibilities has expanded considerably in the last three decades. Previously, for over 100 years, vaginal hysterectomy with anterior and posterior colporrhaphy was the standard gynecologic procedure for any form of cystocele, uterine descensus, or rectocele. This usually can correct descensus satisfactorily. However, the recurrence rate is relatively high and amounts to 37% after 12 months for anterior colporrhaphy according to the current guideline for genital descensus [11]. Therefore, analogous to hernia surgery, attempts have been made to improve long-term stability by implanting alloplastic meshes and ligaments. The anatomical recurrence rate was significantly lower after implantation of alloplastic material (7%) [12]. In the subjective assessment, the difference is smaller. Due to a frequent lack of experience in surgeons and a generous use of the initially too small-pored and too heavy-weighted meshes, there have been considerable adverse events and complications, so that now, especially in Anglo-Saxon countries, alloplastic meshes and tapes are banned or can only be used under strict regulations [13]. The German Working Group for Urogynecology and Pelvic Floor Surgery (AGUB) has a more differentiated view and considers the use of these materials with an appropriate indication in the case of recurrent prolapse, very weak connective tissue or severe descensus with a high risk of recurrence in the hands of a urogynecologically specialized surgeon as justified and often necessary [9]. The complication rate could be significantly reduced with the further development of materials and the optimization of the surgical technique. In addition to the vaginal approach, the abdominal/laparoscopic approach has also gained importance in recent years. Today, hysterectomy is mostly only part of a descensus operation if there is a corresponding additional indication.

#### **7.3 Surgical therapy: rectocele**

Only after exhausting the conservative methods should surgical therapy of a rectocele be considered. In gynecology, a rectocele is usually treated with a posterior vaginoplasty. On closer inspection, this is not a consistent surgical procedure. Under this term, the posterior colporrhaphia, the pelviperineoplasty, a fasciaspecific repair or a median fascia lift are summarized- in each case with or without *Pelvic Floor Disorders in Females: An Overview on Diagnostics and Therapy DOI: http://dx.doi.org/10.5772/intechopen.101260*

levatorplasty or bulbospongiosus lift, which differ considerably in the structures that are "lifted". For stabilization, an alloplastic mesh can also be implanted. However, the results between simple posterior plastic and mesh-supported posterior plastic differ less than with the anterior plastic. Biological patches can be also used, but showed worse results [11].

A transanal or transperineal operation, a Stapled Trans Anal Rectal Resection (STARR) or a laparoscopic or open resection rectopexy are the portfolio of a coloproctological surgeon. Studies that would provide valid data comparing the different gynecological and surgical techniques are still not available. In surgical studies, the change in the stool diary is usually used as a success parameter. The gynecological studies mostly assess the anatomical success of the posterior vaginal wall without recording the improvement in quality of life.

In the current German gynecological guideline on descensor surgery, after extensive literature research on rectocele correction, the following results were found [7]:

Success rates (follow-up time > 12 months):


Alloplastic materials are definitely indicated for recurrent rectoceles, pronounced findings, high risk of recurrence and accompanying enteroceles that are otherwise often difficult to correct. Since there is little self-tissue in the upper posterior part of the vagina to stabilize a rectocele, it can sometimes be difficult to correct the rectocele without using an alloplastic mesh and without causing dyspareunia through conventional colporrhaphy. Reconstruction of the rectovaginal septum alone to reduce the posterior vaginal wall without reducing the circumference of the rectum, which is usually too large, increases the risk of intussusception. If intussusception or rectal prolapse is more pronounced preoperatively, an interdisciplinary gynecological and coloproctological investigation should be carried out. Coloproctological surgery procedures are often more suitable here. Less pronounced intussusceptions can be treated via transanal access. If there is a posterior wall prolapse combined with a rectocele and intussusception or anal prolapse, a two-stage surgical concept can be useful [8].

First, a gynecological reconstruction is carried out and then, if the result is functionally unsatisfactory, a secondary coloproctological operation can be carried out- or vice versa. Ultimately, when planning therapy, focus should be on restoring quality of life by reducing symptoms.

#### **7.4 Surgical therapy: enterocele**

An enterocele is a challenge for surgical therapy. Since an enterocele rarely occurs isolated, correction is carried out in combination with interventions to repair a cystocele, rectocele or descent of the vaginal stump or uterus. In case of vaginal access, an opening and resection of the enterocele hernial sac with a subsequent "high peritonealization" is carried out. An alloplastic mesh can be used to stabilize the upper part of the posterior vagina, as there is usually little autologous tissue available here [8].
