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Pelvic floor repair

If you are considering having pelvic floor repair, or have a pelvic floor repair operation planned, it is important to know all you can about it. This includes:

 

  • why you need this pelvic floor repair operation

  • what it will be like

  • how it will affect you

  • what risks are involved

  • any alternatives.

 

The information here is a guide to common medical practice. Each hospital and doctor will have slightly different ways of doing things, so you should follow their guidance where it is different from the information given here. Because all patients, conditions and treatments vary it cannot cover everything. Use this information when making your treatment choices with your doctors. You should mention any worries you have. Remember that you can ask for more information at any time.

 

 

What is the problem?

You probably feel as if something is coming down into your vagina. This is because of a weakness in your pelvic floor. The organs in your pelvis can pass through this weak area and press against the wall of your vagina.

 

What are the structures in the pelvis?

To explain what structures are in your pelvis and what they do, the best place to begin is the vagina. The vagina is a tube about five inches long. It runs from just in front of your rectum up into your pelvis. It is just behind your bladder. You can feel your bladder in your lower abdomen when it is full of urine. A tube takes urine from your bladder to the outside just in front of your vagina. It is called the urethra.

Pelvic floor repair

 

At the top of your vagina is your uterus. It is about the size of your clenched fist. It is where a baby develops during pregnancy. It is made of thick muscle, but is hollow inside. The lowest part of your uterus, which juts into your vagina, is ‘the neck of the womb’, also called your cervix. Cervical smears are taken from the surface of your cervix.

 

The rest of your uterus is called the body. It thins out at the top to form two hollow tubes called the Fallopian tubes. You have a Fallopian tube on each side. These run sideways to end near your left or right ovary. Your ovaries are slightly smaller than a golf ball. They lie deep in your pelvis just below your waist. Your ovaries make hormones and contain tiny eggs, which are too small to see with the naked eye.

 

What is the pelvic floor?

Your pelvic floor holds the structures in your pelvis in place. It is made of sheets of muscle and tough bands of fibre, called ligaments. These stretch across the inside of your pelvis. You can feel your pelvic floor tighten when you try to hold in urine.

 

Your uterus, bladder and the upper part of your urethra normally lie above your pelvic floor. Your vagina, rectum and the lower part of your urethra all pass through your pelvic floor to the outside. Your vagina passes through the centre of your pelvic floor with your urethra to the front of it and your rectum behind.

 

What has gone wrong?

Your pelvic floor has weakened and given way. Causes may include:

 

  • Stretching during childbirth.
  • The change in hormones at the menopause.
  • Being overweight.
  • Having a chronic cough.

 

When an organ drops from its normal position it is called a prolapse. Your bladder, urethra, uterus and rectum can all prolapse through your pelvic floor. If they do, they will press against some part of the wall of your vagina causing a swelling. Any or all of these organs can prolapse at the same time.

Pelvic floor repair 2

 

The different types of prolapse are:

 

  • Cystocele - A prolapse of the bladder into the front wall of the vagina.
  • Hysterocele - A prolapse of the uterus into the back, front or top of the vagina.
  • Rectocele - A prolapse of the rectum into the back wall of the vagina.
  • Urethrocele - A prolapse of the urethra into the lower front wall of the vagina.
  • Enterocele - A prolapse that contains loops of bowel.

 

If you have a cystocele, where your bladder prolapses, you will feel it bulging against the front wall of your vagina. It may cause urine to leak, called urinary incontinence.

 

If you have a hysterocele, where your uterus prolapses, there are three degrees of severity. A first-degree prolapse is minor; the uterus comes down into the vagina but is still completely inside. A third degree prolapse is severe; the uterus and cervix drop outside the vagina. This is also called a total prolapse or procidentia. A second degree prolapse lies somewhere between these two.

Pelvic floor repair 3

 

Sometimes, the prolapse is not as severe as it first seems due to the cervix lengthening rather than both the uterus and cervix dropping.

 

The aims

A pelvic floor repair will remove the swelling in your vagina. It will stop any bleeding, pain or leak of urine. We do the operation through a cut in the wall of your vagina. We will usually push your prolapsed organs back into their normal positions above your pelvic floor. Then we do a repair operation, where we tighten the surrounding ligaments to hold your organs in place.

If you have a hysterocele, where your uterus has prolapsed, it may be best to remove the uterus along with your cervix. This operation is called a total vaginal hysterectomy. Without a uterus you cannot bear children and you will have no more periods. Although this may treat painful, heavy periods you need to be sure you never want to become pregnant before agreeing to a hysterectomy.

 

If you have a hysterectomy, we will usually leave healthy ovaries in place. They will continue to produce hormones until you reach the menopause. You will still have your usual premenstrual symptoms but will not have period pain or bleeding. During the menopause, you can still expect hot flushes and dizzy spells as usual. All women have a small chance, about one in 250, of developing cancer in their ovaries. Leaving them in at a hysterectomy does not increase this chance, but sometimes we remove healthy ovaries to prevent this. Discuss all the options with your gynaecologist. If your ovaries are not healthy, they should be removed at the same time as the hysterectomy. It may be possible to remove your ovaries and Fallopian tubes during a vaginal hysterectomy, but this gives a danger of damage to other parts of your pelvis. The operation to remove both Fallopian tubes and ovaries is called a bilateral salpingo-oophorectomy.

 

If you have a long cervix as the main feature of the prolapse, we may just remove this instead of your whole uterus.

 

Are there any alternatives?

 

  • Pelvic floor exercises or electrical implants - These may help to strengthen your pelvic floor muscles if your prolapse is minor.
  • Vaginal pessary - This is a plastic ring put inside your vagina to prevent any loose vaginal skin from coming down. It can be an effective and comfortable alternative to surgery, but does not work for everyone. With regular checking it may work for many years.
  • Laparoscopic surgery - This is an operation using keyhole instruments. We repair your pelvic floor through a number of small cuts in your abdomen rather than through your vagina.
  • Burch colposuspension - This is an abdominal operation to lift the bladder. If your bladder has prolapsed, especially when you also have problems with leaking urine, this may be the best treatment. There is a separate leaflet within this series covering this operation.

 

All of these alternative treatments may be improved by hormone replacement therapy (HRT) or by using hormone creams, called oestrogens. These help by increasing the blood supply to your pelvic organs.

 

What if you do nothing?

Without treatment your prolapse will usually become steadily worse. Although a prolapse can be very uncomfortable, it rarely causes a serious risk to your health. If your vaginal skin lies outside your body it will be damaged as it becomes sore, cracked and dry.

 

If you have a third degree prolapse it can sometimes put pressure on your ureters and kidneys, causing serious problems with passing urine. If the prolapse can be repaired, there is usually little sense in putting up with the symptoms.

 

Author: Dr David Hutchon F.R.C.O.G.  Consultant Gynaecologist.

© Dumas Ltd 2006

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