Patient Education
Surgical Expectations
What to expect after surgery
Intervention for pelvic organ prolapse should never be considered when the prolapse is not associated with symptoms. Would you replace the bottom of your car if it had some rust? Of course not, as long as the car is driving fine and not at risk of breaking down, you leave it alone. Well, pelvic organ prolapse is not dangerous and when it is not causing any problems, should be left alone. If it is causing symptoms, surgery is a reasonable option for POP-Q stages 2-4 disease (explanation of POP-Q). Although a well performed surgery will restore your anatomy, many symptoms may not improve.
Constipation may not improve with surgical correction of posterior compartment failure (repair of rectoceles). There are many potential causes for constipation. When a patient needs to push on the skin near the anus or inside the vagina to make a bowel movement, posterior compartment failure may be contributing to constipation and surgical correction may be beneficial. However, many patients will still remain with constipation secondary to dysmotility. This means that the bowels no longer contract in the normal wave-like manner. There is no surgical treatment for such. Dietary and lifestyle modifications are often helpful. Some drug therapies for irritable bowel syndrome may also be beneficial.
Fecal Incontinence rarely improves with prolapse surgery. However, when the prolapse is associated with impaction (large amounts of stool building up in the rectum and bulging into the vagina), some patients will describe fecal incontinence to very loose stool. Some of these patients will experience improvement with surgical correction of posterior compartment failure. Most fecal incontinence is not caused by prolapse but by injury or weakness to the muscles responsible for controlling the bowel. When weakness is identified, physiotherapy and dietary changes may be beneficial. When fecal incontinence is associated with urgency of defecation (the strong urge to make a bowel movement), treatments for irritable bowel syndrome are often helpful. Many patients with this type of fecal incontinence also improve with sacral nerve stimulation therapy. Although this can be quite dramatic, the use of sacral nerve stimulation therapy for fecal incontinence is still under evaluation. Many patients receiving Interstim® therapy for OAB notice substantial improvement with fecal incontinence.
Urinary Retention can be caused by prolapse. Retention is the inability to empty the bladder. Many patients with advanced anterior compartment failure (cystoceles) describe difficulty emptying the bladder. Patients often describe needing to stand up or lean forward to empty. Some patients will need to push the prolapse in to urinate. These patients are the ones who are most likely to benefit from surgical correction. A pessary may also improve urinary retention from anterior compartment failure. A patient who improves with a pessary will usually also benefit from surgery. Hence, a short pessary trial may be used to identify good surgical candidates.
Urinary Tract Infections occur more commonly in women with stage three and four pelvic organ prolapse. However this is more correlation than causality. What does that mean? Most women who have significant pelvic organ prolapse also have several other risk factors for recurrent or persistent urinary tract infections. Age, hypoestrogenism (low estrogen), obesity, diabetes, and fecal incontinence have all been associated with an increased risk of urinary tract infection. So when a woman has multiple risk factors, removing just one, the prolapse, may not lead to resolution of UTIs. Urinary retention predisposes to infection. When surgical correction of anterior compartment failure (cystocele) leads to a resolution of urinary retention, some women will cease to have recurrent UTIs. When surgical correction of posterior compartment failure lead to improvement of fecal incontinence, some women will cease to have recurrent UTIs. Unfortunately, less than 50% of women with recurrent or persistent urinary tract infections will cease to have this problem after prolapse surgery.
Stress Urinary Incontinence and anterior compartment failure often occur as a pair. Many women with a cystocele also suffer from movement of the urethra and associated stress incontinence. Surgical correction of the anterior compartment failure without specific attention to surgical correction of the urethral movement should not be expected to treat stress incontinence. Indeed, surgical correction of the anterior compartment failure (cystocele) can often worsen stress incontinence or reveal stress incontinence. This means that a patient without symptoms of stress incontinence may suddenly display stress incontinence symptoms after anterior compartment surgery. How could this occur? Coughing, laughing, sneezing, bending, and straining can cause the bladder to fall or prolapse more than the urethra. This creates a little kink where the bladder and urethra meet and prevents dripping of urine. If the bladder prolapse is repaired and the movement of the urethra is not addressed, the resolution of kinking reveals stress incontinence. We perform Urodynamic testing before surgery to help identify those patients at risk of postoperative stress incontinence. These patients are offered a sling surgery at the time of their prolapse surgery.
OAB and Urge Incontinence may improve with surgical correction of significant anterior compartment failure. The chance that improvement will occur is greatest in those women who have retention associated with their prolapse. However, some women without retention may improve as well. This is the exception and not the rule. Hence, all other options for the treatment of OAB and Urge Incontinence she be explored prior to considering surgery. If all other reasonable options fail, a short pessary trial may be used to identify good surgical candidates. Patients who improve with a pessary will usually also benefit from surgery. Some patients undergoing surgical correction of ACF for other reasons do experience improvement in OAB symptoms.
Coital Dysfunction - Problems with Intercourse should not be expected to improve with surgical correction of prolapse. Prolapse, when not associated with fecal impaction (severe constipation) should not cause problems with penetration. Even severe prolapse rarely causes penetration problems. Most couples who describe such problems also suffer from erectile dysfunction (the male partner no longer forms good erections). The problems with intercourse are remedied by treating the erectile dysfunction not the prolapse.
Vaginal Relaxation Syndrome
may improve with the surgical correction of prolapse. Pelvic organ prolapse may be associated with complaints of "loss of feeling", "feeling loose", "feeling too big down there", and or "difficulty feeling the penis". Some of this is anatomical (the support of the vagina is damaged and the muscles are weak) and some of it is psychological. Knowing that you have prolapse can in itself effect the enjoyment of intercourse. It is this collection of symptoms cause by both anatomic and psychological factors that we refer to as Vaginal Relaxation Syndrome. Restoring anatomy can improve many symptoms associated with VRS. However, restoring anatomy is a very complex formula. Poorly performed prolapse surgery can distort vaginal anatomy and cause sexual function. Furthermore, the majority of surgeries performed for pelvic organ prolapse do not adequately address the anatomic component of VRS. Hence, when we consider surgical intervention for VRS, we carefully review the anatomic defects. Many defects are better treated with a type of surgery we refer to as Vaginal Restoration. Many patients and doctors refer to this as Vaginal Rejuvenation. We do not like this term for several reasons. The first problem is that most surgeons claiming to perform Vaginal Rejuvenation are simply doing old-fashioned prolapse surgery. Also, we feel that the word rejuvenation is misleading and imprecise. Our goal is to restore normal anatomy and appearance.
We use our own patent pending method that allows us to restore more normal form, size, and shape without removal of tissue. We also believe that our unique method is associated with the lowest risk to underlying nerves. Many of these nerves are important to normal sexual function.
Mechanical Symptoms are those symptoms directly related to prolapse. These symptoms include a feeling of vaginal pressure, a sensation of something filling the vagina, "feeling like a tampon is in the vagina", a pulling sensation, irritation and or bleeding from the prolapse rubbing on clothing, and or discomfort from protrusion of the prolapse beyond the opening of the vagina. These symptoms typically resolve with surgical correction of the prolapse. Lower back discomfort is typically caused by back disease and should not be expected to improve with prolapse surgery.
