Kernaussagen
Unter den häufigsten gutartigen Erkrankungen der Frau findet sich der Deszensus genitalis. Aufgrund der demografischen Entwicklung und durch eine gewisse „Enttabuisierung” steigt die Anzahl der Patientinnen an, die sich einer Deszensusoperation unterziehen. Zu den Risikofaktoren für Genitalsenkungen zählen vaginale Geburten, insbesondere aus hinterer Scheitelbeinstellung, vaginal-operative Entbindungen, chronisch erhöhter intraabdomineller Druck, Alter, ein erhöhter Body-Mass-Index und vorausgegangene Operationen im kleinen Becken. Therapeutisch steht eine Vielfalt von Verfahren zur Verfügung, beginnend bei konservativen Ansätzen und klassischen Operationstechniken bis hin zu transvaginal eingebrachten Kunststoffnetzen. Letztere sind jedoch aufgrund von Komplikationen bei schlecht vergleichbaren Literaturdaten und unzureichender medizinischer Evidenz nicht unumstrittenen.
Grundlage für Diagnostik und Therapie des Genitalvorfalls ist die genaue anatomische Kenntnis der einzelnen Beckenbodenstrukturen. Die Ausrichtung der Therapie orientiert sich am Leidensdruck der Patientin im Hinblick auf Miktion, Defäkation und Sexualität. Dabei ist die Symptomatik stark abhängig von der Art und Ausprägung des Deszensus oder Prolaps. Die Ausprägung der Symptome korreliert dabei jedoch nicht zwingend mit dem Grad des Vorfalls.
Konservative Therapieverfahren umfassen eine Gewichtsreduktion, Kräftigung der Beckenbodenmuskulatur und die Anwendung von Hilfsmitteln wie Würfel, Ringe oder Pessare mit entsprechender lokaler Östrogenisierung.
Zu den klassischen operativen Verfahren zur Behebung eines Deszensus gehören die vordere und hintere Kolporrhaphie zur Korrektur eines endopelvinen Fasziendefekts sowie Fixationsverfahren des Scheidenabschlusses, der Gebärmutter oder des Muttermundes an die Bindegewebestrukturen des kleinen Beckens.
Weil die Reparatur defekter, überdehnter Faszien und ausgerissener Haltestrukturen durch Raffung und Duplikatur relativ hohe Rezidivsenkungsraten aufweisen kann, wurden Techniken entwickelt mit künstlichen Gewebeersatznetzen bzw. solchen aus biologischem Material – allerdings mit strenger Indikationsstellung v. a. bei der jüngeren Patientin, und mit noch kontrovers diskutierten Komplikationsraten.
Die Bildung sog. interdisziplinärer Beckenboden- Zentren soll bei Diagnostik und Therapie die beste Behandlungsqualität sichern. Hier steht zugunsten einer optimalen Patientenversorgung die interdisziplinäre Zusammenarbeit über der Arbeit innerhalb althergebrachter Grenzen einzelner Fachrichtungen.
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Dr. med. J. Lermann
Frauenklinik Universitätsklinikum Erlangen
Universitätsstraße 21–23
91054 Erlangen
eMail: Johannes.Lermann@uk-erlangen.de
