Ever Since I Had My Baby

by Roger Goldberg

  Stop taking aspirin. Aspirinlike products can interfere with blood clotting and should most often be discontinued a week before surgery. Check with your doctor about whether this applies to you.

  Medical clearance. Usually includes a full physical examination, electrocardiogram, chest X-ray and blood tests. Your primary-care doctor may be asked to perform a head-to-toe checkup before your surgery.

  Bowel preparation. Occasionally, patients may be asked to self-administer an enema or take a strong laxative at home the day before surgery.

  Pretreating with vaginal estrogen. For postmenopausal women with signs of vaginal atrophy, vaginal estrogen in the form of a cream, tablet, or ring may be recommended in the weeks before surgery. By improving the thickness and strength of the vaginal skin, estrogen may increase your chances for surgical success.

  YOUR PRESURGERY CHECKLIST

  As you decide on surgery for your postreproductive problem, make a list of questions and topics to discuss with your surgeon. Here are a few that may be useful:

  Is this procedure old or new?

  What type of incision will I have? What type of scar?

  How long will the procedure take?

  How long will I be in the hospital, off work, and out of the gym?

  What are the chances of a complete cure? During what time period do most failures occur?

  How does my minimally invasive option compare to its older gold-standard alternative?

  What new problems might arise after the surgery?

  Do my vaginal tissues have enough estrogen supply to optimally heal?

  What choices of anesthesia will I have: general, epidural, spinal, or local?

  Will you use my own ligaments and tissues for this repair, or do you plan to use a piece of graft or mesh? If so, where will it come from, and what are the risks?

  Will I have any long-term activity restrictions?

  Will this be covered by insurance?

  Five Common Concerns After Surgery

  I was forty-four years old when I had a vaginal hysterectomy and repair of my cystocele and rectocele. Now it’s six years later, and I’ve begun to notice pressure inside my vagina after I’ve been standing at work. Worse than that? I’m wearing pads again, because bending, coughing, and sometimes even just walking have been making me leak. Last week, though, was the real killer. While the doctor was doing my Pap smear, she told me that it looks like I’ve prolapsed again. What have I done wrong—and more importantly, what can I do? I feel like a helpless case.

  —Mara, e-mail correspondence

  CONCERN #1: “MY PROBLEM’S STILL THERE”

  Any type of prolapse or incontinence surgery can fail, even the best procedure performed by the best surgeon. The numbers are still encouraging for most pelvic-reconstructive operations, with odds for success ranging from 65 percent to over 90 percent in the first one to five years. Why, though, might a surgery fail?

  THE WHOLE PROBLEM WASN’T FIXED

  Failure can result from not repairing all of the defects that were present in the pelvic-floor supports: for instance, choosing to leave behind a partially prolapsed uterus while fixing a large cystocele or rectocele. Experienced surgeons will go to great lengths to identify all areas of prolapse at the time of surgery, including small enteroceles (small-bowel hernias behind the upper vagina), which can often be challenging to find.

  YOU HAVE A NEW PROBLEM

  In other cases, even after a perfect prolapse repair, the forces of gravity may begin to bear down on other, newly exposed nearby organs. This may predispose you to a totally new prolapse bulge. You might increase this risk by resuming heavy physical activity too soon after surgery, stressing the repair before full healing has occurred. Getting back on your feet after pelvic surgery is a good thing, but pushing too hard is not. Until your healing is truly complete, follow the rules and restrictions of your recovery plan for long-term success.

  YOU’RE LOOKING FOR TOTAL PERFECTION

  A surgery may seem to have failed because of unrealistic expectations for success. While it’s true that around 85 percent of women are significantly improved after surgery for stress incontinence, becoming completely, totally, and utterly “Sahara Desert dry” is far less likely. You may still have an accident every now and then, but hopefully much less often than before.

  YOU HAVE ANOTHER PROBLEM

  Persistent symptoms after surgery may continue due to a problem your surgery was not meant to fix, such as an overactive bladder. Most often these separate conditions can be effectively relieved with medications, physical therapy, or perhaps simple office treatment. If you head into the operating room with several postreproductive problems, the expectation of rolling out of the operating room “good as new in every way” can be a setup for disappointment. Fortunately, the vast majority of women who enter surgery with realistic expectations will be very pleased with their results.

  CONCERN #2: “I’M DONE WITH SURGERY … AND STILL LEAKING!”

  There may be nothing more disappointing after surgery than returning to activity only to notice leakage. Suddenly, the relief of having your operation behind you can be replaced by a sense of failure, even guilt. “Did I lift something too heavy? Do I have a hopeless case?” Don’t panic or throw in the towel. Leakage after surgery usually boils down to one of a few common causes, and they’re all treatable.

  OVERACTIVE BLADDER

  Any woman choosing an operation for stress urinary incontinence should understand that after surgery for stress incontinence, an overactive bladder can develop in 6 to 20 percent of those who never had one before surgery. Among women who had an overactive bladder before their operation, 75 percent can expect it to persist. Only around one in four women entering surgery with mixed incontinence will have the good fortune to experience relief of their overactive bladder after their stress incontinence is surgically repaired.

  The underlying message behind all of these statistics? Don’t panic if your bladder still misbehaves after surgery. If an overactive bladder causes leakage after your surgery for stress incontinence, begin with a bladder diet and bladder drills (see chapter 8); with more time for healing, many cases will resolve on their own. If the problem persists, then medications or physiotherapy, using biofeedback or pelvic-floor stimulation, may be needed.

  TYPE 3 INCONTINENCE

  Sometimes the walls of the urethra are simply too thin to form a good seal, even after its floppiness has been stabilized (see “Floppy Urethra” and “Thin-Walled Urethra,” chapter 8). A relatively simple procedure performed right in the office—periurethral injections—can often achieve dryness. The newer tension-free operations for stress incontinence are also demonstrating reasonable odds of success in some of these cases (see chapter 8).

  VAGINAL DISCHARGE

  Vaginal discharge after surgery is very common as tissues heal and stitches dissolve. During the first several weeks after vaginal surgery, the discharge can be heavy enough to be mistaken for leakage of urine.

  CONCERN #3: “MY BLADDER’S NOT EMPTYING RIGHT!”

  Pam was thirty-eight years old when she underwent a vaginal sling procedure for a long history of urinary stress incontinence. The surgery itself was a breeze—she was walking that evening, home the next day, and in much less pain than she’d anticipated. There was only one problem: two weeks later, she still couldn’t urinate more than a few drops of urine on her own. She had learned to insert a self-catheter before the operation, and every few hours, she used it to drain a healthy amount of urine. But without the catheter, she just couldn’t empty. She called the office, very concerned. “What happened to my bladder?” she asked. “Did something go wrong?”

  URINARY RETENTION: WHAT IS IT, AND WHAT CAN BE DONE?

  An inability to completely empty your bladder, causing urinary retention, can occur after many different types of pelvic surgery—including those that directly involve your bladder or urethra, and even those that involve just the nearby structures and supports. Mild retention
is not a big deal, usually resolving on its own within a period of days or weeks, and often not even noticed by the patient. A persistent total inability to void is rare. The good news is that the newest operations for stress incontinence are generally less obstructive to the bladder. Nevertheless, the problem is still relatively common. If you’re dealing with retention and waiting for normal bladder function to return, some basic tips may help to speed the process.

  Minimize pain and swelling. After any type of pelvic surgery, pain and swelling can make it difficult to empty both your bladder and bowels by overloading the delicate bundle of nerves surrounding your pelvis and bladder. This is the most common reason for voiding difficulties right after surgery. Although the phenomenon can occur after abdominal surgery, it’s a great deal more likely following vaginal surgery, due to urethral swelling and perineal pain.

  Maximize relaxation. In order to pass urine, the urethra and surrounding pelvic-floor muscles need to relax as the bladder simultaneously contracts. Focus on fully relaxing all of the muscles you’d tighten during a Kegel routine. Whistle, hum a tune, or run the faucet. To relieve the tension caused by dangling legs, use a stepstool if your feet don’t reach the floor while you’re sitting on the toilet. For women who have difficulty fully relaxing their pelvic floor and bladder neck, muscle relaxants like Valium, or urethral relaxers like Hytrin or Minipress, can help. Finally, although it may seem logical to strain, avoid the temptation. After certain procedures, straining makes emptying more difficult and may put your stitches in jeopardy.

  Urethral dilation. In some cases, your doctor can loosen the urethral supports by inserting small dilators in the urethra. This is an office procedure.

  Urethrolysis. If your difficulty with emptying persists, or if you are able to urinate only in awkward positions even after all of your healing is complete, it might become necessary to surgically release the tension of your repair. This is called urethrolysis, which involves simply cutting enough sutures or sling material to loosen up the bladder neck and urethra a bit. It’s successful in up to 85 to 90 percent of cases, very often without disrupting the ability of the original surgery to keep you dry. In most cases, you can do it as an outpatient under local anesthesia, but doctors usually wait several weeks or even months before considering this option.

  If you’re having a problem, don’t deny it … treat it! Dealing with bladder problems after surgery is frustrating. In order to understand your problem and get you back to normal, your doctor may want to perform a urodynamics test to be sure that you’re entering your operation with healthy voiding—meaning the presence of a strong bladder-muscle contraction, and the ability to relax your pelvic floor during a void. Postoperative roads often have bumps and unexpected turns. Always try to face them squarely, and focus on the long-term destination of better health and function that lies ahead.

  USING A CATHETER

  Whatever the cause, if your bladder is not empting the majority of its contents after surgery, you’ll need to learn how to use a catheter, a small strawlike device made of flexible rubber that will allow you to empty and prevent your bladder from overfilling during the healing process. There are three basic options.

  Self-Catheterization

  This involves inserting a tiny catheter through the urethra and into the bladder on your own. If you’re able to insert a tampon, it’s just about that easy. However, it requires a bit of learning and practice before your operation.

  Wash your hands before and after catheterization.

  Dip the catheter’s tip into lubricating jelly (plain water-soluble, or anesthetic jelly prescribed by your doctor). Don’t touch the catheter tip to anything else before insertion.

  Spread the labia, and find your urethra. You can wear rubber gloves if you’re concerned about long fingernails scratching or irritating this sensitive area. Sit, and use a mirror to directly visualize the urethral opening. Or use an index finger to locate the vaginal canal. Your urethral opening is a smaller opening that lies just about a half inch above your inserted finger.

  Insert the catheter into this opening, and advance it (angling up toward your belly button) about an inch or two until the urine starts flowing. Stop inserting once you see a steady urine flow.

  After emptying, wash the catheter with warm soapy water and allow it to dry. Store the catheters in a Ziploc bag.

  The advantage is that you’re bag-free and tube-free at all times between voids. You can try to void on your own at any time, which will allow you to keep day-to-day tabs on your bladder’s progress. But if you have poor coordination or mobility, or if you can’t get used to the idea of inserting something into your body, self-catheterization may not be for you.

  Foley (Transurethral) Catheter

  The Foley is a regular catheter inserted into the urethral opening and held inside the bladder by a small inflated balloon at its tip. While the catheter is in place, it is attached to a small, concealable bag that straps around the leg or belly during the daytime; at night, it can be hooked to a larger-sized bag for continuous drainage during sleep. The Foley catheter is easy to place, and it drains the bladder on a continuous basis. But you can’t urinate through the urethra without removing the catheter, and as a result, you can’t monitor your bladder’s daily progress, and your ability to fully void on your own. As you wait for bladder function to fully return, the Foley may need to be removed and replaced at the doctor’s office several times, to evaluate your ability to void.

  Suprapubic (SP) Catheter

  This catheter is placed through the actual wall of the bladder, through a tiny incision in the lower abdominal area. Like a Foley, the suprapubic catheter can also be hooked to a small or large drainage bag. Unlike a Foley, the urethra itself is free of any catheter. The SP is typically more comfortable than a Foley catheter. You’re able to attempt voiding at any time, through the urethra, by simply clamping the suprapubic catheter shut and allowing the bladder to fill. If you’re not able to empty at that time, you simply unclamp the suprapubic catheter and resume drainage. As with self-catheterization, this allows you to keep daily tabs on your bladder progress. The SP’s disadvantage is that it requires a tiny abdominal incision. After catheter removal, urine will drain from this incision for one to two days before it permanently closes. A pad or dressing is worn over the incision during this period of time.

  HANGING IN THERE

  The average time you’ll need to catheterize is difficult to predict. A substantial number of women need only a day or two of bladder rest; for the newer, tension-free procedures, many women are able to resume voiding right after surgery and can avoid the inconvenience of catheterization altogether. The average time for recovery from stress incontinence procedures tends to range between one and two weeks, but some women will require more time before resuming normal bladder function. Needing to catheterize forever is an extremely rare complication of bladder surgery.

  Don’t overfill. Distending the bladder to large volumes will stretch the muscle and make it temporarily weaker, perhaps extending the number of days you’ll need to catheterize.

  Try to be patient. Stay focused on the long-term result that led you to have surgery. Waiting can be a frustrating process for both you and the doctor, but allowing the bladder a bit more time to heal is often the most effective therapy of all.

  Keep in contact. Stay in touch with your doctor or the office nursing staff, and call about any obvious changes. If you ever notice very cloudy urine, bladder pain, flank pain, or fevers, then an evaluation or a course of antibiotics may be warranted in order to prevent a more severe infection. If you’re unable to empty and you feel like your bladder has become uncomfortably full after surgery, call your doctor or head for the nearest emergency room.

  Live your life! During your days or weeks of catheterization, don’t let it slow down your overall recovery. Walking, shopping, and socializing with friends and family should not wait for the return of full bladder function. Resuming an active life is the best thing yo
u can do for yourself after surgery.

  CONCERN #4: “I’M TIRED, UNCOMFORTABLE, AND FEEL LIKE I’VE BEEN HIT BY A TRUCK”

  Many women after pelvic reconstructive surgery are surprised by how quickly they bounce back to relative comfort. Although the first few days can be trying, by the time they visit the doctor’s office a few weeks after surgery, the majority of women already feel themselves turning the corner. But not all women.

  It is important for your surgeon to evaluate persistent pain. Only he or she can determine whether your pain is routine, or reason to be concerned. At the very least, your doctor will be able to help you maximize your pain relief. Fortunately, after most minimally invasive operations, persistent pain tends to be the exception, not the rule. Fatigue, on the other hand, is more the rule than the exception. There’s something about surgery, however it’s performed, that takes the wind temporarily out of your sails. If you need more help at home, call a friend. If working full days at the office is a struggle, try half shifts for a few transitional weeks. Your energy level will return, but there’s little you can do to hurry the process.