Gynaecology - Anterior vaginal wall prolapse/repair

What is an anterior vaginal wall prolapse?

●    Anterior means towards the front, so an anterior vaginal wall prolapse is a prolapse of the front wall of the vagina
●    The other name for an anterior vaginal wall prolapse is a cystocele. The structure bulging into the vagina is the bladder (see Fig 1)
●    The pelvic floor muscles form a sling or hammock across the opening of the pelvis. These muscles, together with their surrounding tissue are responsible for keeping all of the pelvic organs (bladder, uterus, and rectum) in place and functioning correctly
●    Prolapse occurs when the pelvic floor muscles, their attachments or the vagina have become weak. This usually occurs because of damage at the time of childbirth but is most noticeable after the menopause when the quality of supporting tissue deteriorates. It is also related to chronic strain caused by heavy lifting and constipation
●    When the anterior vaginal wall is weak, the bladder pushes down into the vagina causing a bulge. This sometimes can be large and push out of the vagina, especially on straining e.g exercise or passing a motion (Figure 1)
●    A large cystocele can often cause or be associated with urinary symptoms such as urinary leakage, urinary urgency (strong and sudden desire to pass urine), having to go frequently, difficulty passing urine or a sensation of incomplete emptying
●    Some women have to push the bulge back into the vagina or lean forward in order to completely empty the bladder. Incomplete bladder emptying may make you prone to bladder infections (urinary tract infection)
●    Some women find that the bulge causes a dragging or aching sensation, or is uncomfortable when having sexual intercourse

Figure 1
Diagram (sideward view) showing bladder bulging through the anterior (front) vaginal wall (in standing woman)

Alternatives to surgery

●    Do nothing – if the prolapse (bulge) is not distressing, then treatment is not necessarily needed. If, however, the prolapse permanently protrudes through the opening to the vagina and is exposed to the air, it may become dried out and eventually ulcerate. Even if it is not causing symptoms in this situation, it is probably best to push it back with a ring pessary (see below) or have an operation to repair it

●    Pelvic floor exercises (PFE). The pelvic floor muscle runs from the coccyx at the back to the pubic bone at the front and off to the sides. This muscle supports your pelvic organs (uterus, vagina, bladder and rectum). Any muscle in the body needs exercise to keep it strong so that it functions properly. This is more important if that muscle has been damaged. PFE can strengthen the pelvic floor and therefore give more support to the pelvic organs. These exercises may not get rid of the prolapse but they make you more comfortable. PFE are best taught by an expert, who is usually a continence nurse advisor or women’s health physiotherapist. These exercises have no risk and even if surgery is required at a later date, they will help your overall chance of being more comfortable.

Types of pessary

●    Ring pessary - this is a soft plastic ring or device which is inserted into the vagina and pushes the prolapse back up. This usually gets rid of the dragging sensation and can improve urinary and bowel symptoms. It needs to be changed every 6-9 months, or earlier if there is any bleeding or discharge, and can be very popular; we can show you an example in clinic. Other pessaries may be used if the ring pessary is not suitable. Some couples feel that the pessary gets in the way during sexual intercourse, but many couples are not bothered by it
●    Shelf pessary or Gellhorn - If you are not sexually active this is a stronger pessary which can be inserted into the vagina and again needs changing every 4-6 months

General Risks of Surgery

●    Anaesthetic risk. This is very small unless you have specific medical problems. This will be discussed with you
●    Haemorrhage. There is a risk of bleeding with any operation. The risk from blood loss is reduced by knowing your blood group beforehand and then having blood available to give you if needed. It is rare that we have to transfuse patients after their operation
●    Infection. There is a risk of infection at any of the wound sites. A significant infection is rare. The risk of infection is reduced by our policy of routinely giving antibiotics with major surgery
●    Deep Vein Thrombosis (DVT). This is a clot in the deep veins of the leg. The overall risk is at most 4-5% although the majority of these are without symptoms. Occasionally, this clot can migrate to the lungs which can be very serious and in rare circumstances it can be fatal (less than 1% of those who get a clot). DVT can occur more often with major operations around the pelvis and the risk increases with obesity, gross varicose veins, infection, immobility and other medical problems. The risk is significantly reduced by using special stockings and injections to thin the blood (heparin)

Specific risks of this surgery

●    Damage to local organs - this can include bladder, ureters (pipes from kidneys to the bladder) and blood vessels. This is a rare complication but requires that the damaged organ is repaired and this can result in a delay in recovery. It is sometimes not detected at the time of surgery and therefore may require a return to theatre. If the bladder is inadvertently opened during surgery, it will need catheter drainage for 7-14 days following surgery
●    Prolapse recurrence - if you have one prolapse, the risk of having another prolapse sometime during your life is 30%. This is because the vaginal tissue is weak. The operation may not work and it may fail to alleviate your symptoms
●    Pain: General pelvic discomfort, this usually settles with time, and tenderness on intercourse due to vaginal tethering or mesh erosion. Occasionally pain on intercourse can be permanent
●    Overactive bladder symptoms (urinary urgency and frequency) usually get better after the operation, but occasionally can start or worsen after the operation. If you experience this, please make us aware so that we can treat you for it. Stress incontinence may develop in up to 5% of women
●    Reduced sensation during intercourse: Sometimes the sensation during intercourse may be less and occasionally the orgasm may be less intense

The operation for anterior vaginal wall prolapse (anterior colporrhaphy)

●    This operation has been performed for a long time
●    There is a high recurrence rate (symptoms returning) but the operation can be repeated
●    As this prolapse involves the bladder, a test of bladder function (urodynamics) is sometimes required prior to the operation, especially if the prolapse is large or if you already have urinary symptoms (frequency, urgency or incontinence)
●    The benefits are that you are likely to feel more comfortable, intercourse may be more satisfactory and you may empty your bladder more effectively

After the operation - in hospital

●    On return from the operating theatre you will have a fine tube (drip) in one of your arm veins with fluid running through to stop you getting dehydrated
●    You may have a bandage in the vagina, called a ‘pack’ and a sanitary pad in place. This is to apply pressure to the wound to stop it oozing
●    You may have a tube (catheter) draining the bladder overnight. The catheter may give you the sensation of needing to pass urine but this is not the case
●    Usually the drip, pack and catheter come out the morning after surgery or sometimes later the same day. This is not generally painful
●    The day after the operation you will be encouraged to get out of bed and take short walks around the ward. This improves general wellbeing and reduces the risk of clots in the legs
●    It is important that the amount of urine is measured the first couple of times you pass urine after the removal of the catheter. An ultrasound scan for your bladder may be done on the ward to make sure that you are emptying your bladder properly. If you are leaving a significant amount of urine in your bladder, you may have to have the catheter re-inserted into your bladder for a couple of days more
●    You may be given injections to keep your blood thin and reduce the risk of blood clots (normally once a day) until you go home or longer in some cases
●    The wound is not normally very painful but sometimes you may require tablets or injections for pain relief
●    There will be slight vaginal bleeding like the end of a period after the operation. This may last for a few weeks
●    The nurses will advise you about sick notes, certificates etc. You are usually in hospital for 1 to 4 days

After the operation - at home

●    Mobilisation is very important; using your leg muscles will reduce the risk of clots in the back of the legs (DVT), which can be very dangerous
●    You are likely to feel tired and may need to rest in the daytime from time to time for a month or more, this will gradually improve
●    It is important to avoid stretching the repair particularly in the first weeks after surgery. Therefore, avoid constipation and heavy lifting. The deep stitches dissolve during the first three months and the body will gradually lay down strong scar tissue over a few months

Avoiding constipation

●    Drink plenty of water/juice
●    Eat fruit and green vegetables, especially broccoli
●    Eat Plenty of roughage e.g bran/oats
●    Do not use tampons for 6 weeks
●    There are stitches in the skin wound in the vagina. Any stitches under the skin will dissolve by themselves. The surface knots of the stitches may appear on your underwear or pads after about two weeks, this is quite normal. There may be little bleeding again after about two weeks when the surface knots fall off, this is nothing to worry about
●    At six weeks gradually build up your level of activity
●    After 3 months, you should be able to return completely to your usual level of activity
●    You should be able to return to a light job after about six weeks. Leave a very heavy or busy job until 12 weeks
●    You can drive as soon as you can make an emergency stop without discomfort, generally after three weeks, but you must check this with your insurance company, as some of them insist that you should wait for six weeks
●    You can start sexual relations whenever you feel comfortable enough after six weeks, so long as you have no blood loss. You will need to be gentle and may wish to use lubrication (such as KY jelly) as some of the internal knots could cause your partner discomfort. You may, otherwise, wish to defer sexual intercourse until all the stitches have dissolved, typically 3 months
●    Follow up after the operation is usually six weeks to six months. This maybe at the hospital (doctor or nurse), with your GP or by telephone. Sometimes follow up is not required

Contact numbers if you have any problems or questions

Please contact your consultant's secretary or in case of an emergency please contact Ward F5, The Royal Oldham Hospital on 0161 656 1431/1432.

Useful references

Where can I obtain more information?
Bladder and Bowel Foundation SATRA Innovation Park Rockingham Road
Kettering, Northants, NN16 9JH
Nurse Helpline for medical advice: 0845 345 0165
Counsellor Helpline: 0870 770 3246
General enquiries: 01536 533255
Fax: 01536 533240
mailto:info@bladderandbowelfoundation.org http://www.bladderandbowelfoundation.org
Also: http://www.nice.org.uk/nicemedia/pdf/IPG267PublicInfo.doc , http://www.easyhealth.org.uk/

British Society of Urogynaecology
27 Sussex Place, Regent’s Park, London, NW1 4RG Telephone: +44 (0) 20 7772 6211
Facsimile: +44 (0) 20 7772 6410 Email: bsug@rcog.org.uk Website: www.bsug.org.uk