PROLAPSE AND ITS TREATMENT

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1 PROLAPSE AND ITS TREATMENT Information Leaflet Your Health. Our Priority.

2 Page 2 of 14 What is a prolapse? A prolapse occurs when the muscles and ligaments supporting the uterus become weak and the vaginal walls become relaxed. If this muscle sheet and ligaments are weak, the organs it supports can sag down with gravity. Having babies and getting older may weaken the pelvic floor muscles. This sagging forms bulges into the vagina because the walls of the vagina are stretchy. This sagging is called prolapse: When the womb is sagging it is called uterine prolapse. Sometimes the womb sags so much that the neck of the womb protrudes out of the vaginal opening When the front wall of the vagina is sagging this is called anterior vaginal wall prolapse, anterior means towards the front The other name for an anterior vaginal wall prolapse is a cystocele which describes the structure bulging into the vagina; the bladder When the back wall of the vagina is sagging this is called posterior vaginal wall prolapse means towards the back. Posterior vaginal wall prolapse is called a rectocele which describes the structure bulging into the vagina; the rectum Prolapse may occur singly or in any combination. What causes a prolapse? Difficult or prolonged labour and multiple pregnancies Obesity Chronic strain caused by heavy lifting and constipation The menopause Genetic factors (weak collagen in the supporting ligaments)

3 Page 3 of 14 Problems you may have experienced? Anterior vaginal wall prolapse The sensation of something coming down. Some women with anterior vaginal wall prolapse have to push the bulge back into the vagina or lean forward in order to completely empty the bladder Some women find that the bulge causes a dragging or aching sensation, or is uncomfortable when having sexual intercourse Stress urinary incontinence Urinary frequency and urgency Difficulty in passing urine and sensation of incomplete emptying of the bladder. Incomplete bladder emptying may make you prone to bladder infections (Urinary Tract Infection) Posterior vaginal wall prolapse The sensation of something coming down. Some women with posterior vaginal wall prolapse have to push the bulge back into the vagina or support the perineal area (the area between the anus and the vagina) with their fingers in order to complete a bowel movement. Some women have to insert a finger in the back passage to facilitate evacuation of their bowel, this is called digitation If a woman has difficulty in emptying the back passage or has to use her fingers to achieve bowel emptying, a special x-ray test to assess bowel emptying may be needed in planning the surgical approach. The X-ray will involve inserting a special paste in the back passage and taking X-rays while trying to evacuate the paste from the back passage Some women find that the bulge causes a dragging or aching sensation Uterine (womb) prolapse Uterine prolapse can cause you to have a lump in the vagina that you can see or feel. The lump is often smaller first thing in the morning but gets bigger during the day when you are on your feet The lump can be uncomfortable; it may get in the way of having sex or putting in tampons If the lump protrudes, it can rub on your underwear and get sore and sometimes gets in the way of the bladder emptying properly.

4 Page 4 of 14 Treatment of prolapse Alternatives to surgery Do nothing If the prolapse (bulge) is not distressing then treatment is not necessarily needed. If, however, the prolapse permanently protrudes through the opening to the vagina and is exposed to the air, it may become dried out and eventually ulcerate. Even if it is not causing symptoms in this situation it is probably best to push it back with a ring pessary (see below) or have an operation to repair it. Pelvic floor exercises (PFE) The pelvic floor muscle runs from the coccyx at the back to the pubic bone at the front and off to the sides. This muscle supports your pelvic organs (uterus, vagina, bladder and rectum). Any muscle in the body needs exercise to keep it strong so that it functions properly. This is more important if that muscle has been damaged. PFE can strengthen the pelvic floor and therefore give more support to the pelvic organs. These exercises may not get rid of the prolapse but they make you more comfortable. PFE are best taught by an expert who is usually a Physiotherapist. These exercises have no risk and even if surgery is required at a later date, they will help your overall chance of being more comfortable. Types of Pessary Ring pessary This is a soft plastic ring or device which is inserted into the vagina and pushes the prolapse back up. This usually gets rid of the dragging sensation and can improve urinary and bowel symptoms. It needs to be changed every 6-9 months and can be very popular; we can show you an example in clinic. Other pessaries may be used if the ring pessary is not suitable. Some couples feel that the pessary gets in the way during sexual intercourse, but many couples are not bothered by it. Shelf Pessary or Gellhorn If you are not sexually active this is a stronger pessary which can be inserted into the vagina and needs changing every 4-6 months.

5 Page 5 of 14 Surgical operation for prolapse The operation can be done with a spinal or general anaesthetic and you may have a choice in this A spinal anaesthetic involves an injection in the lower back, similar to what we use when women are in labour or for a Caesarean Section. The spinal anaesthetic numbs you from the waist down. This removes any sharp sensation but a pressure sensation will still be felt A general anaesthetic will mean you will be asleep (unconscious) during the entire procedure General risks of surgery Anaesthetic risk This is very small unless you have specific medical problems. This will be discussed with you. Haemorrhage There is a risk of bleeding with any operation. The risk from blood loss is reduced by knowing your blood group beforehand and then having blood available to give you if needed. It is rare that we have to transfuse patients after their operation. Infection There is a risk of infection at any of the wound sites. A significant infection is rare. The risk of infection is reduced by our policy of routinely giving antibiotics with major surgery. Deep Vein Thrombosis (DVT) This is a clot in the deep veins of the leg. The overall risk is at most 4-5% although the majority of these are without symptoms. Occasionally this clot can migrate to the lungs which can be very serious and in rare circumstances it can be fatal (less than 1% of those who get a clot). DVT can occur more often with major operations around the pelvis and the risk increases with obesity, gross varicose veins, infection, immobility and other medical problems. The risk is significantly reduced by using special stockings and injections to thin the blood (heparin).

6 Page 6 of 14 Anterior Vaginal Wall Prolapse repair (Anterior Colporrhaphy) How the operation is performed The legs are placed in stirrups (supported in the air) The front vaginal wall is injected (infiltrated) with local anaesthetic A vertical cut is made in the front wall of the vagina over the area of the bulge The vaginal skin is then separated from the bladder Two or three repair sutures are placed in the tissues at either side of the bladder These stitches are then tied in the centre thus bringing the fibrous tissue into the middle so that the bladder is elevated behind them and thus supported. This stops the bladder bulging into the front vaginal wall. Any excess vaginal skin is trimmed and then the vaginal skin closed with dissolvable stitches Specific risks for anterior vaginal wall prolapse repair (Anterior Colporrhaphy) Damage to local organs This can include bladder, ureters (pipes from kidneys to the bladder) and blood vessels. This is a rare complication but requires that the damaged organ is repaired and this can result in a delay in recovery. It is sometimes not detected at the time of surgery and therefore may require a return to theatre. If the bladder is inadvertently opened during surgery, it will need catheter drainage for 7-14 days following surgery. Prolapse recurrence If you have one prolapse, the risk of having another prolapse sometime during your life is 30%. This is because the vaginal tissue is weak. The operation may not work and it may fail to alleviate your symptoms. Pain General pelvic discomfort, this usually settles with time and tenderness on intercourse due to vaginal tethering or mesh erosion (if mesh was used). Occasionally pain on intercourse can be permanent. Overactive bladder symptoms Urinary urgency and frequency usually get better after the operation, but occasionally can start or worsen after the operation. If you experience this, please make us aware so that we can treat you for it.

7 Page 7 of 14 Stress incontinence This may develop in up to 5%, having a prolapse sometimes causes some kinking to the exit of your bladder. This can be enough to stop urine leaks on coughing, laughing or sneezing caused by a weak bladder. By removing the prolapse this kink gets straightened out and the leaks are no longer stopped. Urinary retention may also develop in a small number of patients Reduced sensation during intercourse Sometimes the sensation during intercourse may be less and occasionally the orgasm may be less intense Posterior vaginal wall prolapse repair (Posterior Colporrhaphy) How the operation is performed The legs are placed in stirrups (supported in the air) The back vaginal wall is infiltrated with local anaesthetic A horizontal cut is made where the back wall of the vagina meets the skin just outside the vagina A vertical cut is then made in the back wall of the vagina, over the area of the bulge The vaginal skin is then separated from the rectum (lower bowel) Two or three stitches are placed in tissue at either side of the rectum These stitches are then tied in the centre thus bringing the tissue into the middle so that the rectum is held behind them and thus supported. This then stops the rectum bulging into the back vaginal wall Sometimes a Perineorrhaphy, which is a surgical repair of the perineum (the skin and muscle between the front and back passage), will be performed. This can improve the prolapse repair but can result in tightening of the vaginal entrance and pain during sexual intercourse Any excess vaginal skin is trimmed and then the vaginal skin closed with stitches A vaginal pack (ribbon gauze to apply pressure) may then be inserted into the vagina which is removed the following morning. A catheter may also left in the bladder overnight

8 Page 8 of 14 Specific risks of the operation for posterior vaginal wall prolapse repair (Posterior Colporrhaphy) Damage to local organs This can include bowel and blood vessels. This is a rare complication but requires that the damaged organ is repaired and this can result in a delay in recovery. It is sometimes not detected at the time of surgery and therefore may require a return to theatre. If the rectum (back passage) is inadvertently damaged at the time of surgery, temporary colostomy (bag) may be required but this is exceptionally rare. Prolapse recurrence If you have one prolapse, the risk of having another prolapse sometime during your life is 30%. This is because the vaginal tissue is weak. Pain General pelvic discomfort, this usually settles with time but occasionally pain on intercourse may occur and can sometimes be permanent. Reduced sensation during intercourse Sometimes the sensation during intercourse may be less and occasionally the orgasm may be less intense. Change in bowel function Occasionally patients can become constipated after the operation but often bowel function is improved. Vaginal Hysterectomy How the operation is performed Your legs are placed in stirrups (to elevate them) and the vagina and surrounding skin cleaned with antiseptic solution Often some local anaesthetic will be injected into the vagina even if you are asleep as it can help to make the operation easier and reduce bleeding A cut is made around the neck of the womb (cervix). Alongside the womb are strong ligaments (which help to hold the womb up) and the blood vessels to and from the womb. These are cut and tied off with dissolvable stitches The womb is taken out and sent to the laboratory so that they can look at it under a microscope and check it is a normal womb

9 Page 9 of 14 The hole at the top of the vagina is stitched closed with dissolvable stitches. Once it has healed, the vagina will have a smooth top Usually a catheter tube is passed along the urethra (water pipe) to drain the bladder. Once any swelling around the bladder has gone down, this will be removed Sometimes a long bandage called a pack will be put in the vagina to press on the wound and soak up any spilled blood. This is removed the next day Specific risks of the operation for uterine prolapse Vaginal Hysterectomy Getting another prolapse Unfortunately, having a vaginal hysterectomy does not always stop you from getting a further prolapse. Although the womb has been removed, the vaginal walls or the top of the vagina (the vault) can sag with time. About 1 in 3 women who have an operation for prolapse get another prolapse during their lifetime. This second prolapse may not cause them bother. Keeping your weight normal for your height, avoiding unnecessary heavy lifting, and not straining on the toilet, will help prevent a further prolapse although even adhering to this sometimes does not prevent a further prolapse. A change in the way your bladder works Having a prolapse sometimes causes some kinking to the exit of your bladder. This can be enough to stop urine leaks on coughing, laughing or sneezing caused by a weak bladder. By removing the prolapse this kink gets straightened out and the leaks are no longer stopped. If your doctor thinks this might happen to you, they may suggest having some bladder tests before the operation so that you know what the risks are. After a vaginal hysterectomy, the bladder becomes irritable or overactive in up to 15% of women. This means that for every 100 women who have a vaginal hysterectomy, 15 get an irritable or overactive bladder that they didn t have before. This gives symptoms like needing to rush to the toilet or needing to pass urine more often. Sometimes an overactive bladder can make you leak because you can t get to the toilet in time. A change in the way your bowel works Having some constipation after an operation is very common and this usually settles quickly. Women rarely find their bowels have changed after a vaginal hysterectomy. Needing to make a cut in your abdomen (tummy) Occasionally an incision is required in the abdomen to remove the womb. This may be because there is heavy bleeding making it difficult to see or because the womb is much bigger than expected or because there is scar tissue from a past operation sticking to the womb. If the incision is needed it is usually a bikini line cut. A hysterectomy via the abdomen (abdominal hysterectomy) is usually more painful than a vaginal hysterectomy so you may need extra painkillers and a bit longer in hospital. Your doctor will explain why it was needed so you know what happened in the operating theatre.

10 Page 10 of 14 Damage to the bladder or bowel During the operation, cuts and stitches are made very near the bladder, ureter (tube taking urine from kidney to the bladder), and bowel, and occasionally the surgeon may make a hole in the bladder or bowel by accident. It is usually possible to repair the hole straight away but it may affect your recovery. Your doctor will explain what happened and what, if anything, needs to be done about it. Painful sexual intercourse Once the wound at the top of the vagina has healed, there is nothing to stop you from having sex. The healing usually takes about 6 weeks. Some women find sex is uncomfortable at first but it gets better with time and sometimes improves using a bit of extra lubrication (KY Jelly). Sometimes sex continues to be painful after the healing has finished but this is rare especially if only a vaginal hysterectomy has been performed. Change in sensation with intercourse Sometimes the sensation during intercourse may be less and occasionally the orgasm may be less intense. What happens before your operation? (Pre-assessment Clinic) A doctor or nurse practitioner will explain your operation to you and ask you to sign a consent form for the operation. A copy of the consent form will be given to you to keep. All risks and complications associated with your surgery will be discussed with you prior to signing a consent form. You will be asked to attend a pre-assessment clinic prior to your admission; the aim of the assessment is to confirm you are fit for surgery. Routine blood samples will be taken. Pulse and blood pressure is checked. The nurse carrying out your assessment is a Nurse Practitioner and will ask you questions concerning your general health. The nurse will assess if you require any further investigations and will arrange these. Other tests may include ECG (tracing of your heart), chest X-ray, spirometry (test for assessing if your lungs are working effectively). Please inform the nurse if you have had a recent cold as this may pose a hazard if you are having a general anaesthetic.

11 Page 11 of 14 The assessment will take approximately 40mins. If further investigations are required, please allow up to 1½ hours. You can contact the Pre-Assessment Clinic on between 8am 3pm. If you develop a cold after you have attended for your assessment, please phone the Jasmine Suite for advice on When you come into hospital Please bring into hospital all medications taken including enough to last for a week The anaesthetist will see you prior to your surgery. If you feel anxious you may be prescribed a premedication usually taken an hour prior to surgery You will be asked to have a bath/shower; do not use deodorant or body lotion following this. The nursing staff will provide you with a gown to wear; no underwear, jewellery, nail varnish, false nails or make-up are to be worn The nursing staff will help you with any questions you have or worries After the operation Following your operation you will be taken into the recovery room in theatre. The nurses will look after you until you are ready to come back to the ward On return to the ward your blood pressure, pulse and vaginal loss will be monitored You may have a drip in your arm; this will keep you hydrated and help your kidneys produce urine and help keep blood pressure stable. This will be taken out when you feel able to drink A catheter may be put into your bladder to drain urine; this will be done in theatre while you are asleep. A catheter will give your bladder a rest following surgery and help the nurses on the ward monitor the amount of urine you are producing. The catheter will stay in your bladder usually for hours. The surgeon will tell the nursing staff if it needs to stay in any longer depending on the type of surgery you have had Occasionally a bandage is inserted into the vagina called a vaginal pack to help stop any bleeding; this is done in theatre and will be removed 24 hours later by a nurse on the ward You will be given regular medication to alleviate the pain, nausea or any discomfort You will be assisted with hygiene needs the first day following your surgery, usually by the bedside. By the second day following your operation you will be able to have a bath

12 Page 12 of 14 Mobility is encouraged in the early stages of recovery to prevent circulatory problems. You may be given a daily injection of a drug called heparin this will help prevent any clots developing in your legs Depending on your condition you will be discharged home 2-3 days following surgery Please inform staff on admission if you would like to see a social worker who may be able to help with shopping and cleaning When you are ready to go home A week s supply of new medication will be given to you. A sick note will be given to you if needed. This will provide cover while you have been in hospital when you are recovering. If you have any concerns you can phone the ward day or night to ask for advice, the phone number is When you go home Avoid lifting for 3 months, this includes carrying shopping bags, vacuuming / cleaning, ironing (for 6 weeks), moving furniture, going to the gym, swimming (6 weeks). Avoiding constipation. Drink plenty of water / juice and eat fruit and green vegetables. Plenty of roughage e.g. bran / oats At six weeks gradually build up your level of activity. After 3 months, you should be able to return completely to your usual level of activity. You should be able to return to a light job after about six weeks. Leave a very heavy or busy job until 12 weeks. You can drive as soon as you can make an emergency stop without discomfort, generally after 4 weeks, but you must check this with your insurance company, as some of them insist that you should wait for six weeks. Avoid sexual intercourse for 6 weeks. You will need to be gentle and may wish to use lubrication (such as KY jelly) as some of the internal knots could cause your partner discomfort. You may, otherwise, wish to defer sexual intercourse until all the stitches have dissolved, typically 3 months. Do not use tampons as this may cause infection, sanitary towels are advised. Following surgery you will have a light vaginal discharge; this is normal and may continue for 7 14 days. If the loss becomes heavy or offensive please contact your GP who will advise you.

13 Page 13 of 14 Useful references - Where can I obtain more information? NHS direct online may be a good starting point for finding out more information about vaginal prolapse. For more information on your anaesthetic, you can visit a useful website supported by the Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland Things I need to know before I have my operation Please list below any questions you may have, having read this leaflet: 1).. 2) 3).. 4) 5) Please describe what your expectations are from surgery: 1). 2)... 3).. 4).. 5).. Contact us Jasmine Ward

14 Page 14 of 14 If you would like this leaflet in a different format, for example, in large print, or on audiotape, or for people with learning disabilities, please contact: Patient and Customer Services, Poplar Suite, Stepping Hill Hospital. Tel: Information Leaflet. Our smoke free policy Smoking is not allowed anywhere on our sites. Please read our leaflet 'Policy on Smoke Free NHS Premises' to find out more. Leaflet number MAT61 Publication date April 2014 Review date April 2017 Department Jasmine Ward, Woman's Unit Location Stepping Hill Hospital

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