Vaginal Surgery
It is quite surprising what can be done this way and it is the source of all those jokes about Gynaecologists re-building car engines through the letterbox. In this regard, it can be complex and challenging.Largely, vaginal surgery is performed for prolapse or urinary incontinence or both. The method of repair will use either your own tissues (Native tissue repair) or Mesh or both. Results also vary based on a patient's weight, age, hormone status, degree of prolapse, constipation, chronic asthma, past surgery, lifestyle etc.
There are 3 areas to operate on, in any combination:
Front wall prolapse (Anterior Vaginal Repair)
- This involves the bladder +/- the urethra
- 30% chance it will fall down again within 6 weeks to 6 years
- 50% chance incontinence will get better in the short term
- 5% chance incontinence will be worse after surgery or appear when it wasn't there before
- 10% chance you will develop some urinary urgency. This usually resolves within 4 weeks but may persist
- Small chance of putting a hole in the bladder. This usually heals well but you will have a catheter in the bladder for 7-10 days.
- Small chance of kinking or tying off a ureter, possibly requiring a 2nd operation to fix the ‘oops'. A cystoscopy is done during the operation to check for this.
- Swelling and bleeding in the area can make it too difficult to empty the bladder and you may need to go home with a catheter for a week before returning for a Trial of Void.
- This is done when the bowel is pushing up through the back wall of the vagina or when childbirth has stretched the supports and there is a bulge of this area.
- Some women who have lost vaginal sensation, have a Posterior Repair to improve sensation during sex - a 'designer vagina'
- The long term results are good, with a low recurrence rate
- There is a small chance of vaginal scarring, making sex painful
- There is a very small chance of significant scarring making sex impossible. This is more likely with multiple attempts at surgery
- There is a small chance of a bowel injury
- The top of the vagina can prolapse, a bit like a sock turning inside out -- Putting this back can be difficult and the method often (not always) depends on the presence or absence of a uterus, your age, degree of prolapse and how many previous operations have been done.
- It is often combined with a repair of the front and back walls
- It often involves a mesh repair
An In-Dwelling Catheter (IDC) is often present for 24 - 48 hours depending on the operation. It will remain for 7-10 days if the bladder was opened for any reason or if you do not pass your Trial of Void.
Vaginal Pack - this is a long piece of gauze dressing, used to apply pressure to the vaginal walls and reduce blood loss. It will give you a ‘full bowel' feeling and is usually left in until the next morning unless you find it too uncomfortable. It does not hurt to remove.
Pain after surgery varies with the procedure but most women find it tolerable and require little pain relief. Pain in the hips due to positioning on the table or sutures / mesh passed through ligaments is also operation dependent.
Bowel Function is very important. Make sure you continue taking stool softeners and have plenty of fluids. Constipation is a big problem, especially after a Posterior Repair.
Urinary Tract Infections occur in about 3% of patients.
Recovery is always 6 weeks. Don't do any heavy lifting or straining. If you weigh 100+ kg, this includes heaving yourself up into 4 wheel drives. Take it easy, because if you stretch the newly formed scar tissue, you will get a recurrence.
A few words about Continence (urethra and bladder neck) operations:
- As a general rule, I repair prolapse and then review the continence issues later.
- Although prolapse surgery can cure incontinence, it can also reveal incontinence which was hidden. A large bladder prolapse can kink off the urethra which is why some women find that as their prolapse gets worse, their incontinence gets better.
- Urodynamics is done prior to continence surgery
Mesh Repairs for prolapse or incontinence utilize one of a number of commercially available polypropylene products which replace and enhance existing tissue supports. These are often utilized when doing repeat procedures or for the very large prolapse. Continence operations now use these products as a routine first line measure.
The mesh is a permanent structure and there are some complications, specific to these products, which can occur.
- Exposure of the tape. If you do not heal well, have poor tissues or we cannot get good coverage of the mesh, it can gradually break through the vaginal surface and become exposed. This can result in bleeding, scarring and pain with intercourse. Usually a 6 week course of a vaginal oestrogen will allow the vagina to close over the mesh but sometimes part of the mesh will need to be removed in theatre.
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