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Pelvic Organ Prolapse

What is prolapse?

Prolapse is a hernia of the vagina that a woman may feel as a bulge or pressure. This is referred to in many different ways. Sometimes it is called a “dropped bladder,” “dropped uterus,” “dropped vagina,” or “dropped rectum.” Your doctor may have also called this a cystocele, rectocele, or enterocele.

Prolapse is caused by a weakening of the vaginal tissues. Prolapse is associated with pregnancy and childbirth. However, prolapse can happen in women who have never had children. Prolapse is also associated with repetitive heavy lifting, chronic constipation, chronic cough, and weak or poor tissue. Prolapse symptoms may be worse at different times in the day. Some women notice that they feel more pressure after walking or standing for long periods of time.

My doctor told me I have a “dropped bladder.” What is this?

Sometimes the vaginal tissue under the bladder becomes weak and causes a hernia. This is called prolapse. You may feel a bulge outside the vagina or pressure. Your doctor may also have called this condition a “cystocele.”

Is prolapse something serious?

Prolapse may be uncomfortable, especially if you can feel the bulge after walking or standing for long periods of time. The good news is that prolapse is generally not life-threatening and many treatment options are available. For most women, the treatment they choose depends on how much they are bothered by their symptoms. Many non-surgical treatment options are available including dietary changes, pelvic floor muscle exercises, and physical therapy . One treatment for prolapse is a device inserted into the vagina called a pessary. Finally, there are surgeries to correct prolapse.

Can prolapse get worse?

For some women, their prolapse gets worse over time. For others, their prolapse will stay the same with conservative treatment options. Prolapse generally does not improve without surgery, but symptoms can be managed with less invasive treatment options.

What will happen if I just ignore this problem? Will it get worse?

Prolapse, left untreated, can stay the same, get better or get worse with time. The one exception to this rule is that new prolapse that is noticed by a patient or doctor in the early postpartum period will often get better within the first year after the delivery.

Treatment of prolapse should be based on your symptoms. In rare cases, severe prolapse can cause urinary retention (inability to empty the bladder) that progresses to kidney damage or infection. When this occurs, prolapse treatment is recommended. In most other cases, patients should be the ones to decide when to have their prolapse treated - based on the symptoms they are having.

Do I have to have a hysterectomy as a part of my surgery?

No. Any or all of the operations for prolapse and incontinence can be performed with or without a hysterectomy. However, hysterectomy is often performed along with these operations for a variety of reasons. In some cases, removing the uterus first makes the rest of the surgery easier to perform. In other cases, there is another reason besides prolapse or incontinence (such as cancer or excessive bleeding) to remove the uterus.

Whether or not to remove the uterus is individualized, and should involve a discussion between you and your surgeon.

Recently, there has been renewed interest in the possibility of repairing the prolapse without taking the uterus out (uterine preservation). Reasons to consider uterine preservation include the following:

Potentially decreasing the operative time and risk of surgery, because the hysterectomy part is not required.
Reducing vaginal incisions, which might in turn reduce some kinds of complications like erosions, and leave more of the support structures intact.
Individual patient preference.
The desire to become pregnant. Most surgeons, however, discourage prolapse surgery until childbearing is complete.

There are, however, reasons to be cautious about leaving the uterus in place, which include the following:

Presence (or development) of abnormalities, such as fibroids or cancer.
Continued need for Pap smears, especially if there have been abnormal Pap smears in the past.

As always, these issues require a careful conversation between you and your surgeon.

I have prolapse, but I don't leak urine. Do I still need bladder testing?

Possibly. If you are going to have surgery to correct the prolapse, bladder testing (called urodynamics) is often done first. That's because the prolapsed portion of your vagina may be pushing on your urethra and preventing urine leakage. If that is the case, having the prolapse corrected can reveal urinary incontinence. The best way to tell whether a continence procedure is needed at the time of prolapse surgery is to perform urodynamics while holding the prolapse up in its normal position.

If my surgery is successful, how long will it last?

The goal of continence or pelvic reconstructive surgery is to recreate normal anatomy permanently. Most patients do not require another surgery. However, none of these procedures are successful 100% of the time.

How successful is surgery for pelvic organ prolapse?

Many factors affect the outcome of reconstructive surgery. Some of the factors that originally contributed to your pelvic floor problems, such as decreased muscle and nerve function and weak connective tissue, might still exist after the reconstructive procedure has been performed.

Pelvic organ prolapse, like a hernia, is the abnormal protrusion of an organ through a weak pelvic floor. Hernias in the pelvic floor are technically more difficult to repair than other hernias because pressure in the pelvic floor from daily activities puts a lot of stress on the surgical repair. As a consequence, some women have a persistence or recurrence of their prolapse after surgery.

It is important to have realistic expectations: some patients cannot be cured. Surgery may result in fewer symptoms, but all of your symptoms may not be relieved. Sometimes surgery for pelvic organ prolapse fails to relieve any symptoms. Discuss the success rates of your particular procedure, or combination of procedures, with your surgeon.

If I decide to have surgery, what can I expect during the recovery period?

You will often be able to go home the same day after surgery. Depending on the extent of your surgery, you may need to be admitted to the hospital, which would typically be a stay of one, or perhaps rarely two days. Many women have difficulty urinating immediately after the surgery and have to go home with a catheter in place or opt to learn to self-catheterize to drain the bladder. Catheterization is usually only necessary for 3 to 7 days. Many patients require at least some prescription strength pain medicine for a brief period after surgery. After any surgery to correct urinary incontinence or prolapse, we ask that patients “take it easy” usually for at least 6 weeks to allow proper healing. This means no lifting more than 5-10 pounds (the weight of a two-liter bottle of soda), no intercourse, nothing in the vagina, and no exercise other than walking unless otherwise instructed.

The amount of time necessary for you to "bounce back" from surgery has a lot to do with the route of surgery. In other words, if an abdominal incision is necessary to perform your operation, you will probably have more pain after surgery than if your procedure is performed through a laparoscope or through the vagina. However, some patients are not good candidates for the vaginal or laparoscopic approaches. Your doctor should be able to explain his/her choice regarding the type of surgery you need.

Even if your surgery is performed via a less invasive route, prolapse operations tend to be "major surgery." In other words, all of these operations are a big deal and shouldn't be taken lightly. If you are bothered enough by your symptoms to want a surgery to fix them, then you should give yourself the best chance of success by following the doctor’s instructions after the surgery, even if you feel okay.

What is a pessary?

A pessary is a silicone device that can be used to help support prolapse. It is used for women who do not want surgery. Pessaries come in different shapes and sizes and can be fitted to help women with different degrees and types of prolapse. Pessaries are safe to use and are latex free.

Once you decide that you would like to try a pessary, you will be fitted for the correct size and shape to help support the prolapse without causing any discomfort or pain. The pessary that fits best will be able to support the prolapse, feel comfortable and allow you to urinate and have bowel movements without difficulty.

Remove your pessary to clean it on a regular basis. Most pessaries are easy to remove, clean and replace daily or weekly, though some may be kept in longer. Some pessaries are difficult to remove and require you to be seen in the doctor’s office for removal, cleaning and replacement. A pessary can be used for any woman who is bothered by her prolapse but does not want to have surgery or for women with other medical conditions that makes surgery more risky. Pessaries can be used for as long as the woman desires.

Bladder Control

What is stress urinary incontinence and is it a common problem?

Stress urinary incontinence (SUI) is loss of urine that occurs at the same time as physical activities that increase abdominal pressure (such as sneezing, coughing, laughing, and exercising). These activities can increase the pressure within the bladder, which behaves like a balloon filled with liquid. The rise in pressure can push urine out through the urethra, especially when the support to the urethra has been weakened; this is what we call stress urinary incontinence. Approximately 1 out of 3 women over the age of 45, and 1 out of every 2 women over 65 have SUI.

What are surgical treatment options for stress urinary incontinence?

Surgeons have developed different techniques for supporting the bladder back to its normal position. The three main types of surgery are: retropubic suspension and two types of sling procedures.

Retropubic suspension: Uses surgical threads called sutures to support the bladder neck. In this operation, the surgeon makes an incision in the abdomen a few inches below the navel and then secures the threads to strong ligaments within the pelvis to support the urethral sphincter. This common procedure is often done at the time of an abdominal procedure, such as a hysterectomy.
Sling procedures: Performed through a vaginal incision. The traditional sling procedure uses a strip of your own tissue called fascia to cradle the bladder neck. Other slings may consist of donor natural tissue or synthetic material. The surgeon ties both ends of the sling to the pubic bone or ties them in front of the abdomen just above the pubic bone.
Mid-urethral slings: Newer procedures that you can have on an outpatient basis. These procedures use synthetic mesh materials that the surgeon places midway along the urethra. The two general types of mid-urethral slings are retropubic slings, such as the transvaginal tapes (TVT), and transobturator slings (TOT). The surgeon makes small incisions behind the pubic bone or just by the sides of the vaginal opening as well as a small incision in the vagina. The surgeon uses specially designed needles to position a synthetic tape under the urethra. The surgeon pulls the ends of the tape through the incisions and adjusts them to provide the right amount of support to the urethra.

How do I know if a sling is a good option for me?

Make this decision in consultation with your doctor. Discuss all of your options and determine which treatment is most appropriate for your specific medical situation. This is a personal choice. Ask your doctor to discuss it with you.

How long is the sling surgery?

In most cases, the surgery should last less than 30 minutes. If your doctor recommends, the procedure can be performed under local anesthesia with IV sedation. Sling procedures are frequently outpatient procedures, in which case you may be returning home the same day of surgery. Many times, the sling is part of another procedure and you may need additional surgery to support a prolapsed bladder, uterus or rectum. Your doctor will discuss this with you.

What is a Public Health Notification?

A Public Health Notification is an important message from the Center for Devices and Radiological Health, U.S. Food and Drug Administration (FDA), to the health care community describing a risk associated with the use of a medical device and providing recommendations on its use.

What did the FDA say in its October 20, 2008 Public Health Notice?

On October 20, 2008, the FDA issued a Public Health Notification (PHN) regarding potential complications associated with transvaginal placement of surgical mesh to treat pelvic organ prolapse (POP) and stress urinary incontinence (SUI). The PHN provided recommendations and encouraged physicians to seek specialized training in mesh procedures, to advise their patients about the risks associated with these procedures and to be diligent in diagnosing and reporting complications.

What has happened since the 2008 PHN?

In July 2011, the FDA issued an update to the October 2008 PHN. In this update, the FDA maintained that adverse events for POP mesh repair are not rare, as previously reported, and questioned the relative effectiveness of transvaginal mesh as a treatment for POP as compared to non-mesh surgical repair.

On September 8 and 9, 2011, the FDA convened an Obstetrics and Gynecology Devices Panel of the Medical Devices Advisory Committee to further address the safety and effectiveness of transvaginal surgical mesh used for repair of POP. The panel recommended to the FDA that slings for the treatment of SUI are properly classified by the FDA with respect to risks and benefits offered. Regarding standard retropubic and transobturator slings, the panel concluded that no additional post-market surveillance studies are necessary. Regarding mini-slings, the panel recommended pre-market studies for new devices and additional post-market studies

Has the FDA recalled slings?

No, the FDA has not recalled slings.

I have a sling implanted for bladder leakage. Should I have it removed?

As with all important medical decisions, consult with your physician. There is no need to remove your sling if you are satisfied with your surgery and are not having complications or symptoms. Because a sling integrates with your own tissues, removal may cause complications or symptoms. The FDA recommends you continue with your annual and other routine check-ups and follow-up care. Notify the surgeon if complications develop (persistent vaginal bleeding or discharge, pelvic or groin pain during sex).

Bowel Control

What are bowel control problems?

Bowel control disorders affect the normal pattern of emptying your bowels. For example, you may have bowel movements not often enough, you may have very loose or hard bowel movements, you may have abnormal consistency of bowel movements, or you may not be able to hold in the bowel material. Common types of bowel control problems include:

Accidental Bowel Leakage (ABL, also called anal incontinence or fecal incontinence): Leakage of gas, mucus, liquid stool, or hard stool. Often happens when you have loose stools and diarrhea. Or, a feeling of urgency and great need to get the bathroom for a bowel movement.
Constipation: Difficulty passing bowel movements or the need to strain for bowel movements. You will be irregular and have hard stools. Plus, you may need to support the back wall of the vagina to pass stool that is trapped in a pocket or a bulge.

These problems can be caused by some medical conditions, certain medicines, injuries from childbirth, or as side effects from other surgeries or radiation.

How can I help my bowel control problems?

Making changes to your diet is the best first step. For both ABL and constipation, increasing intake of soluble and insoluble fiber is very helpful. It helps draw water into the stool, making the stool a soft, formed mass that are more easily held in the rectum than watery stool but is also easy to pass when it’s time to defecate. Aim for 25 to 35 grams of fiber per day.

If you are experiencing ABL, you can also try eating at regular times helps to regulate bowels, avoiding spicy foods or stimulants such as caffeine, which speed up transit time in the bowel. Also, try reducing intake of artificial sweeteners (sorbitol, mannitol, xylitol), which can induce diarrhea.

Constipation can be prevented by avoiding starchy low-fiber foods, such as white rice, pasta, or white bread, and increasing your intake of foods that contain indigestible carbohydrates and other compounds that are natural laxatives. Try to avoid using narcotics and other medications that can slow down the bowels.

Who should treat my bowel control problems?

Your primary care physician should be your first stop for bowel control problems. They may refer you to a specialist for a more thorough evaluation of your symptoms, such as a urogynecologist, colorectal surgeon, or gastroenterologist. Sometimes you need a team of doctors to help manage several aspects of these conditions. The evaluation should always begin with discussion of the symptoms and physical examination.

Chronic bowel diseases such as Crohn’s Disease, ulcerative colitis or irritable bowel syndrome should be treated by a gastroenterologist.

Most of all, tell SOMEONE. It’s never normal to leak stool, and you’re not alone. Reach out and speak up so that you can start to get better.

Where does a urogynecologist fit into my treatment?

Often a team of doctors will handle your bowel problems, and this specific answer depends on your diagnosis. It’s often best to start with your primary care doctor, or maybe your regular gynecologist to help know the next step.

Chronic bowel diseases such as Crohn’s Disease, ulcerative colitis or irritable bowel syndrome should be treated by a gastroenterologist.

If you need surgery on the bowels, that is usually done by a colorectal surgeon.

If you have a rectocele (bulging of the rectum into the vagina), a fistula, or problems with the pelvic floor, seek out a urogynecologist. At your first visit, the urogynecologist will take your history and do a thorough pelvic exam. After that, it depends on the diagnosis. Your urogynecologist may discuss prolapse treatments if you have a rectocele, discuss other ways to diagnose a fistula, or refer you to a pelvic floor physical therapist for help with the pelvic floor muscles. For some of these problems, surgery may help, and your urogynecologist may discuss that with you. The urogynecologist will also involve a pelvic floor colorectal surgeon if that surgery needs to be done together by both surgeons.

Will I need surgery to treat these issues?

Most women find relief through diet changes, over-the-counter medications and/or pelvic floor PT for bowel control problems. It depends on your diagnosis, but not every woman needs surgery. Your physician will help you assess whether surgery is necessary.

Bowel control surgery is a big decision. Consult with a colorectal surgeon or urogynecologist. And, consider getting a second opinion before moving forward.

I just had a baby - why can’t I control my stool?

Congratulations! As you’ve probably learned by now, having a baby is a big, exciting event. Lots of things about life change with a new baby, but it doesn’t mean you have to leak stool.

Everything may not be solved at your six-week postpartum visit. It might take longer. It’s also OK to call with these concerns before your scheduled appointment. Be sure to mention your symptoms to your doctor, who may consult a urogynecologist. A urogynecologist can help with complicated laceration repairs or persistent bothersome symptoms after simple treatment options have been tried without success. Seeing a pelvic floor physical therapist may improve your symptoms more quickly.

If you had a vaginal delivery, the process of delivering the baby causes damage to the muscles and nerves of the pelvis. Some of this will heal over time. Your urogynecologist may suggest doing pelvic floor physical therapy to help the muscles and nerves recover. You also need a careful exam to make sure the vaginal walls healed after your delivery, especially if you had a large episiotomy or tear.

Even if you had a C-section, the weight of the pregnancy over the last nine months or so can cause some damage on its own.

Surgery

How long will I be in the hospital?

Depending upon the type of surgery you have, you may be sent home on the day of surgery or you may stay for one or more nights. Your doctor will decide when you go home.

When will I be able to get out of bed after surgery?

As soon as possible! Getting out of bed early lowers the risk of blood clots and improves how quickly you will return to normal eating.

How soon after surgery can I have food?

There are usually no dietary restrictions for outpatient procedures and most vaginal surgery. Your appetite is your best guide. It is OK if you do not eat a regular meal. Do not force yourself to eat or you may vomit. You may be given medicine to help with nausea. If you are thirsty you should drink water. If you had a long abdominal surgery, your doctor may choose not to feed you for a short time. Doctors check how well your intestines are working by listening with a stethoscope, by feeling your abdomen to check for swelling and by asking you whether you have passed gas from below or had a stool.

Will I need to use a catheter after surgery?

Following incontinence and prolapse surgeries, some women have difficulty emptying their bladders completely. In this case, a small tube called a catheter is commonly used to drain the bladder. The catheter is inserted into the bladder either through where you urinate (the urethra) or through a small incision on your lower belly. You may also be taught to insert the catheter into your own urethra. Physicians use these catheters to help rest the bladder and to determine how much is left in your bladder after you urinate.

How long will I have to use a catheter after surgery?

The length of time you may need to use a catheter will vary. Return of normal bladder function is unpredictable. It may occur quickly after surgery or it may take a few days or weeks following the operation. This is entirely normal. Before you leave the hospital you and your doctor will have designed the best plan for your temporary bladder problem.

If you are performing intermittent catheterization or you have a suprapubic catheter, you will be asked to keep track of how much urine is drained by the catheter. When the amount that you urinate is greater than that drained by the catheter, you are on your way to stopping the catheterization. A common time to stop using the catheter is when less than 100 mL of urine is left in your bladder after you urinate and the amount you urinate is at least 200 mL. Your doctor or the office staff will instruct you when to stop or when to have the catheter removed.

If you are sent home with a catheter in place, your doctor will have you return to the office in about a week to test if you still need the catheter. In some cases, visiting nurses may be sent to your home to do the testing and report back to your doctor.

How will I receive pain medication after surgery?

Your pain medication will depend upon whether you are able to drink and eat after surgery. If you do not have nausea and can swallow them. If you cannot drink or eat your pain medicine maybe placed directly through an intravenous catheter (IV). Sometimes, patients are given a small hand-held device called a PCA or patient-controlled analgesia that allows you to push a button when you want to receive pain medication. If you had an epidural for your surgery, the epidural catheter may be left in place in your back so that you can receive medication through this epidural catheter. Let your doctor or nurse know if your pain is not well controlled so we can change medications to make you more comfortable.

Will I be on medication after discharge from the hospital?

You may be given a prescription for pain medication to take at home. Sometimes pain medications can cause or worsen constipation. To prevent constipation increase fiber and water in your diet, try eating fruits, vegetables and prune juice. You can also take stool softeners and laxatives which you can buy in the pharmacy or grocery store.

When will I have my first postoperative visit?

Your discharge instructions from the hospital should include when to make your first postoperative appointment. Depending upon the procedure, your doctor will want to see you within 2-6 weeks after surgery. When you return for your postoperative visit, your doctor will review your pathology report if there was tissue removed during surgery. He or she will examine you and answer any questions you may have about your recovery and your future activities. Make a list of your questions so that you do not forget them.

When can I resume my normal activities?

You will receive detailed instructions describing what you should and shouldn’t do for the first 6 to 12 weeks after surgery. Everyone recovers differently. Remember that your condition, general health and operation may be quite different from a friend of yours. When it comes to activity – use your common sense, if what you are doing causes pain or discomfort especially at your incision or in the vagina - STOP! REST, try again in a week or two. Additional things to remember as you work toward getting back to your normal activities:

Rest is important and short naps (20 minutes) can refresh you during the day.
It is important to walk so that you do not become weak.
Usually you will be allowed to climb stairs.
Avoid jumping, running and lifting heavy objects.
Check with your doctor about when you can resume more rigorous exercise or other high impact activities.
If you belong to a gym, a doctor’s note will frequently allow you to put the membership on hold until you are cleared to return.
Do not soak in a hot tub or swim without first clearing this with your doctor. Your incisions are at risk for infection.
Do not place anything in your vagina (tampons, douches, or medications inserted by vaginal applicator) during the first 6 weeks after surgery without discussing it with your doctor.
How soon after surgery your can resume vaginal intercourse depends on how quickly your vaginal incisions heal. It may be 6 weeks post-surgery before you can have vaginal sex. Discuss this topic with your doctor at your post-op visit.

Interstitial Cystitis

What does the name interstitial cystitis mean? Why are doctors now calling it bladder pain syndrome or painful bladder syndrome?

Interstitial cystitis was first named in the 1800s. At that time, it was thought that the symptoms were caused by an infection in the inner lining (interstitial) of the bladder (cystitis means bladder infection). That is why it was first called interstitial cystitis. Researchers now know that IC is not a bladder infection. The symptom that is most bothersome is the bladder pain. This is the reason for the alternative names. Luckily, they are also easier to pronounce!

Why does it take so long to diagnosis IC?

There is no test to diagnosis IC. Instead, doctors must make the diagnosis by excluding other conditions that have similar symptoms. If certain tests are not positive for other conditions, then your doctor may diagnosis you with IC. In addition, not all doctors are familiar with IC. This means that you may need to see a specialist like a urologist or urogynecologist to confirm the diagnosis of IC.

How does pregnancy affect IC?

For many women with IC, the symptoms wain during pregnancy. We don’t know the reason for the improvement in symptoms. Researchers think that it may relate to hormonal changes. But, for some women their IC symptoms remain the same. Therefore, the exact reason for the change in symptoms is not known.

Should I avoid all fruits and vegetables because they contain natural acids that can burn the bladder?

There is a lot of information on the internet that advocates for not eating acidic foods. However, this information is not correct. When your body digests acidic foods (like orange juice), it can make your urine less acidic. In contrast, low-acid foods like meats and other protein foods, increase the acidity of your urine.

At this time, we don’t know why certain foods bother people with IC. It is recommended that women with IC start by eliminating the list of most bothersome foods. These items appear to impact many people with IC. If you want to learn more about other foods that might be triggering your IC, ask a dietitian about how to do an elimination diet to help determine other foods that might be bothersome for you.

Is it safe for women with IC to take probiotics?

There is limited evidence supporting the use of probiotics for IC symptoms. In fact, many with IC report that tempeh, soy beverages, and fermented milks - which contain natural probiotics - provoke IC symptoms. Other patients, however, have found that probiotic supplements help control their symptoms.