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Facts About Urinary Incontinence and Uterine Prolapse – The Solution

Author: Dr Daryl Greebon

In part one of this discussion, we discussed disorders referred to as pelvic floor disorders, or as disorders of pelvic support. These disorders include urinary stress incontinence (urinary leakage), uterine prolapse (dropped uterus), cystocele (dropped bladder), rectocele (bulging of the back wall of the vagina), enterocele (A form of internal hernia), and vaginal vault prolapse (dropped vagina after hysterectomy). We discussed some of the causes and the symptoms associated with pelvic floor disorders. In this portion of the discussion, I would like to discuss the potential solutions to these problems.

Treatment Options

For the most part, the treatment of all of these disorders is surgical. When uterine prolapse or urinary incontinence symptoms are mild, surgery is to be avoided if possible and conservative measures such as avoiding heavy lifting, managing fluid intake, and using stool softeners can help mitigate the symptoms and delay the need for surgery. Unfortunately, the physical stresses and activities of life almost always cause progression of these problems, so that most women who have these disorders eventually need surgery. For elderly women who are not sexually active and not good surgical candidates because of other medical problems, the use of a pessary (a plastic or rubber device that fits into the vagina to hold the uterus and bladder in better position) can be used. However these are not adequate for anyone who is sexually active, or has moderate physical activity.

We will now discuss the various procedures necessary to correct pelvic organ prolapse. Because there are often multiple problems (uterine prolapse, cystocele, rectocele) more than one procedure is often required.

Hysterectomy

Hysterectomy – When there is uterine prolapse (dropped uterus), usually a vaginal hysterectomy is required. The tubes and ovaries can be removed vaginally as well for those postmenopausal women who need to have the ovaries out. Occasionally, vaginal repairs listed below may be done in association with and abdominal hysterectomy, or a daVinci robotic hysterectomy.

Tension Free Vaginal Tape

TVT – Tension Free Vaginal Tape. This is a procedure to repair the bladder neck. This does not take care of significant bulging of the vagina, but is all about control of urinary incontinence. Needles are passed either behind the pubic bone, or around the lateral pelvic bones and into the space between vaginal wall and bladder. A 1 cm. wide mesh tape is threaded through the needle and the needle is pulled out . In this way, the vaginal tape is anchored in place and lays without tension beneath the urethra so that when the woman coughs or sneezes the urethra is compressed against the mesh and the resulting fibrous tissue that is laid down around the mesh. This compression prevents urinary incontinence.

Anterior Repair

Anterior repair – (also medically known and anterior colporraphy). This is a repair of the anterior or front wall of the vagina beneath the bladder. This is done to correct the extensive bulging of a large cystocele. An incision is made in the vaginal wall, the vaginal tissue is then separated from the underlying bladder. In the older type of anterior repair, suture is used to pick up some bladder wall on one side, then on the other, and when this suture is tied, it pulls the tissue together and lifts and supports the bladder. Unfortunately, when women have weak connective tissue to begin with, the tissue which is used for support is often not as strong as we might like, and therefore, with conventional old-style anterior repairs, the failure rate is higher. To avoid this problem, newer procedures have been developed which use a mesh material, like a loose weave thin cloth, which can be placed beneath the bladder to provide support. In today’s world, these surgeries are often done with kits, which provide conveniently shaped pieces of mesh with “arms” of mesh material that can be passed thru tissue with a needle much like the TVT described above. The arms help anchor the mesh is place long term, and seem to give better long-term results. The primary problem with placing mesh material in the vagina is the possibility of erosion such that the vaginal tissues do not heal completely over the mesh graft, or the possibility of pain with intercourse if this mesh is used in women prior to menopause.

Posterior Repair

Posterior repair – (posterior colporrhaphy) This procedure is a repair of the back wall of the vagina over the rectum. The description of this procedure would be identical to the description above of an anterior repair. The vaginal wall is opened, the vaginal tissues are dissected off of the underlying rectum, and then either sutures are placed to obliterate the defect and provide support, or mesh materials are used as described above to provide better long-term support.

Vaginal Vault Suspension

Vaginal vault suspension – This is a procedure to lift or elevate the vaginal vault (top of the vagina after hysterectomy). Some doctors try to accomplish this simply by doing a good anterior and posterior repair. If there is significant vault prolapse, I do not believe that this is adequate to prevent recurrence. There are however, additional procedures that can be done, some vaginally and some abdominally to support the top of the vagina when necessary. Sometimes the top of the vagina is anchored with sutures to the sacrospinous ligament, or high up on the uterosacral ligament. These are both strong structures which can give a better chance of long-term support, and both of these can be done vaginally. Each procedure has its relative strengths and weaknesses.

Abdominal Sacrocolpopexy

Traditionally the “gold standard” procedure for repair of vaginal vault prolapse is the Abdominal Sacrocolpopexy. This requires an abdominal incision, and the 4 – 6 week recovery attendant with an abdominal incision. This procedure uses a 3cm. piece of mesh material sewn to the top of the vagina with multiple stiches. The other end of the mesh is attached to the sacrum internally. Fortunately, today this procedure can usually, though not always be done as a daVinci robotic sacrocolpopexy. Using robotic surgery, it is possible to attach mesh both to the top of the vagina, and to the sacrum using laparoscopic techniques. This means less pain, quicker recovery, and easier return to work than the traditional open operation, and still gives the “gold standard” result.

Discuss Your Options with Your Doctor

There obviously are nuances about when these procedures should be applied and in what combination. Results with many of these procedures are directly dependent on the surgeon’s skill and experience. For instance, a talented and experienced surgeon can usually do a vaginal hysterectomy in 30-45 minutes and do vaginal hysterectomy with anterior repair and posterior repair and TVT in about 2 hours, whereas an inexperienced or less expert surgeon can take 2.5 to 3 hours for vaginal hysterectomy alone. While the time one takes to do a surgery is not a direct measure of quality, long operating times often suggest that the surgeon was either struggling or uncomfortable doing the case. The message is to make sure as much as possible that your surgeon knows and has considered all of the surgical choices available to you, and that he/she is choosing the best surgery for you, and that he/she is skilled at performing these operations.

I hope that this two part discussion has been helpful in understanding the problems of pelvic Relaxation or pelvic support disorders, and it is my sincere hope that this information serves you well if you or a loved one are having problems in these areas or are contemplating surgery in the near future.

About the Author:

Dr Daryl Greebon is a board certified OBGYN with Women’s Specialists of Plano. Dr Greebon is a member of the Baylor Regional Medical Center at Plano medical staff. Daryl Greebon, M.D., gynecologist, graduated from the University of Texas Southwestern Medical School. He went on to serve his internship and residency at the University of Pittsburgh Medical Center. http://www.obgynplano.com/womens-doctors-physicians/dr-daryl-greebon-md/

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