Urogynaecology
Pelvic organ prolapse & Prolapse Management
Pelvic organ prolapse is a common condition that often presents with symptoms of pelvic pressure, discomfort, vaginal bulge or lump. Prolapse can cause bladder symptoms like incomplete emptying, poor urinary stream, frequent urination and recurrent urinary tract infections. It can also cause bowel symptoms like incomplete emptying of bowels, needing to use fingers vaginally or rectally to facilitate evacuation of stools and sometimes soiling of underwear. It can also affect sexual intercourse with a feeling of something in the way, affecting body image and also causing anxiety. Sometimes you may not be aware of the prolapse (asymptomatic) and it can be picked up on a routine clinical examination with a doctor or a nurse.
Prolapse results from weakened or damaged pelvic floor ligaments, muscles, nerves and tissues that are responsible for supporting the pelvic organs (vagina, uterus, bladder, uterus and rectum). Prolapse is not a dangerous or life-threatening condition, but it can be quite uncomfortable and distressing. Treatment is only indicated when the prolapse is symptomatic (i.e. causes problems or is uncomfortable). There are non-surgical and surgical options for treatment of prolapse.
Non-surgical options
Pelvic floor exercises
Strengthening pelvic floor by exercises especially under the supervision of a specialised physiotherapist helps in improving symptoms related to prolapse and prevents it from getting worse. Details on how to do these can be found under stress urinary incontinence.
Pessaries
Pessary is a removable device that is fitted in the vagina to support the prolapse. These devices are made out of plastic or silicone and a variety of shapes and sizes are available. Dr Gopinath would be able to recommend the best type for you. The pessary will be fitted specifically to your body to hold your pelvic organs in position without causing any discomfort.
Surgery
Surgery is an option if physiotherapy or pessaries fail to improve prolapse symptoms. Majority of women will have improvement of their symptoms following an operation.
Many different operations can be performed for prolapse. The type of surgery that is recommended will depend on many factors such as age, the severity of the prolapse, if there has been previous failed prolapse surgery or a previous hysterectomy. Prolapse surgery can be performed along with surgery for urinary incontinence and about 35% of women who have prolapse surgery will also need surgery for urinary incontinence.
Some of the possible surgical procedures used to treat a vaginal prolapse include:
Reconstructive surgery (reconstruction of vagina)
Vaginal repair
This involves removal or uterus and cervix on most occasions. At times, cervix (Subtotal hysterectomy) or uterus (Manchester repair) can be left behind depending on the type of prolapse repair. Uterus is elevated into its position either by tightening its own supports (uterosacral ligaments) or by additional supports using dissolvable stitches (Sacrospinous fixation) or synthetic mesh (Sacrocervicopexy). Overall recovery is around 6-8 weeks especially if additional vaginal repair is undertaken.Hysterectomy (Vaginal, laparoscopic, robotic)
This involves removal or uterus and cervix on most occasions. At times, cervix (Subtotal hysterectomy) or uterus (Manchester repair) can be left behind depending on the type of prolapse repair. Uterus is elevated into its position either by tightening its own supports (uterosacral ligaments) or by additional supports using dissolvable stitches (Sacrospinous fixation) or synthetic mesh (Sacrocervicopexy). Overall recovery is around 6 week especially if additional vaginal repair is undertaken. She also undertakes vNOTES (Vaginal Natural Orifice Transluminal Endoscopic Surgery) procedure where cervix, uterus and/or tubes and ovaries are removed through a cut in the vagina using laparoscopic instruments, thereby avoiding cuts on the tummy. This is allows quicker recovery and less post operative pain. This can be considered as an alternative to total laparoscopic hysterectomy which is often undertaken through the tummy.Post hysterectomy Vaginal vault suspension (Vaginal, laparoscopic, Robotic)
Vaginal vault suspension is otherwise called Sacrospinous fixation and is often undertaken along the same time as a vaginal repair. Laparoscopic or robotic surgery involves suspension using synthetic mesh (sacrocolpopexy) or your own tissue (Fascia lata graft) or sutures (suture colpopexy).Uterine preserving surgery (Vaginal, laparoscopic, Robotic)
Hysteropexy or uterine preserving surgery can be undertaken by any of the above routes. This can also be done using dissolvable, non dissolvable stitches or using synthetic mesh.
Obliterative surgery (closure of vaginal passage)
Colpocleisis.
This is often done in women who are no longer sexually active and have no intentions of being so in the future. This is quite a successful procedure, with quicker recovery time often reserved for women have other medical complications and pose a significant risk for anaesthetic.
Possible surgical complications
There are general risks involved with having any surgery.
Common risks include adverse reactions to the anaesthetic, excessive bleeding, infection and the potential for blood clots.
Antibiotics are given during surgery and continued after your operation to reduce the risk of infection.
Medication (e.g. Fragmin or Clexane) to thin your blood is given during surgery and while you are in hospital to reduce your risk of developing blood clots.
It is very uncommon to experience serious bleeding or need a blood transfusion.
Generally, there is improved sexual function after prolapse surgery, however about 2% of women experience painful intercourse after surgery and this may require minor corrective surgery or the use of vaginal dilators.
Occasionally bladder problems can occur after surgery (e.g. difficulty with bladder emptying, cystitis or urinary leakage) but these problems usually settle soon after surgery. However, if incontinence remains a problem then further surgery or medication may be required.
Pain may occur immediately after surgery, but this generally settles after a few days or weeks. It is rare for women to experience long-term pain following prolapse surgery.
Rare complications from prolapse surgery may include injury to a nearby structure (e.g. bowel, bladder, ureter, nerve). We usually inspect the bladder with a fine telescope (cystoscopy) at the completion of surgery to exclude any bladder or ureter injury.
Rare long-term complications after laparoscopic or robotic prolapse surgery include bowel obstruction from adhesions and abdominal hernia. Further surgery may be necessary if a complication occurs.
Whenever synthetic graft is used during robot-assisted surgery, there is a small risk of a small portion of the synthetic graft becoming exposed in the vagina. This is usually treated either by vaginal oestrogen pessaries or a small vaginal operation to remove the exposed synthetic graft (usually the entire graft will not need to be removed).
Recovery time and post operative care
Most women stay in hospital for one, two or three nights.
It is MOST important to rest after the operation and allow the area to heal.
You will be seen by Dr Gopinath 6 weeks following surgery to check for any problems. You will also have a final check up at 12 months.
Completely restrict your level of physical activity for two weeks.
General recommendations
From two to four weeks do light activity only.
Avoid heavy lifting (nothing heavier than 5 kg) for four weeks, including small children.
Abstain from sexual intercourse for six weeks.
Avoid playing sport and impact exercises such as jogging or jumping for four weeks.
Pain relief
If you experience pain after discharge we suggest that you take pain control medication (e.g. Panadol) every four hours as required until pain resolves.
Make sure you take some time each day to rest.
Maintain good bowel habits
Try do drink approximately 1.5 litres of fluids each day.
Maintain a healthy diet.
Use Movicol or similar preparations (available at the chemist or supermarket) if required to maintain regular bowel function and to keep your bowel motions soft.
Any stitches that you still have in when you go home will dissolve in about 10 days (but possibly up to three weeks). These do not need to be removed.