Uterine Prolapse
Having Prolapse, Cystocele and Rectocele Fixed Without Hysterectomy
Frederick R. Jelovsek MD
"Is a hysterectomy absolutely necessary in order to repair a rectocele? Is there some procedure for repair without having to also have a total hysterectomy? This is after menopause, age 52, difficult birth of a child 24 years ago, now the herniated rectum (rectocele) is protruding through the vagina ... not all the time...more after being tired at the end of a day." G.T.
"I am 50 yrs old and have been diagnosed with a prolapsed uterus, bladder, and rectum. From what I have read, this will be an increasing problem for the baby boom generation, as we age. The only treatment my doctor recommends is hysterectomy with rectal and bladder repair, which can fail and lead to other problems. Is any research being done into more effective ways to correct this problem? Are uterine resuspensions, using materials other than the patient's own tendons, a good option for older women?
I started periods at 12 and still having regular periods. I'm not taking any prescription drugs on regular basis. I have fibrocystic breast disease and my doctor does not want to prescribe estrogen. I do eat soy products. I feel the general public should be more aware of this condition and its causes, such as heavy lifting when you're older (my problem!!), certain delivery techniques, family history,etc ". Z6
Pelvic relaxation with its attendant possible loss of bladder support, rectal support, and support of the uterus and the vagina, is definitely a problem on the rise with an aging population. In post menopausal women, the rich blood supply of the vagina and surrounding tissues becomes less with age and the physical organ support those blood vessels play become less and less with time. This allows previous weakness in the support structure to worsen and allows pelvic organs to drop further until they come outside the vaginal opening or come close to the opening and just put stretch and pain on the remaining ligament attachments.
The condition of pelvic organ prolapse has had many different surgical approaches depending upon the surgeon's conceptual model of what the actual anatomical hernia defect is. It now appears that there can be multiple different defects in the supporting tendons (fascia) of the pelvis and even though the primary defects may be repaired at a given surgery, other secondary defects weaken with time resulting in the need for further surgical repair. The mesh of tendinous attachments of the vagina and uterus are like a nylon stocking that is attached to the sidewalls of the pelvis and the tailbone (sacrum). The "hosiery" comes in sheer, medium and support thickness just as women differ in their genetic makeup and tendon strengths. With childbirth, the "hosiery" mesh gets "runs" in it in one or more places. At first the runs are not big enough to cause loss of support. As more and more straining takes place on those "runs", some of them widen and lengthen and allow the organs that lie on the outside of the stocking, such as the bladder, rectum or uterus at the end, to fall down and collapse the stocking shut and eventually to turn it inside out. Surgeons need to know where the "runs" are in order to fix the defects.
Let us look at some of the factors at work in this still-to-be-better-defined condition of pelvic relaxation.
Why do doctors often recommend hysterectomy as part of the repair for prolapse?
I think it is true that most doctors will include hysterectomy (if all childbearing desire is done) in their recommendations for pelvic prolapse surgery. Scientific studies have not adequately addressed whether removing the uterus makes prolapse surgery any more or less successful than when the uterus is left except in the case of genuine stress incontinence. When genuine stress incontinence is present, loss of urine with coughing or sneezing, the support defect is called urethrocoele or loss of the urethrovesical angle. Studies have shown that correction of stress incontinence alone is neither more nor less successful if hysterectomy is performed (1).
The bottom line is that hysterectomy DOES NOT need to be performed when fixing pelvic support defects. With support defects such as bladder dropping (cystocoele), rectal wall protrusion into and out of the vagina (rectocoele), cul-de-sac hernia (enterocoele), and uterine prolapse, there have not been any large surgical series reported in which the uterus was left in place. Some of the smaller studies (2) reported for fixing uterine prolapse without hysterectomy seem to imply there is not a difference in the recurrence rate. So why do doctors almost always suggest hysterectomy? Here are some of my opinions:
- Many women request hysterectomy at the time of major prolapse surgery. Premenopausal women request it because they feel that the absence of menses will be more convenient or, if they are having pain, abnormal bleeding or Pap smear problems, that those conditions will go away. Postmenopausal women request hysterectomy because removing the uterus with its cervix and the ovaries will almost totally abolish the chance of ovarian, uterine and cervical cancer.
- Doctors find that patients have more difficulty with hormone replacement therapy (HRT) because they must take progestins along with estrogen so they do not develop endometrial cancer. The progestins and even natural progesterone tends to produce more mood side effects and bleeding side effects. These side effects of HRT entirely go away if a woman has a hysterectomy because the source of the bleeding (uterus) is gone and there is no need for progestin or progesterone and their side effects since the endometrium has been removed and does not need to be protected from cancerous changes.
- In their training, many physicians did not learn or commonly practice surgical techniques in which the uterus was left in. Thus they are "more comfortable" in their surgical experience with removing the uterus at the time of prolapse surgery. Almost always with cystocele or rectocele, there is also some degree of vaginal vault prolapse and the procedures to suspend the vagina so it does not prolapse in the future are almost as extensive as the hysterectomy as far as surgical and anesthesia time, as well as the risks of surgical complications or injury.
- There is a common unsubstantiated conception among many patients and some physicians that the weight of the uterus will put more downward pressure on the pelvic support structures and worsen prolapse in the long run, thus making their surgery less likely to be successful.
- Post operative recovery time from pelvic hernia surgery is about the same whether or not the uterus is removed. It is about 6 weeks before a woman should return to work unless she has a very sedentary job, and for another 6 weeks there should be very little intraabdominal straining in order not to disrupt the prolapse repairs.
Keep in mind there are many physicians who are comfortable correcting prolapse defects surgically without removing the uterus. One organization of surgical specialists in prolapse surgery is the Society of Gynecologic Surgeons. They have a geographic list of physicians.
How effective is surgery at fixing these prolapse problems?
Almost all prolapse surgery has some failures. Successes of most of the procedures range from 65%-90% although the longer the patients are followed, the lower the permanent success rate. The biggest reason for recurrence of prolapse problems is that all of the anatomical defects present were not recognized or not evident at the time of the original surgery. Every gynecologic surgeon has had experiences in which patients return 1-5 years or more later with symptomatic prolapse of one of the sites not originally thought to be a problem. Sometimes when one anatomic area is fixed, all of the excess intraabdominal pressure from lifting, straining or chronic coughing is redirected to a weaker area. This weaker area over time develops a hernia.
Women who undergo surgery for prolapse should take at least 3 months off from any lifting over 10 pounds and any intraabdominal straining as much as possible. In my opinion they should never engage a strenuous occupation or regular leisure activities that demand increased intraabdominal pressure. Many of the surgical failures that I am aware of had episodes of moving furniture, a sudden fall with moderate impact or some other episode of abdominal straining during which they felt a "pop" and then subsequent pelvic pressure.
What are some of the complications of prolapse surgery?
The major complication is failure of the procedure to keep the pelvic organs supported. Other complications are those of any major surgery such as wound infection, blood clot to the lung, anesthetic complications, lung or bladder infections, or injuries to adjacent organs such as the rectum, bowel, bladder urethra (tube from the bladder to the outside) or ureter (tube from the kidney to the bladder).
Another complication more unique to prolapse and hernia surgery is infection in the area of non human materials used during the surgery. Synthetic mesh, bone tacks, and even non dissolving sutures that are used during the surgery can become infected (about 3-5%) and produce chronically draining pus sinuses. Surgeons like to use the natural tissues and ligaments to repair these hernias if possible but sometimes the tissues are just too weak and a synthetic material is needed.
Long term residual pain in the areas of scarring along surgical suture lines is a rare but major complication of this surgery. In the case of rectocoele repair the pain can be with intercourse or with having bowel movements or even with walking (3) and sometimes fecal incontinence can occur. In the case of cystocoele or bladder repair, pain can also be with intercourse, voiding of urine or a chronic pubic bone pain.
Are there new techniques and materials being tested to improve the surgical success of this problem?
There are always new publications about different procedures, methods and materials to help improve the success of prolapse surgery. For stress incontinence, "bone tacks" are being tried. Synthetic mesh made of Prolene®, Mersilene® and Gore-Tex® have been used for support of the vagina or cervico- vaginal area to repair uterine or vaginal prolapse (4)
What are the key considerations when faced with a decision for possible surgery for prolapse.
(Note -- The following suggestions about surgical procedures may seem highly technical, but the only way to avoid a high likelihood of recurrent prolapse is to have the most appropriate surgical repairs done in the first place.)
A primary consideration with pelvic organ prolapse is whether or not you have associated urinary incontinence with straining or coughing. If you do not have incontinence at present, do you get incontinence if you wear one or two large tampons in the vagina to elevate the bladder and uterus? Also, during your pelvic exam by the doctor, you should expect a "Q-tip" test. This is an exam in which the doctor puts a small cotton-tipped applicator lubricated with xylocaine gel into the urethra. Then you are asked to strain down. If the applicator rises 30 degrees or more, this means that the urethra-bladder neck drops down with straining and it is very likely that if you do not already have stress urinary incontinence, you will develop it after the surgery if the doctor does not plan to include some type of bladder neck suspension as part of your surgical procedure.
Another consideration is for the doctor to carefully examine any bladder dropping (cystocoele) and determine whether or not the anatomical defect is in the middle of the vaginal wall under the bladder or whether it is at the sides of the vagina (paravaginal). Doctors previously only performed a procedure called anterior colporraphy as if all cystocoeles were midline defects. Now we know that most defects are paravaginal. Therefore the surgeon's plan for correction of a cystocoele should almost always include a paravaginal repair done from a vaginal, abdominal or laparoscopic approach. If not, at least the doctor should be able to explain why a specific procedure is being planned for.
Finally, if any uterine or vaginal prolapse is present, ask the doctor what tissues the vagina will be reattached to to prevent it from falling down again. Usually the answer will include either the uterosacral ligaments, the sacrum or the sacrospinous ligament. If the doctor suggests you should not worry about the precise method of suspension or just suggests a vaginal hysterectomy with an anterior cystocoele and posterior rectocoele repair, it might be prudent to get a second opinion. That does not mean these procedures are not effective, but they can be a marker for a surgeon who is not following the recent literature closely.
This article has been updated 5/7/00 from its original publication on October 17, 1999.
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