Information Sheet for Women Considering Surgery for Prolapse
What type of surgery should I choose?
There are a number of different operations for prolapse. Your choice of surgery will depend on the type of prolapse you have, but there are other important factors. A desire for future pregnancy is one such consideration. Your surgeon might also recommend a particular operation for medical reasons. Of course as you are aware not proceeding with surgery is also a reasonable option and one could consider conservative choices if you wish.
Surgery for prolapse should be regarded as a major procedure. Most commonly it is performed to treat the primary symptoms of a lump coming down in the vagina, or helping correct where the walls of the vagina have weakened. It may also lead to secondary improvements in bowel and bladder symptoms, but this is not always the case, and indeed these symptoms may occasionally worsen.
Surgery can be done vaginally or abdominally (usually this is done by keyhole surgery), and there are various indications and benefits and risks of either approach. Depending on the extent of your prolapse the surgeon may discuss the need to treat prolapse of the womb.
This leaflet has been produced to help you decide whether surgery is the right treatment for you. You will need to make the final decision.
What are the alternatives to surgery?
Before you consider surgery, you should think about other options:
- Carrying on as you are.
- Pelvic floor physiotherapy.
- The use of a vaginal pessary.
If you decide not to have treatment, you will continue to be troubled by your symptoms. However, you are very unlikely to come to any harm.
Physiotherapy is an effective treatment, especially if your prolapse is not too severe. Around half of women who engage in physiotherapy will find that their symptoms improve. Physiotherapy appears to continue working provided that you do not stop practising your exercises. If your prolapse is quite severe, we are not sure how well physiotherapy works.
Vaginal pessaries are an alternative treatment. A pessary is a removable device that is placed in your vagina. Most are made of soft plastic or silicone and shaped like a ring. There are different types of pessary and they come in different sizes. Pessaries relieve prolapse symptoms by keeping the womb and vaginal walls in their normal position. A number of women might experience some bleeding or discharge when they use a pessary. Rarely, a minor infection might develop. These problems are usually easy to treat.
What are the complications of surgery?
All operations can be associated with complications. These are undesirable or unwanted effects that happen as a result of surgery. If a complication affects you, it does not mean that something must have gone wrong during the surgery.
The risk of having a complication varies depending on the type of surgery you have.
Complications that can be associated with surgery include:
- Bleeding and blood transfusion.
- Blood clots in the legs travelling to the lungs.
- Damage to the bowel, bladder, and other organs.
- New or worsening bowel or bladder symptoms.
- Painful sexual intercourse.
- Long-term problems with pain.
- Problems with implanted mesh used to repair prolapse.
- Failure of the operation to cure the prolapse – unfortunately because prolapse is a result of weak tissue coupled with lifestyle factors, there is a high rate of failure of some prolapse operations. This is why different techniques have been developed to try and lessen the recurrence rates of prolapse and why preparing for surgery before and taking care following surgery is so important.
Although the risk of most complications is low, we recommend that patients try non-surgical treatments before surgery. This is because non-surgical alternatives are generally not associated with serious complications. More details about the complications of surgery can be found in information sheets on each surgical procedure.
Will I need more than one operation?
Sometimes prolapse might only affect one area. An example might be prolapse that only affects the womb. Similarly, some women might only be troubled by prolapse of the vaginal walls. More commonly, these problems affect more than one area at a time. For this reason, your surgeon might need to perform more than one surgical procedure to help you.
If you are affected by prolapse in more than one area, your surgeon will explain which types of surgery they think are needed. If you need to combine two or more procedures, this is usually performed at the same time. Sometimes, combining different operations on the same day might significantly increase the risk of complications. If this is the case, your surgeon might recommend having separate operations instead. You may require treatment to address urinary problems at a later date.
Can I have surgery if I want more children?
It is generally recommended that you avoid surgery if you are planning to have more children. The concern is that further pregnancy or vaginal delivery might reduce the long-term success of your operation. However, if your symptoms are difficult to control with non-surgical treatments your surgeon can discuss other options.
If you have prolapse of the womb, the womb can be lifted using stitches or sometimes mesh inserted using keyhole surgery. Pregnancy is possible after this procedure, although the success of the operation might be affected. If you have vaginal wall prolapse, a vaginal operation to repair the prolapse using stitches is an option. One does not usually recommend such surgery if pregnancy is planned. It would be usually recommended to have a caesarean section to deliver your baby in a future pregnancy. Sometimes, just getting pregnant again can affect your repair, even if you do not deliver vaginally. For this reason, it is best to avoid surgery and try other treatments until your family is complete.
Is the operation done vaginally or abdominally?
There are generally two different ways of treating prolapse – via the vagina or the abdomen (usually via “keyhole” laparoscopic surgery). This really depends on the nature of your prolapse. Usually if the prolapse involves the upper half of the vagina, an abdominal approach is used, as there is reasonable evidence to suggest this route is most successful in treating prolapse. For prolapse in the lowest parts of the vagina, depending on symptoms, a vaginal operation may be suggested. Sometimes both approaches are required. Different gynaecologists, depending on their experience and expertise, may use different approaches for the same prolapse and there is certainly no universal one size fits all approach for treating prolapse.
What about mesh ?
Prolapse occurs as a result of weakness in a woman’s supporting tissues that cause the problem of prolapse. Historically prolapse was fixed surgically with an array of different operations which normally use the patient’s own tissues. Unfortunately there is a reasonably high failure rate and this in part is down to the fact that one relies on the patient’s tissue which has already failed for the repair.
This desire to improve the failure rate of standard repairs gave rise to a range of different surgical techniques and alternatives being sought. Mesh is a synthetic or biological material that has been used in medicine for many years and indeed hernia surgeons use this quite regularly as it offers a favourable result in terms of recurrence rates following surgery to correct muscular weaknesses. Gynaecologists started to use mesh following some of the successful use of mesh in other surgical procedures. The thought process is that by using a stronger material, the failure rates of operations would lower.
For women who have already had their womb removed who then still return with prolapse, they may have a vaginal operation (commonly a sacrospinous fixation using stitches onto a ligament in the pelvis) or an abdominal operation using mesh (sacrocolpopexy). The success rates of surgery are higher in the mesh groups likely due to the strength of the reinforcement compared to using the patients own already weakened tissue.
Quite differently, rather than using this abdominal approach, there was an introduction of an array of different vaginal mesh kits, allowing the surgeon to insert mesh but through the vagina. Unfortunately , it is these vaginal mesh kits that chiefly were responsible for causing the most amount of controversy and indeed medical law suits as well as subsequent legislation in some countries. Whilst they were successful for some women, there was a significant amount of mesh related complications with these mesh kits. These were chiefly related to meshes eroding in to the vagina causing problems with discharge and chronic pain. We do not use vaginal prolapse repair mesh kits, mostly for these reasons.
There are also reports of adverse body reactions to mesh but certainly this is pretty uncommon and not something that we are particularly aware of in any of the patients that we have treated.
What about using mesh to treat my uterine prolapse?
The reason for suggesting mesh is to try and better some of the results that have been achieved using the conventional operation which would normally be to remove the womb (a hysterectomy). The operation that utilises this is called a laparoscopic sacrohysteropexy and there is a separate information sheet detailing this operation.
The mesh is used abdominally and kept well away from the vagina. As such we have not had any reports of mesh eroding in to the vagina as it is kept well away from this area. We therefore feel pretty confident that this is an unlikely sequelae for patients. There does of course however, remain theoretical risks of using mesh in other parts of the body. Indeed there are very occasional reports of mesh migrating towards or into the bowel or towards the bladder and causing mesh related complications but these are low.
When considering risks and benefits one also must consider the possible benefits of using the mesh and certainly with respect to a laparoscopic mesh hysteropexy we see significant reductions in our failure rates of surgery compared to some of the standard techniques that do not use this approach.
Whilst this is a relatively new procedure which needs scrutiny, what we can say is that on the hundreds of patients that we have operated on since 2009 we have not had any of the mesh related problems that are associated with the vaginal mesh kits. A group in Oxford have performed an even higher number of mesh hysteropexies with similar safe outcomes, and not one mesh erosion into the vagina in over a thousand patients.
All of the above being said there still remain degrees of uncertainties and sadly there is no way of giving absolute guarantees concerning surgery. Ultimately any operation carries a small degree of major complication risk as well as more common minor risks.
It may well be that you think that you still would like to avoid using mesh and the alternative to consider would be to have a hysterectomy (removal of your womb and usually cervix). This does mean that you will of course not be able to have further children, although the presumption with anyone having pelvic floor surgery should be that you do not contemplate having further children. We would try and minimise the chances of having a prolapse recurrence by putting in some stitches at the top of the vagina to try and secure the vaginal vault.
If you were very keen to preserve your uterus then also we could perform a lift up of the uterus without using mesh – a laparoscopic suture hysteropexy – this would be the most inferior of all of the operation choices with respect to success rates.
What about removal of fallopian tubes and ovaries?
Should you wish to proceed with surgery, particularly if you have requested to remove your womb, you should consider whether you would like to have your ovaries and fallopian tubes removed as well. The ovaries do not serve much of a purpose after the menopause as most of the hormonal production has stopped at the menopause. They do produce the hormone testosterone, which may affect energy levels and libido, although it is widely believed that women do not suffer adverse sequalae having their ovaries removed after the menopause.
For those women who are premenopausal, removal of the ovaries may help with pain, or premenstrual syndrome, but it would be important for most women to take adequate hormone replacement therapy until the average age of the menopause (around 51) at least to prevent some of the proven adverse problems of early removal of the ovaries and cessation of hormonal production.
Removing the ovaries and fallopian tubes does reduce the risk of getting any cysts or abnormal growth in the ovaries or fallopian tubes in later life. This is the main rationale for removing them. It does not add much to the operative time or risks and you should consider this prior to us deciding on your definitive surgery.
Like many areas of surgery, gynaecology and medicine there are many controversies and different viewpoints for all of the above and it is important that you understand these differences and feel comfortable with your decision-making. Your surgeon’s role will be to facilitate and action this decision-making.
Where can I get more information?
The British Society of Urogynaecology
Telephone: 020 7772 6211
Fax: 020 7772 6410
The International Urogynecological Association
Email at: www.iuga.org/general/?type=CONTACT