Prolapse and Urinary Incontinence Surgery Information Sheet

Your doctor has recommended a vaginal reconstructive procedure to treat your condition. The operation involves surgery to reattach the vagina to its original supports. In some instances your doctor may suggest removal of the uterus as part of your operation to correct prolapse. However it may be possible to preserve the uterus during vaginal reconstructive surgery and your doctor will discuss this option with you.

Definition of Prolapse and Urinary Incontinence

These two conditions often co-exist and may need to be treated together.

Prolapse: This term refers to weakness in vaginal supports that results in a protrusion of the vaginal wall(s). This is more likely to occur during activities which increase the pressure inside the abdomen and pelvic floor such as heavy lifting or straining, coughing or sitting on the toilet to pass a bowel action. This may result in a noticeable bulge, lump or dragging sensation in the vagina. The lump may be due to a weakness in the front, back or top of the vagina or a combination of all three.

The bladder sits in front of the vagina and the bowel (rectum) sits behind the vagina. The cervix and attached uterus lie at the top of the vagina and above this are small bowel loops in the pelvis. A lump that comes out of the vagina can contain one or more of these organs. This is why some people have trouble emptying their bladder or "holding on" (frequency and urgency) or opening their bowels.

When the upper most supports of the vagina give way, the vagina can turn inside out like a sock. In severe cases this can produce a mass protruding outside the vagina. This mass may contain the uterus (unless it has been previously removed), bladder and/or bowel.

Occasionally prolapse can distort the anatomy causing obstruction to the urinary tract masking incontinence (see below). Surgery to repair prolapse may reverse this obstruction causing incontinence post operatively.

Urinary incontinence: Can be defined as the involuntary loss of urine. There are three main types:

• Stress incontinence - urine is lost during activities (stress) that increase the pressure within your abdomen. Examples are coughing, sneezing, lifting or exercise. Pelvic floor exercises along with a reduction of caffeine intake can significantly improve symptoms. When these measures do not work surgery can be performed.
• Urge incontinence - there is usually an uncontrollable urge to go to the toilet (urgency or detrusor instability) that is often followed by the leakage of urine before the toilet is reached. Medications are used to treat this type of incontinence.
• Mixed incontinence - a combination of urge and stress incontinence.

Both prolapse and urinary incontinence are more common in women who have had children. It is thought that changes due to childbirth worsen with age, leading to the gradual onset of prolapse. Some women seem particularly prone to developing prolapse.

There are many surgical procedures that can correct your problem. Your surgeon will discuss what they feel is best for you. For your information some of the options are listed below.

VAGINAL SURGERY

An incision is made in the vagina to gain entry to the deep supportive muscle, fascia and ligaments (tissues). Stitches, artificial mesh or tapes are then used to correct the vaginal supports and /or stress urinary incontinence.

Types of procedures:

• Anterior and Posterior Repair - Incisions are made inside the vagina over the area that is lacking in support. A layer of stitches is used to support the underlying structures. Excess (over stretched) vaginal skin may be trimmed and then the vagina is closed with dissolving stitches.
• Sub-urethal Sling for urinary incontinence - This relatively new operation is for treatment of stress urinary incontinence. Small incisions are made in the vagina and in the lower abdomen or inner thighs. A synthetic strap like tape is passed through the vagina and out through 2 very small incisions. The tape is then positioned without tension to support the bladder neck at times of straining (raised pressure inside the abdomen & pelvis) and thus correct the stress incontinence. Data from a number of studies demonstrate that this minimally invasive method is equivalent to the more traditional Burch colposuspension operation at 5-7 years with a success rate of 80-90%.
• Sacrospinous Fixation - This operation is performed to elevate and support the top part of the vagina. An incision is made in the vaginal wall and extended to the top of the vagina. Usually 2 permanent stitches are placed into a tough fibrous structure known as the sacrospinous ligament. The stitches are then secured to the top of the vagina just beneath the skin. Sometimes the procedure is done on both sides (bilateral sacrospinous fixation) and more recently may be combined with an artificial support known as vaginal mesh.
• Vaginal Mesh - Sometimes the overstretched vaginal wall tissues forming the prolapse (bulge) may not be suitable for a standard repair particularly when a prior vaginal repair has failed. Unfortunately even after the most careful repairs a recurrent prolapse may occur in 20-30% of women. This is more likely if the woman continues to experience high pressures in her abdomen (eg: constipation, heavy lifting or straining, smoker's cough, or significantly overweight). In such cases your doctor may recommend the use of a permanent vaginal mesh to provide a new supporting layer beneath the bladder or above the rectum. Various products are available including synthetic mesh or biological mesh obtained from the small bowel wall of pigs- "porcine mesh". These products are relatively new to gynaecological surgery but so far appear quite promising with approximately 90% success rates.

ABDOMINAL SURGERY

The operation is performed through a 15-20cm incision in the abdomen. The incision is usually horizontal and quite low (Bikini line).

Examples of this include

• Burch Colposuspension - This is the traditional approach to treatment of urinary incontinence and until recently was regarded as the gold standard against which new procedures such as the sub-urethral sling are compared. Through a cut in your abdomen (laparotomy) permanent stitches are placed in the vagina either side of the bladder and urethra (tube which carries urine from the bladder to the out side). These stitches support the urethra where it joins the bladder ("bladder neck") to treat stress urinary leakage.
• Abdominal Sacro Colpopexy - In this procedure a non-dissolvable mesh is sewn from the top of the vagina to the sacral bone inside the pelvis. This elevates the vagina and corrects the prolapse. Today this procedure is reserved for more difficult cases or where other types of surgery have already failed.
• Abdominal Pelvic Floor Repair - These operations are similar to the laparoscopic procedures described below. These procedures are gradually being replaced by "key hole" surgery techniques.

LAPAROSCOPIC SURGERY

The operation is performed through 4-5 small incisions in the abdomen. "Keyhole surgery" is used to identify and repair the defects causing prolapse or incontinence.

Examples of this include

• Laparoscopic Burch Colposuspension - This is identical to the Burch Colposuspension described above. The only difference being that instead of one large incision in the abdomen 4 small incisions are used. Studies have now shown that this method has equivalent longterm success rates (70-90%) to the more traditional open surgical approach.
• Laparoscopic Pelvic Floor repair: - From within the abdomen and without cutting the vagina, permanent stitches are placed between the vagina and the supportive structures adjacent to it.

  This operation takes longer and has a slightly higher rate of complications than a vaginal repair. The main advantage over vaginal procedures is that laparoscopic or abdominal pelvic floor surgery can repair prolapse without vaginal scaring or narrowing.

  This surgery may be more appropriate for younger patients or patients who have a recurrence of prolapse after previous surgery. Recently some gynaecologists have learnt to perform the mesh sacro colpopexy, described above, with keyhole instruments (laparoscopic surgery) thus reducing postoperative pain and providing a quicker recovery.

Please Note:

• Pelvic floor exercises, weight reduction and a decrease in caffeine, alcohol, or nicotine intake will all reduce the incidence of urinary incontinence.
• These conservative measures alone may be enough to treat urinary incontinence or prolapse symptoms.
• Pelvic floor exercises should be taught and supervised by a physiotherapist who specialises in pelvic floor defects. Ideally these should be initiated prior to having surgery to maximise your pelvic floor function and reduce the potential for recurrent prolapse.
• Please speak to our reception staff for contact details or a referral.

Success Rates of Pelvic Floor Surgery

Surgery for Stress Urinary Incontinence - Around 80-90% of women will be cured by their operation. Unfortunately as time goes by a number of women will get a return of their urinary leakage. This is most noticeable 5 to 10 years after surgery.

Success Rate for Prolapse Surgery - Success rates for prolapse surgery are less well studied. It is generally believed that up to 20-30% of women will require a second operation to treat prolapse in the future. This may be due to the recurrence of an old prolapse or development of a new type of prolapse.

Complications after Surgery for Prolapse or Incontinence

These risks of surgery can be divided into general risks associated with any operation and risks specific to the surgery you are having.

General risks of surgery

These include:

• wound, chest or urinary tract infection, (2-11% risk)
• major haemorrhage requiring blood transfusion, (1-4% risk)
• blood clots in the legs or lungs (<1% risk)
• risks of the anaesthetic including heart attacks or strokes. (<1% risk)
• abnormal scar tissue formation (keloid)

Risks specific to prolapse or incontinence surgery

These include risk of injury to adjacent organs including,

• Bowel or Ureter (<1% risk)
• Bladder
  • prolapse repair (<1% risk)
  • Incontinence surgery (3-8% risk)
• Pelvic haematoma (blood clot) (1-2% risk)

After incontinence surgery bladder problems can occur.

Temporary difficulties with urination occur in up to 15% of cases. Some patients require prolonged bladder drainage (catheterisation). Permanent inability to urinate is very rare.

Up to 6% (sub urethral sling) to 15% (Burch Colposuspension) of patients can develop symptoms of urgency after the operation. (See urge incontinence above)

Where synthetic mesh has been placed beneath the vaginal skin it can sometimes cause a small ulcer ("erosion") in approximately 5-10% of cases. Unless very small it may be necessary to have a minor procedure to removed the small area of visible mesh to allow healing of the erosion.

Vaginal mesh may become infected in approximately 1% of cases. Such infections may require removal of the mesh. In rare cases rejection of the mesh may occur.

Abnormal scarring of the vagina can in rare cases make sex difficult or impossible.

When laparoscopic surgery is planned an open (abdominal) operation may be required to complete the surgery due to technical difficulties.

The above list is not exhaustive and does not include all possible risks. If you have any further concerns please feel free to ask your specialist.

What to expect after your surgery

Hospital Stay

• With a vaginal or laparoscopic pelvic floor repair surgery you will usually go home within 3 days of surgery.
• Abdominal or incontinence surgery usually requires a longer stay. (4 - 5 days)

Post operative pain

• Within a day of your vaginal or laparoscopic operation, most patients require only oral pain medications and are usually up and walking around.
• Abdominal surgery usually requires 48hrs of pain relieving injections (narcotics) and patients are slower to mobilise.

Vaginal bleeding

• A small amount of vaginal bleeding is common after vaginal surgery and it may persist for 3-4 weeks. It can sometimes be associated with an unusual odour.
• Have some ultrathin sanitary pads on hand - best to avoid tampons
• Sometimes you may pass a small amount of dissolving suture material (stitches) from your vagina 2-4 weeks after surgery.
• Please tell your doctor about any discharge that is offensive or becomes heavier than a period.

Return to normal activity

• You may return to non-strenuous employment within 4-6 weeks of surgery.
• Activities should be limited for 6 weeks after surgery (including most housework).
• It is important that you do not do any heavy work or lifting (more than 5-10 kgs) for 6-8 weeks after surgery.
• Try to avoid excessive coughing.
• As a general rule, if it hurts do not do it!
• Intercourse should not be resumed until six weeks after surgery and until one week after the bleeding stops.
• It is advisable not to drive a car until completely comfortable and feeling well. This may be anywhere between 2-6 weeks. Do not plan a long trip even as a passenger for at least a couple of weeks after your discharge from hospital.
• Frequent short walks increasing over time is beneficial (i.e. 5-10 minutes building to 20-30 minutes)
• Gentle swimming is fine once all vaginal discharge has settled
• Prevent constipation - Avoid straining when opening your bowels. If this is a problem increase your fibre and fluid intake (have at least 1-1½ litres of water per day). Coloxyl tablets (1-2 tablets once or twice a day) may also be useful.

Pelvic floor exercises

• May be commenced when they can be done comfortably, usually within a week or two of surgery. Remember to flex your pelvic floor muscles with any exertion (i.e coughing, sneezing, laughing etc).

Urinary Catheter

• A soft latex tube (catheter) may be required to drain the bladder for 24-36 hours to allow it to rest after surgery.
• After incontinence surgery a small number of women may have ongoing difficulty emptying their bladder and thus require a catheter for a longer period of time.
• In these cases you can go home with a urinary drainage bag and return a week or 2 later to have the catheter removed.
• Alternatively you may be taught to insert a small catheter to empty your bladder on a regular basis until your bladder function returns to normal.

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