Kegel exercises for prolapse -- are they useful?
In general, no. But if a woman is very motivated, premenopausal and performs Kegel exercises for 6 months (it takes that long to show a difference), it can help quite a bit if the prolapse is not very severe. By "not severe", I mean if you put your index finger in the vagina and up to the knuckle joint (2nd crease on your finger) before you feel the cervix (feels like the end of your nose), then the grade of uterine prolapse is probably 2 or less the way doctors measure.
If you are post menopausal or the cervix comes almost down to the vaginal opening or more with straining, then in my experience it is unlikely that exercises will significantly improve the discomfort due to prolapse.
Tissue falling out of the vagina
It may be the bladder or the entire vagina. This is called vaginal vault prolapse. Ultimately, it will probably need to be surgically repaired. In the meantime a pessary can sometimes be successful in holding up the tissue most of the time so it doesn't get irritated by coming out of the vaginal introitus and rubbing on clothes.
This is a common reason for putting off such surgery. Especially if she has to lift your sister, it's better to wait for the surgery. If women have to lift heavy objects, the surgery for this condition is often unsuccessful because the tissue used to repair this hernia may tear itself and the prolapse just returns. We restrict our patients from lifting over 10 pounds for at least 3 months after prolapse surgery and encourage them not to ever lift more than 20 lbs again.
The vaginal skin lining can bleed due to irritation from being outside the body and rubbing on clothes. It can be treated by her doctor with estrogen cream which makes the vaginal skin tougher and more resistant to inflammation.
Can hysterectomy cause prolapsed vaginal walls?
In one respect, your doctor is correct in that if only a hysterectomy is done without additional support of the end of the vagina and the paravaginal spaces, then you could be at risk for future vaginal prolapse and stress urinary incontinence.
On the other hand, those are standard, known problems that are easily corrected at the time of the hysterectomy. It takes a little longer surgically to take the extra steps to fix existing or prevent future prolapse or incontinence, but your recovery time is the same.
What type of surgery for prolapse?
Usually either abdominal or vaginal. There are some laparoscopists doing suspensions but the best results still seem to be with the more major procedures. An exception would be with the uterus still in place and mild prolapse. Laparoscopy work well for that.
This depends on the degree of prolapse. Most severe prolapses are treated with abdominal procedures. Less severe with vaginal procedures but it also depends upon what other pelvic defects are present, e.g., cystocele, rectocele, paravaginal defect, urethrovesical neck descensus etc.
The most common method is to ask other patients of even physicians that know him. The medical staff department of the hospital he works at can give you training and licensing information.
Redundant sigmoid colon after surgery
No. A hysterectomy does not cause a redundant sigmoid colon. If you have one, many women do, it was there prior to the hysterectomy. Perhaps are you referring to a rectocele or enterocele or rectal prolapse? These are sometimes present in patients who have had a prolapsed uterus in the past. This condition is when the rectal wall toward the vaginal canal protrudes into the vagina. Defecation is often relieved by digital pressure to the posterior vaginal wall. Could this be what you mean by redundant sigmoid colon?
A redundant sigmoid colon is like a knee-high sock in the space of an ankle-high sock. It has a lot of excess material. In the case of the sigmoid colon, this is not infrequent and is not a problem unless the rectum is turning inside out (rectal prolapse). Rectal prolapse is very infrequent. Ask your doctor if that is what is going on. If you don't have that, then the sigmoid colon does not need to be operated on. Colon resection will not help either rectocele or enterocele, only rectal prolapse.
How long does a uterine suspension last?
There's no scientific data that I know of for how long a suspension lasts. From urinary incontinence surgery results I would say that only a very few, e.g., 30-40% last a lifetime. At about 10 years, a 50% success rate is not uncommon for both prolapse and incontinence surgery. At the time of menopause, within about 1-5 years, more relaxation takes place and any natural ligaments helping the support tend to loosen at that time. I would expect surgery using mesh to last on the longer side of those numbers.
Repair of prolapsed uterus and bladder without hysterectomy
Prolapse of the bladder often accompanies uterine prolapse either at the same time or later. When a hysterectomy is done for prolapse, the bladder is usually supported at the same time to prevent future bladder prolapse. You should know be informed, however, that prolapse of the uterus and bladder can be treated surgically with suspension of the uterus and bladder without a hysterectomy.
There are several different surgical techniques to do a uterine suspension with prolapse but many of them depend upon what associated support defects, if any, accompany the uterine descensus. I've included some of the abstracts below.
Preliminary experience in pelviscopic uterine suspension using Webster-Baldy and Franke's method.
Koh LW, Tang FC, Huang MH
Department of Obstetrics and Gynecology, Show Chwan Memorial Hospital, Changhua, Taiwan, R.O.C.
Acta Obstet Gynecol Scand 1996 Jul;75(6):575-8
OBJECTIVE. To find which method gives the best relief from dyspareunia and pelvic pain caused by a retroverted uterus using the two methods mentioned as compared to other methods reported in the medical literature. SUBJECTS. Twenty-five patients, with ages ranging from 25-55 years old, complaining of mild to severe pelvic pain and dyspareunia seeking treatment in our OPD were evaluated and treated in a span of 3 years' time. METHODS. Pelviscopic retrouterine ligament fixation using Webster-Baldy and Franke's method were done after each patient was evaluated as to the uterine position, degree of misalignment of the uterus and severity of adhesion. Pelvic pain and dyspareunia were reproduced by palpation of the retroverted uterus. Ultrasonographies were performed to confirm initial findings and to rule out any ovarian or uterine abnormalities. Orthopedic and psychological consultations were done to rule out any orthopedic disorders or non-organic causes of their problem. RESULTS. Of the twenty-five patients treated, 20 patients were treated using Webster-Baldy method and five patients were treated using Franke's method, all the patients (100%) experienced great improvement 6 weeks after the operation. After 6 months, 16 patients (80%) with the Webster-Baldy method and four patients (80%) with the Franke's method had complete relief from pelvic pain and dyspareunia. The remaining four patients (20%) with the former method and one patient (20%) with the latter method complained of mild abdominal discomfort. After 6 months to 2 years of follow-up, 17 patients with Webster-Baldy method and five patients with Franke's method (88%) had improved sexual life and the remaining three patients were lost to follow-up. CONCLUSION. When dyspareunia and pelvic pain are caused by a retroverted method, we believe uterine suspension using different procedures will certainly relieve this problem. We have presented and have chosen these two procedures mainly due to their simplicity and the almost nil possibility of bowel intussusception into the anterior cul-de-sac as compared to other methods.
Surgical support and suspension of genital prolapse, including preservation of the uterus, using the Gore-Tex soft tissue patch (a preliminary report).
van Lindert AC, Groenendijk AG, Scholten PC, Heintz AP
Department of Gynecology, University Hospital Utrecht, The Netherlands.
Eur J Obstet Gynecol Reprod Biol 1993 Jul;50(2):133-9
Abdominal-retroperitoneal sacral genito-colpopexy using the expanded polytetrafluoroethylene (ePTFE) soft tissue patch has been found to be highly effective for repair of genito-vaginal prolapse. We treated 61 patients in this way, including patients who had failed multiple previous attempts at repair. At a mean of 32 months of follow-up, more than 95% of patients were still classified as successfully treated. To preserve the uterus in cases of complete genito-vaginal prolapse, we have developed a new surgical technique, which we describe in this paper.
A new technique of uterine suspension to pectineal ligaments in the management of uterovaginal prolapse.
Department of Obstetrics and Gynecology, K. E. M. Hospital, Rasta Peth, Pune, India.
Obstet Gynecol 1993 May;81(5 ( Pt 1)):790-3
The incidence of uterovaginal prolapse in young women is high in developing countries. Preservation of the uterus is of prime importance in the surgical management of these patients. A new technique of uterine suspension to the pectineal ligaments is presented as an alternative to traditional procedures. Through a Cherney incision, the uterus is suspended to the pectineal ligaments on both sides with mersilene tape. A simultaneous Burch colposuspension can be useful in selected cases. The operation has been done in 20 women, who averaged 27.5 years of age. There was no early or late morbidity during the follow-up period of 6-30 months. Of nine women desiring further childbearing, seven conceived within 6 months of surgery and thus far five have had an uneventful vaginal delivery at term; the other two have continuing normal gestations. There was no recurrence of prolapse at 6 weeks postpartum in any of the women.
[Anterolateral hysteropexy via abdominal approach. Results and indications. Apropos of a series of 92 patients].
[Article in French]
Rimailho J, Talbot C, Bernard JD, Hoff J, Becue J
Service de Chirurgie Generale et Gynecologique, Hopital Rangueil, Toulouse.
Ann Chir 1993;47(3):244-9
Of the possible surgical techniques for the treatment of genito-urinary prolapses, abdominal suspension is reserved for young patients in whom retention of sexual function is desirable. Fixation to the sacral promontory is the reference method but has some contraindications. Anterolateral suspension of the uterine isthmus to the anterior superior iliac spines by a strip of non-absorbable mesh, as described by Kapandji, is then a good alternative. We report our results with this technique over an 8-year period in 92 patients. Mean follow-up was 5 years. There was no intraoperative mortality nor major complications. Anatomical results were satisfactory in 87% of cases at 5 years, with however 4 reoperations for total recurrent prolapse, of which one was posterior. Functional results showed two cases of deep dyspareunia and 12% post-operative stress urinary incontinence, of gradual onset. In conclusion, anterolateral hysteropexy associated with removal of the pouch of Douglas is a reliable procedure with no particular danger. It can be a good alternative to fixation to the sacrum promontory when the latter is contraindicated or dangerous.
Uterine preservation in the surgical management of genuine stress urinary incontinence associated with uterovaginal prolapse.
Nesbitt RE Jr
Department of Obstetrics and Gynecology, State University of New York Health Science Center, Syracuse.
Surg Gynecol Obstet 1989 Feb;168(2):143-7
Retropubic ventral suspension of both the uterine isthmus and the vesical neck is presented as a new operative approach designed to correct uterovaginal prolapse as well as genuine stress urinary incontinence while preserving the uterus. This operation, which has been performed 16 times upon patients whose follow-up study has been five years or longer, is simple, conservative, anatomically sound, effective and safe. It represents a rational alternative in selected patients to the traditional procedure, which calls for vaginal hysterectomy together with an anterior and posterior colporraphy.
Is hysterectomy necessary?
Assuming you are not having other problems, especially bleeding, the hysterectomy is not needed to do the paravaginal repair and Burch retropubic urethropexy. Even though the uterus is not dropping down, it would be best to help suspend it, usually with a uterosacral culdoplasty if the uterus is not removed. Just let your doctor know you would rather not have the hysterectomy if it is not absolutely necessary for other reasons. Bladder repairs are not more or less successful whether or not the uterus is removed.
Factors affecting successful repair of prolapse
Without a family history of connective tissue problems and without diseases such as diabetes, the main determinants of success of surgical repair are:
1) giving it time to heal the first 3 months post surgical without any undue strain intraabdominal.
2) lack of a chronic cough from smoking or allergies.
3) being of normal weight.
4) having the surgery done before menopause (which you would probably do).
Another obvious factor to be mentioned in regards to success is to make sure you have a surgeon who is experienced is such surgery.
The repair seems to heal stronger in women who have the repair before menopause. It may well have to do with how collagen heals because even though we give estrogens in the postmenopause, the tissues do not seem to heal as strong as they do when surgery is premenopause.
Yes definitely - I have seen successful resuspensions lasting 20 -30 years or more. Procedures are all different depending upon the different support defects present. The surgeries having abdominal approaches tend to have a higher long term success rate but vaginal repairs can last long also.
Effect of pessary on progression of prolapse
Success with a pessary is not related at all to the surgical success. They are really two different things because the pessary is just providing bulk to hold up tissues and not relying on pelvic attachments. I think a pessary may slow prolapse progression somewhat if the pessary is a good fit. Mainly pessaries help the current symptoms (relieve pressure etc.).
Surgical vs. nonsurgical repair of prolapse in elderly woman
The only nonsurgical treatment would be a pessary. There is an art to fitting one so you will need to find someone who uses them frequently in treatment.
Surgically, the stitch of sewing the the vagina shut (colpocleisis) is about 85% successful and carries less risk of surgical complications than a hysterectomy. If either a vaginal hysterectomy or colpocleisis is done, it can be performed under spinal or epidural rather than general anesthesia. This is safer for the heart in an elderly woman.