Ever Since I Had My Baby

by Roger Goldberg

  Surgery for Prolapse

  Surgery for pelvic prolapse has always been one of the gynecologist’s most difficult tasks. After all, prolapse often means the coexistence of several bulges, such as a cystocele, rectocele, uterine prolapse, vault prolapse, or enterocele; and the problem isn’t fixed until every bulge is gone. Surgeons usually need to draw from a number of techniques to address every unique case, and they tailor them a bit differently each time. Permanently curing prolapse remains a challenge for even the most skilled and innovative reconstructive surgeons.

  Fortunately, the number of techniques known for reconstructing the pelvic supports continues to expand. Prolapse bulges can be pushed up from below during vaginal surgery, or pulled up from above by abdominal or laparoscopic techniques. They can be folded up with stitches, covered with a graft or mesh, or sometimes stretched back and attached to their original supports along the pelvic bones or ligaments. In most cases, a combination of procedures will be used to repair the various components of prolapse that usually coexist.

  REPAIRING CYSTOCELES

  Cystoceles—the bladder dropping or bulging into a weak upper vaginal wall—come in two types. Your pelvic exam in the office will determine which type you have and what kind of repair would be most appropriate.

  THE CENTRAL CYSTOCELE

  A central cystocele occurs when the vaginal wall stretches and weakens, allowing the bladder to sag into the middle or central part of the upper vaginal wall. Imagine the Golden Gate Bridge stretching out at its center, allowing the road to droop in the middle under the weight of too many trucks.

  Anterior colporrhaphy is the basic repair for a central cystocele. It involves tucking up the upper vaginal wall by bunching together the connective tissues beneath the vaginal skin, restoring a stronger floor for the bladder. It’s one of the oldest reconstructive procedures in gynecology and is still commonly used. Following an anterior colporrhaphy, the upper vaginal wall is flat and strong; over the long run, however, recurrent cystocele bulges can develop in somewhere between 3 and 30 percent of women.

  Two types of cystocele: “central” and “paravaginal”

  THE PARAVAGINAL DEFECT

  This type of cystocele develops during childbirth, when the vaginal walls tear away from their attachments along the sidewalls of the pelvis. In this case, it’s not the middle of the Golden Gate Bridge that’s sagging, it’s the ends of the road detaching from their vertical supports and falling inwards after a San Francisco earthquake.

  Paravaginal repair involves reattaching the sides of the vagina to the pelvic walls. It’s a newer approach than the anterior colporrhaphy and is favored by some experts who consider paravaginal defects the most common and critical injuries occurring to the upper vagina during childbirth. Paravaginal repairs can be performed through an abdominal incision, by laparoscopy, or sometimes even through the vagina.

  REPAIRING RECTOCELES

  You’ve learned about the symptoms that can be caused by a rectocele, often the most bothersome of all prolapse types. Surgically repairing a rectocele can relieve or at least improve many of these complaints.

  Bulging. With repair, bulging of the lower vaginal wall and rectum will be improved, with at least 90 percent success. Among all the operations for prolapse, rectocele repairs tend to be among the most durable and effective over the long run.

  Constipation and splinting. The majority of women with difficult bowel movements will experience relief after this surgery and will be able to stop relying on the splinting technique.

  Fecal incontinence and soiling. Bowel control may improve after a rectocele repair, as the rectum is more likely to be completely empty of stool between bowel movements.

  Rectoceles are typically repaired with a vaginal operation. Posterior colporrhaphy is a mirror image of the anterior colporrhaphy. This traditional rectocele repair involves finding the connective tissues between the vagina and rectum and bunching this layer together more strongly.

  The newest surgical approach, site-specific rectocele repair, involves finding discrete areas of injury (or defects) in the connective tissues between the vagina and rectum—ones that were caused, in most cases, by childbirth. After the defects are identified, they are repaired, just like stitching closed a cut in the skin. It’s not yet clear whether the site-specific rectocele repair is more or less successful than the standard posterior colporrhaphy technique, but its potential for success has raised interest in learning more about how childbirth injury affects each woman’s pelvic function during her postreproductive lifetime.

  WHEN YOU NEED A GRAFT OR MESH

  Whenever possible, most surgeons prefer to use each woman’s own pelvic connective tissues and ligaments to repair prolapse. But if your natural supports have become too weak, synthetic materials or grafts may sometimes be utilized for reinforcement. These foreign substances can be anchored to nearby muscles or ligaments, or placed loosely over the cystocele or rectocele bulge.

  Synthetic mesh (Gore-Tex, Prolene, Vicryl, Mersilene) is an entirely man-made woven material. Both absorbable and permanent materials may be used.

  Fascia is a layer of connective tissue that exists throughout the body. When implanted as a graft during pelvic surgery, a strip of fascia will stick around for a period of months or years before it is slowly absorbed. During this process, the fascia is replaced by a new layer of scar. A strip of the patient’s own fascia can be taken from beneath the skin of the leg or abdominal wall, through a separate incision. Sterilized and processed strips, originating from cadavers, are also commercially available.

  Dermis is a strip of skin, obtained from either animals (pigs, for instance) or human cadavers. Like fascia, dermis does not last forever; over time, it is absorbed and replaced by scar.

  Skin and fascia grafts reprocessed for extra strength have been recently developed, possibly adding more durability.

  REPAIRING VAGINAL VAULT PROLAPSE

  These procedures are used when the vaginal vault, or the top of the vagina, has come loose from its attachments deep in the pelvis. Three operations are most common, each using a different anchoring point for reattaching the vagina.

  UTEROSACRAL LIGAMENT SUSPENSION

  This procedure, which can be performed through abdominal, laparoscopic, or vaginal incisions, attaches the upper vagina to the uterosacral ligaments. These strong tissue bands run along the sides of your pelvis, back toward the upper vagina. When reasonably strong uterosacral ligaments exist, this operation can provide excellent long-term support while keeping the vagina straight and wide at the top; in other cases, however, the uterosacral ligaments are simply too weak and stretched, so another technique must be used. When performed vaginally, the procedure is referred to as the McCall culdoplasty, named after a famous surgeon.

  SACROSPINOUS LIGAMENT SUSPENSION

  This operation is performed only through a vaginal incision; it fixes the top of the vagina to a very strong ligament along the floor of the pelvis called the sacrospinous ligament. It is a particularly useful approach for advanced cases of vaginal vault prolapse, and also for women with very weak uterosacral ligaments, since the sacrospinous ligament is a consistently strong anchoring point even in these situations. Although the top of the vagina angles slightly to the side after sacrospinous suspension, this rarely poses a problem during intercourse or otherwise.

  SACRAL COLPOPEXY

  This operation uses an open abdominal technique for repairing vaginal vault prolapse. It utilizes a graft of material, either synthetic mesh or a natural-tissue graft, to fasten the upper vagina back to the sacrum at the rear of the pelvis. It is a sturdy repair (over 90 percent successful, comparable to sacrospinous ligament suspension) that keeps the vagina straight. The major disadvantage is the abdominal incision, resulting in a longer average hospital stay and recovery time. Also, the mesh or graft introduces other risks, including infection or erosion through the vaginal skin, requiring partial or full removal.

  LAPAROSCOPIC SACRAL COLPOPEXY<
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  The sacral colpopexy can also be done through a laparoscopic camera and keyhole incisions, rather than a bikini cut, by experienced laparoscopic surgeons.

  REPAIRING ENTEROCELES

  Enteroceles are most often repaired vaginally, through the same type of incision used to repair a cystocele, rectocele, or uterine or vaginal vault prolapse. This type of prolapse bulge actually contains loops of intestine, just like a hernia. During the operation, the enterocele bulge is carefully entered; then the intestinal loops are replaced back up into the pelvis, and the area where the enterocele originated is closed off and strongly reinforced with stitches.

  Enteroceles can also be repaired during abdominal surgery for prolapse. Special support sutures are used to reinforce the very bottom ligaments and connective-tissue supports of the pelvis, so that the bowel contents are supported more strongly above the vagina. Laparoscopic repair is similar to the other two methods but uses laparoscopy.

  Hysterectomy and Other Surgical Options for Prolapse

  Surgical removal of the uterus, or hysterectomy, has historically been one of the most overused operations in gynecology, at least in the United States, where rates have been up to twice those among British women and four times those in France. In years past, up to a third of women over the age of sixty-five had one. The landscape of gynecology has changed dramatically, and the recent declining rate of hysterectomy in the United States is encouraging. A number of less invasive treatment alternatives are available for a wide range of problems, including fibroids, abnormal bleeding, and pain—and for prolapse, as we’ve discussed.

  On the other hand, if you have pelvic prolapse or incontinence, hysterectomy can be a necessary part of surgical treatment. When properly used, it can have definite benefits. So, under what circumstances is a hysterectomy the right choice for you?

  Bulging of a prolapsed uterus. For advanced prolapse of the uterus, hysterectomy is often the best treatment; around 15 percent of all hysterectomies are performed for prolapse. Despite the understandable impulse to avoid hysterectomy whenever possible, a bulging uterus will usually result in persistent symptoms and may, over time, seriously jeopardize any repair done to the nearby vaginal anatomy. The weight of a prolapsed uterus may simply pull down the vaginal stitches and supports until a new cystocele, rectocele, or other prolapse bulge appears. On the other hand, if the uterus isn’t part of your prolapse bulge, cystoceles and rectoceles can be repaired just as effectively without a hysterectomy. Performing an unnecessary hysterectomy, in these cases, may even raise the risk of recurrent prolapse by weakening the natural supports that surround the upper vagina, and by removing the blocking effect that an enlarged uterus sometimes has at the bottom of the pelvis.

  Sexual pain. A prolapsed cervix that has dropped closer to the vaginal opening can become a source of discomfort when it’s bumped during intercourse.

  Big fibroids, bleeding, and other problems. Factors that are not directly related to your prolapse might also steer your decisions about hysterectomy. Have you been dealing with heavy or irregular bleeding, fibroid tumors (benign growths on the uterus), or abnormal Pap smears? Peripheral conditions such as these sometimes make it advisable to treat definitively with hysterectomy during incontinence or prolapse surgery.

  When is hysterectomy not right?

  For urinary incontinence alone. If you have incontinence without prolapse, hysterectomy is rarely necessary. A recent systematic review showed that hysterectomy might even be associated with higher rates of urinary incontinence later on. All of the operations for stress incontinence can be done just as easily in the presence of a normal, well-supported uterus.

  You’re just not ready. Hysterectomy for many women is not simply another surgery—it’s a symbolic life event that should never be taken lightly. The operation shouldn’t be performed for these benign postreproductive problems until you’re finished with childbearing, informed of your alternatives, and feel that you’re emotionally ready.

  TYPES OF HYSTERECTOMY

  VAGINAL HYSTERECTOMY

  This technique to treat a prolapsed uterus has been around for a hundred years; it remains a standard approach for most cases. Through an incision at the top of the vagina, the uterus and even the ovaries can be removed. In most cases, you can expect relatively mild postoperative pain, a short hospital stay, and quick recovery. At times a vaginal hysterectomy might not be feasible—for instance, if your uterus is too large, your pelvic bones are too narrow, or if prior surgery left you with scarring around the pelvic organs.

  ABDOMINAL HYSTERECTOMY

  Abdominal hysterectomy involves a skin incision, usually a bikini cut just above your pubic hairline. Surgeons who favor an overall abdominal approach to prolapse or incontinence surgery may perform abdominal hysterectomy because it can be naturally combined with other abdominal-route prolapse techniques. The abdominal hysterectomy may also sometimes represent the only option for removing a uterus that is very enlarged or stuck with scar tissue to surrounding structures due to a previous pelvic surgery or infection.

  LAPAROSCOPIC HYSTERECTOMY

  Beyond vaginal and abdominal hysterectomies lies the more high-tech alternative of laparoscopy, taking place through tiny incisions and projected onto a video screen. Laparoscopy can be used to partially detach the uterus in order to make a vaginal hysterectomy easier (laparoscopic-assisted vaginal hysterectomy). In some cases, it can be used to perform the entire hysterectomy (laparoscopic hysterectomy), using special devices that detach the uterus and then remove it in small pieces. Recovery after these procedures is generally rapid, similar to a vaginal hysterectomy—with the added possibility of some upper abdominal or shoulder pain for a few days after surgery, resulting from residual gas bubbles in the abdomen irritating the nerves running to those areas. Critics of laparoscopic hysterectomy argue that it necessitates a longer operating time, can incur greater financial costs, and may increase the risk of certain injuries. Nevertheless, if used in the right instances for the right women, laparoscopic hysterectomy can be a useful and well-tolerated option.

  SUPRACERVICAL HYSTERECTOMY

  This variation involves removal of the uterine body while leaving the cervix attached to its pelvic supports and in its usual position above the upper vagina. It can be performed through either a standard abdominal incision or laparoscopic keyholes, but not as a vaginal surgery. Supracervical hysterectomy involves a few pros and cons.

  Pro. It’s been claimed (more often in checkout-aisle magazines than in scientific journals) that leaving the cervix may help to maintain sexual pleasure and orgasmic function by preserving a bumping sensation against the cervix during intercourse.

  Con. Even if that claim holds true for some, it’s probably least likely to apply to those women with uterine prolapse, whose bulging cervix contributes more often to sexual discomfort than pleasure. Studies have confirmed that among women with prolapse, a substantial percentage of those with deep sexual pain will find improvement in their sexual function after hysterectomy involving removal of the cervix.

  Pro. Could a supracervical hysterectomy help to better preserve your pelvic supports? It’s been proposed in years past that fewer nerves and connective tissues may be injured with supracervical as compared with complete hysterectomy, helping to preserve bladder, bowel, and sexual function.

  Con. A group of British investigators appear to have debunked this claim. Their study involved 279 women scheduled for hysterectomy who received either the total or supracervical operation by random choice. The authors found that contrary to popular belief, supracervical hysterectomy did not result in better bladder, bowel, or sexual functioning one year after surgery. Particularly if you’re having the hysterectomy for prolapsed pelvic supports that have already proven themselves weak, then removing the entire uterus and suspending the upper vagina to more solid structures is probably the best plan.

  Finally, after supracervical hysterectomy, your risk for cervical cancer will remain the same as before,
so you’ll still need regular Pap smears.

  OTHER SURGICAL METHODS FOR UTERINE PROLAPSE

  Several operations can lift a partially prolapsed uterus back into the pelvis by securing it to pelvic ligaments or other supports. If you’re still considering future childbearing and simply can’t succeed with a pessary, then these alternatives may be worth looking into. These uterine sparing alternatives are appropriate only in very specific circumstances, however, and may offer limited long-term success compared with hysterectomy.

  SACROSPINOUS OR UTEROSACRAL FIXATION

  These are the most common vaginal operations for suspending the uterus, using no abdominal incision in most cases. A 1993 report of nineteen women included five who later had a successful vaginal birth. Through a vaginal incision, the ligaments connected to the uterus are secured to the sacrospinous or uterosacral ligaments, located deep in the pelvis.