Pelvic Support Surgery Overview
Frederick R. Jelovsek MD
Many women in the menopausal and perimenopausal age range, require surgery for pelvic support defects such as cystocoele (bladder dropping), rectocoele (rectum protruding), bladder neck dropping (stress incontinence), and uterine or post hysterectomy vaginal vault prolapse. There is not much information about these subjects in the usual health media so it is difficult for women to know what to expect as far as success rates, complications and recovery in general.
At a recent meeting of the Society of Gynecologic Surgeons, some of the scientific papers provided answers to questions that women may have about these subjects.
How often do normal perimenopausal women lose urine with cough, sneeze or increase in abdominal pressure?
In one study by Robinson D et al., women aged 45-55 who did not present for incontinence or evaluation of pelvic relaxation, were questioned to see how often they had episodes of urinary loss with intraabdominal straining. Some degree of urinary loss was reported by 2/3's (66%) but daily loss was only reported by 8%.
|Frequency of urinary loss||Incidence (%)|
|Less than once per month||23.0%|
|Several times per month||13.0%|
|Several times per week||17.0%|
What degree or amount of pelvic relaxation is normal in the perimenopause?
Robinson D et al. also measured the degree of vaginal and uterine prolapse in these asymptomatic, perimenopausal women aged 45-55. She found that only 3% had a degree of prolapse for which surgeons might recommend surgical repair depending upon symptoms.
|Degree of uterine or vaginal prolapse||Incidence (%)|
|Mild (Stage 1)||16%|
|Moderate (Stage 2)||3%|
|Severe (Stage 3)||0%|
|Complete/Total (Stage 4)||0%|
What symptoms are caused by a rectocoele?
In a study by Kenton K et al, of 46 women undergoing rectocoele repair, preoperative symptoms that were felt to be due to the herniation of rectal tissue included protrusion of rectal tissue from the vagina, difficult defecation (bowel movement), constipation, dyspareunia (pain with sexual relations), and manual evacuation or the need to put fingers in the vagina and push down on the rectal protrusion in order to have a bowel movement.
|Rectocoele symptom||Incidence (%)|
How well does rectocoele support surgery decrease symptoms.
In the same study from Kenton K et al, they looked at how well the initial presenting symptoms improved when remeasured at one year after the surgery. Basically, protrusion and painful sexual relations resolved by 90%, but difficult defecation, constipation and the need for manual evacuation only improved by 35-55%.
|Rectocoele symptom||Preoperative(%)||Postoperative (%)|
Can bladder repair surgery be too tight to void afterwards?
Any time the bladder is suspended to attempt to reduce urinary leakage with stress of the intraabdominal pressure, there is always the risk that voiding will go to the opposite extreme, i.e., difficulty or being unable to void at all. How often this occurs as a complication of surgery depends upon the type of surgery performed and how the tissues heal. This problem can occur as high as 5% of the time. Sometimes it can be due to just "being too tight", i.e., compressing the urethra shut during voiding. At other times, it can be due to a bladder that just does not contract well or its contraction during voiding is not coordinated with relaxation of the urethra.
Urodynamic studies (uroflow and cystometrogram) are used to diagnose which is the main problem but if it turns out that the support is just "too tight", the question becomes as to how the problem should be fixed. Should sutures just be cut either from the vaginal side or from the abdominal side? If the sutures are cut, does there need to be some sort of repair done again so that the stress incontinence does not just recur? Steele AC et al, reported that in their hands the abdominal approach to take down the scarring worked best because they had previously seen patients that had attempts at vaginal take down that did not improve the problem. All of their patients underwent abdominal incision for take down (retropubic vesicourethrolysis) and that successfully treated the voiding dysfunction without having to "resuspend" the urethra.
In their patients with voiding dysfunction that had weak bladder muscles, most of them improved with just physical therapy and self-catheterization over several weeks rather than having to have repeat surgery. While voiding problems after anti-incontinence surgery are not common, they can be sucessfully treated.
How successful is repair surgery for stress incontinence?
Different surgeons and different procedures can result in widely different "cure" rates for stress urinary incontinence. Surgeons also know that the cure rates depend on how long after the surgery you check them. Success will always be greater at one year than at five years and even lower at 10 years. This change in success is often due to aging effects that make tissues weaker over time. Surgeons would like to let women know what to expect, however. How likely is it that the surgery is going to cure the problem for a "very long time"?
Tamussino KF, looked five year follow-up results after anti-incontinence surgery. The cure rates varied from 50-60% for vaginal procedures (anterior repair alone or anterior repair with needle suspension) to 80% for the abdominal surgical approach (Burch retropubic urethropexy). These were overall results. They did note, however, that with just mild stress incontinence, the vaginal procedures alone had an 80% 5-year cure rate. Thus they felt the vaginal procedures still have a role in some cases, especially if the urinary loss is mild.