Gynaecology - Uterovaginal Prolapse and Pelvic Floor Repair

What is a prolapse?

The walls of the vagina are quite stretchy to allow intercourse and childbirth. If their support is weakened, a prolapse may develop.

There are different kinds of prolapse, the belief that all prolapses relate to the uterus (womb) is incorrect. Sometimes, it is just the front or back wall of the vagina which is weakened:
●    If the wall between the vagina and bladder becomes weak, it is called a cystocele
●    If the wall between the rectum (bowel) and vagina becomes weak, it is called a rectocele
●    If the wall between the abdomen and vagina becomes weak, it is called an enterocele
●    If the main ligaments holding the uterus and the top of the vagina in place become weak, it is called a uterine prolapse and the womb comes down
●    Prolapse of the womb can sometimes occur without any obvious prolapse of the vaginal walls

The uterine prolapse is graded according to its severity:

●    Grade 1 is when the prolapse comes down a bit but does not reach outside the vagina
●    Grade 2 is when the prolapse comes out but may go back in when lying down
●    Grade 3 is when the whole of the womb comes out of the vagina. If you have had a hysterectomy, the vault (top) of the vagina can prolapse - vaginal vault prolapse

What are the symptoms associated with prolapse?

Usually there is a feeling of “something coming down” or vaginal discomfort. Some women are aware of a “dragging ache” in the pelvis. The degree of prolapse does not necessarily match the severity of the symptoms that you may experience. Sometimes, there is a marked prolapse but you have no symptoms. Other women report quite severe symptoms although there may be only minimal prolapse. Most backaches are due to problems in the back, although, on occasion, repair of a prolapse may provide some relief. If there is a cystocoele there may be urinary symptoms, a rectocele may be associated with problems in opening the bowels.

Why does a prolapse occur?

Prolapse is usually seen in women who have had children delivered vaginally, partularly after forceps delivery. It is less common to see a prolapse in women who have never had children. Vaginal delivery of a large baby is particularly likely to weaken the vaginal supports, and there is a greater likelihood of prolapse if you have a large family. After the menopause, the reduced levels of oestrogen may further weaken the vaginal support. Overweight women are stretching the vaginal support (pelvic floor) as well as their backs and joints. Patients with a chronic cough (e.g. smokers), or chronic constipation may similarly weaken their pelvic floor.

How can prolapse be treated?

The treatment of choice is dependent on the type of prolapse, your general well-being and ultimately an informed choice made with the gynaecologist. In some circumstances other illnesses may prevent surgery, or if it is your preference, an internal support pessary, usually a ring, may be fitted by your gynaecologist.  These pessaries should be replaced every three to six months.

Types of pelvic floor repair operations

This depends on what part of the vaginal wall has prolapsed and the degree of uterine descent (how far the womb comes down).

Anterior and posterior repair

The operation can be performed under general (asleep) or regional (awake) anaesthetic and takes about 1 hour. The vaginal wall is opened and the bladder or bowel is moved out of the way. Stitches are placed on either side and brought together to strengthen the wall. During the operation, a catheter will be passed into the bladder to drain off the urine so that the bladder doesn’t get in the way of the operation. If there is a combination of uterine (womb) and vaginal prolapse, you may be advised to have a vaginal hysterectomy at the same time.

Risks

Anaesthetic

The risks of anaesthesia for elective surgery under modern conditions are very small. You will be carefully monitored throughout the operation by a trained anaesthetist (usually a consultant). However, there are risks with all anaesthetics and if you wish to discuss them please feel free to do so when you meet your anaesthetist before the operation.

As with all surgery there are risks, and the benefits of having the operation must always be balanced against the potential harm. The vast majority of women who undergo surgery will have very few problems and their quality of life will greatly improve, however there are risks including:

●    An allergic reaction to the drugs or anaesthetic
●    A small but significant risk of damage to the bowel, bladder or ureters (small tubes carrying urine from the kidneys to the bladder). If the damage is repaired at the time of surgery there should be no long-term problems
●    Heavy bleeding (haemorrhage)
●    Bladder, wound or chest infections (especially if you are a smoker) antibiotics are often given during or after surgery to reduce the risk
●    Blood clot in the leg, pelvic veins or lung. Blood thinning injections are usually given to reduce this risk after surgery
●    very rarely it may be necessary to perform additional abdominal surgery to deal with these complications

What happens before the operation?

To check your general health, and ensure you are medically fit for surgery e.g. blood samples and where necessary tests may be performed, chest x-ray and ECG.

You will be asked to attend the pre-operative clinic. You will be asked to consent to the surgery in writing. Before signing the consent form, it is important that you fully understand why you need the operation, the benefits, and the complications that could occur. Stopping smoking, healthy eating and regular exercise can help avoid the risk of complications.

What happens on admission to the ward?

The nursing staff will show you around the ward and discuss the plan of care with you. You will need to starve for at least 6 hours before the operation. You will need to remove all nail varnish, jewellery and body piercings. Please inform the nursing staff of any jewellery or piercing you are unable to remove. Clipping (not shaving) your pubic hair before admission may help the surgeon.

The anaesthetist will discuss the anaesthetic and type of pain relief with you.

To reduce the risk of blood clots forming, you will be given special stockings to wear before and after your operation.

If you anticipate any problems at home or need advice regarding services available to you, ask to speak to the hospital social worker or Citizen’s Advice Bureau, they may be able to help.

What are the visiting times?

The nursing staff will inform you of the visiting times, but in order for you to rest, we would advise that you restrict your visitors for the first two days after your operation.

What can I expect after the operation?

You will wake feeling drowsy, due to the anaesthetic and pain relief given in theatre. You may have a drip in your arm to replace fluids and a catheter (tube to drain urine from your bladder). You may be given oxygen for 24-48 hours.

You may have a gauze ‘bandage’ in your vagina for up to 24 hours.

The nurses will regularly check your breathing, blood pressure and pulse, and will ensure that you are given the prescribed pain relief.

You may be given a patient controlled analgesic (PCA) pump.

From the day after your operation it is important to get moving. You will be encouraged and helped to sit out of bed. Gas in the bowel and stomach can cause wind pains, the nurses can give you medication to help relieve this. Drinking diluted peppermint cordial can sometimes help.

The physiotherapist will provide advice (usually written) on exercises to reduce the risk of chest infections, blood clots and to support the pelvic floor. It can take a few days before your bowels start to work normally and if necessary you will be given a mild laxative. It is normal to have some vaginal bleeding and discharge. The doctor will see you, explain your operation, advise you when to start eating and drinking and answer any questions.

When can I go home?

You will be in hospital for three to five days after surgery depending on the type of operation, your recovery, and if you can empty your bladder properly. You may have stitches that dissolve after the operation, this may take some weeks. If they are very uncomfortable then please inform the nursing staff. Before going home you must be seen as medically fit for discharge by the doctor.

Sick/Fit note

If you are advised to return to work in 7 days, then you can cover your sickness absence with a self-certification form, available from the General Office on all hospital sites. The ward will issue you with a medical certificate to cover your anticipated sickness or until your follow-up appointment (where relevant). Please ask a member of staff for this certificate before you are discharged home.

Follow-up

Follow-up is not always necessary. You will be advised if you need a follow-up appointment before you are discharged.

Advice following discharge

Rest and Exercise
●    During the first six weeks it is important to have a period of convalescence
●    For the first two weeks at home, you need to relax and make sure you rest when feeling tired
●    Continue to do the exercises you were taught in hospital
●    Every woman is different in her speed of recovery. If an activity makes you feel tired, you may be overdoing things
●    Exercise is as important as rest. Go for a short walk each day, gradually going further
●    Avoid prolonged standing. You can walk up and down stairs
●    Swimming is beneficial after three or four weeks, if your vaginal discharge has stopped

Housework

You are able to do light household jobs such as dusting, washing up, and making a meal as soon as you feel fit to do so. After six weeks gradually do more household jobs such as vacuuming, ironing etc. until you are more or less back to normal. Avoid all heavy lifting, moving furniture etc. until twelve weeks after surgery.

Driving

You must not drive until you are confident that you can do an emergency stop, and feel comfortable wearing a seat belt.
Check with your insurance company as they may have special rules on this.

Back to work

Your own doctor will advise you when to return to work. It may be anytime between six and twelve weeks after your operation depending on the type of work you do, travel time, the hours you work and your personal recovery.

Hygiene

Try to have a daily bath or shower. The area around your wound mostly inside the vagina should be kept clean to promote healing.

Vaginal bleeding or discharge

This should be no more than it usually is at the end of a period and last for three to four weeks. Use sanitary towels, not tampons, to reduce the risk of infection. If your discharge becomes heavy, or smells offensive, consult your doctor for advice, as it may be a sign of infection.

Intercourse

Most women find it reassuring to know that their own sexual response should be little changed by the operation. It is usual to resume intercourse after six weeks, if you feel comfortable and your vaginal discharge has stopped.

Smear tests

If your cervix has not been removed you will need to continue with regular smear tests if you were having them before.

In most cases where the cervix has been removed, smear tests are not required, but for women who have had a hysterectomy due to abnormal smears or cancer, the consultant may wish to continue to take smears from the vault (top) of the vagina (the area the cervix was removed from).

If you have any other questions or worries when you return home, do not hesitate to contact the ward sister or member of staff at any time of day or night.
 

Contact numbers

Ward F5, Royal Oldham Hospital - 0161 656 1431/1432