Posts Tagged ‘Pelvic Support’
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.
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 – 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 – (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 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.
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/
Facts About Urinary Incontinence And Uterine Prolapse – The Problem
Author: Dr Daryl Greebon
There are many forces that work on the pelvic floor in women. Lifting, laughing, coughing, sneezing, and having babies all have the effect of exerting downward pressure on the floor of the pelvis and in some women this leads to symptomatic problems such as urinary incontinence. These disorders are referred to as pelvic floor disorders, or as disorders of pelvic support. These disorders include urinary stress incontinence (urinary leakage), prolapsed uterus (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).
The common thread in all of these conditions is a loss of support of the uterus, bladder, or vaginal walls. While the forces listed above can cause problems, some women may do heavy work and have two or three babies and not have too much trouble, and others may not do particularly heavy work and have only one baby and still have a problem, so there is clearly more to this story than just the external forces. I believe that some women, or some families inherit a tendency to have weakness in the connective tissues that provide pelvic support. It is this weakness that allows these problems to occur.
It is therefore, no surprise that if a woman has generalized weakness of the pelvic floor, these problems are seldom isolated to one organ. While this is not always true, if a woman has urinary incontinence the odds are pretty high that she will have other issues as well, such as uterine prolapse or rectocele. Furthermore, since these organs are in close proximity, a problem in one may aggravate problems in others, so that a prolapsed uterus (dropped uterus) may over time make a cystocele (dropped bladder) get worse. This is one reason that in some cases if the bladder is repaired, but the uterus is not removed, recurrence of urinary incontinence is more likely. It is important when evaluating these problems for surgical correction that the entire pelvis is evaluated and that all problems are corrected at the same time. Every gynecologist, particularly early in his or her career has done a hysterectomy and repair of bladder, only to have the patient return six months or a year later with a newly developed rectocele because after the repair the forces of pressure were directed in a different place causing the new problem to develop. This could be avoided by choosing the best group of procedures at the start.
Let’s talk for a few moments about the various conditions. First, is a dropped uterus (uterine prolapse). While this can occur at almost any age (the earliest I have seen was a 21 year old nurse), it is more common in the 40’s and 50’s and beyond, after having had children and often after menopause. Uterine prolapse sometimes causes no symptoms until it is quite severe, but can cause pressure and discomfort. If the uterus is enlarged for any reason it is even more likely to cause pressure symptoms as it drops lower. This pressure may be felt in the lower abdomen, in the rectal area, on the bladder, or on the lower vagina. In extreme cases, the uterus can protrude completely outside of the vagina such that the vagina is almost turned inside out.
Second, a dropped bladder (cystocele, or bladder prolapse) can sometimes be subtle. There are two versions of this, one is when the neck of the bladder is dropped or weakened. The bladder neck is the important urinary control element, so when the bladder neck is dropped urinary stress incontinence develops. Urinary Stress Incontinence is a leakage of urine that occurs with coughing, sneezing, lifting or laughing. This is usually a small volume of leakage, maybe just a few drops, but can occur repeatedly throughout the day and can be a major problem. Most women would recognize this since mild versions may be a bit of leakage that occurs with running or sneezing.
There are other kinds of urinary incontinence which are not necessarily caused by a cystocele and which would not necessarily respond to surgical correction, so it is important to have preoperative assessment to decide if urinary stress incontinence is really the problem. The second sort of bladder problem is prolapse or weakness of the upper part of the bladder so that the bladder bulges into the vagina to a large extent. This can cause urinary retention and an increased risk of urinary tract infection. Sometimes this “pouch effect” can prevent urinary leakage, but if the mistake is made to fix the bulging bladder but not support well the neck of the bladder, having surgery might actually create urinary incontinence that a woman did not have before her surgery.
Third, a rectocele is a bulging of the back wall of the vagina over the rectum. This can be quite large at times, and can cause constipation, pelvic pressure, and in some cases a woman may have to place a finger in the vagina and press down to initiate a bowel movement. Different specialties may look at this problem differently. Some colorectal surgeons view this primarily as a bulging of the rectum and will offer a transrectal repair of this problem. Gynecologists on the other hand tend to view this as a defect of support, and it is my belief that any procedure that does not in some way provide better support of the back wall of the vagina is doomed to failure. I had a case in which a young gynecologist correctly diagnosed a rectocele, but his plan of action was to refer the patient to his friend the colorectal surgeon. The surgeon performed a transrectal repair. Immediately after the surgery the patient was concerned that the “bulge” for which she had originally gone in was still present. After six weeks of being told that this was swelling she asked the colorectal surgeon about it only to be told, ”Oh, that is a vaginal problem, you need to see your gynecologist for that”. She chose another doctor.
Fourth, an enterocele is much like an internal hernia in which the abdominal contents try to push their way down between the vagina and the rectum. This is fairly common with large rectoceles, but it is important for the surgeon to recognize this problem, know what it is, and repair it appropriately. Enteroceles are sometimes difficult to diagnose with certainty before surgery and tend to present like and act like a rectocele.
Last, is vaginal vault prolapse. This occurs after a hysterectomy in women who have severe disorders of pelvic support. The normal anchors that hold the vagina in place after a hysterectomy do not hold and the top of the vagina comes down and often protrudes at the vaginal opening. This is often accompanied by pressure and discomfort. It is important in the initial evaluation to be sure what is coming down, is it the bladder, the top of the vagina, or the rectum. This distinction is important because the appropriate repairs might be significantly different.
This concludes our discussion of Urinary Incontinence and Uterine Prolapse – The Problem. Please continue your study of these problems with “Facts About Urinary Incontinence and Uterine Prolapse – The Solution”. Part II continues our discussion of Pelvic Floor Disorders and Disorders of Pelvic Support focusing on the surgical correction of these problems.
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/