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Pelvic Prolapse Surgery

The repair of pelvic prolapse includes repair of the anterior wall (holding up the bladder), apex (where the uterus is or was) and posterior vaginal wall (the wall over the rectum).  

There are two main approaches: the abdominal approach and the vaginal approach. Though the vaginal approach is commonly done to avoid the abdominal incision, in some situations the abdominal approach is still needed to provide a strong repair. In these cases, the robotic abdominal approach may be used to achieve the same repair but through small, telescopic incision.

There are two opposing camps nationally that disagree on the best way to repair prolapse vaginally, those who favor mesh, and those who do not use mesh. We are experienced surgeons who have done both mesh repairs and non-mesh repairs, and will discuss with you whether mesh use is recommended. It is important to realize that we do not have long term follow up data on the mesh repairs .

The Surgical Procedure

Any or all of the three walls of the vagina may be dropping or prolapsing. Therefore, we usually tailor the surgery to each specific patient.

The decision to operate is made based on many factors. Discomfort from the prolapse, urine leakage as a result of the bladder drop, urine flow blockage from more severe bladder drop (including difficulty urinating sometimes resulting in bladder infection or catheter use). A symptom of rectal wall prolapse is stool trapping, a sensation that the bowel movement is caught or stuck in a pocket and is difficult to evacuate. Some patients will push under the vagina or even place a finger in the vagina to push the rectal wall back in position to allow easier bowel movements. A rectal wall hernia is different from constipation. Constipation is often a whole colon problem that may not improve after surgery on just the vaginal wall over the rectum.

The vaginal surgery requires vaginal incisions that are closed with dissolving sutures. There is typically vaginal discharge as these sutures dissolve for up to 4-6 weeks. Sometimes, there is a bloody discharge as well; this is messy but not a safety issue (it is very rare to have surgical bleeding occur after 24-48 hours from surgery).

Rarely will we see an area where the vaginal wall does not heal completely over the mesh, what we call a mesh exposure. This may improve with vaginal estrogen (which is why we have patients use vaginal estrogen for 1-2 months after surgery) or may require simple excision. If excision is required, it is usually several months after surgery and is a simple outpatient procedure.

There are reports of severe reaction to mesh placement with severe vaginal scarring. Patients will even have the mesh removed. We have not seen this type of reaction in the nearly 500 patients we have used mesh.

Post operative issues

There are some rare things that can happen with vaginal surgery.
  • Bleeding. All patients may have some vaginal spotting for as long as 3-4 weeks after surgery. Significant bleeding is very rare but can happen with any surgery, even to the point of blood transfusion.
  • Wound Infection. This is very rare. We provide antibiotics in the operating room, and some doctors also give a few days of oral antibiotics to minimize this problem.
  • Pain. This is variable and depends on the surgery type, but we will provide you with appropriate pain control in the hospital and when at home.
  • Bladder injury. This is very rare, and if it occurs usually is treated with leaving the bladder catheter in for a longer time (usually a few days to a week, depending on many issues). This usually has no influence on the surgery success.
  • Urinary tract infection. Bladder infection can be seen as long as 3-6 months after surgery and can be treated with oral antibiotics.
  • Other issues can include but are not limited to anesthetic problems, low blood pressure, blood clots, heart problems, stroke or even death.

After You Go Home

Difficulty Urinating

Many patients will notice their urine flow is weaker that it was before the surgery. This is common particularly if a sling was done with your prolapse surgery. However, if you feel you are having difficulty urinating, have a very weak stream (dribbling), you need to position to void (lean forward, bend forward, etc.) or you are not emptying your bladder you need to call us. Rarely, we will see patients who need to have their sling loosened and this is best done in the first 2 weeks. Some patients have special circumstances where a catheter will be left in longer that a couple days or they may be taught self catheterization. If you are not sure, we would rather see you in the office to evaluate you. We cannot evaluate these problems over the phone.

Bowel Movement

We want you to have a bowel movement within a couple days of surgery. The anesthesia, pain medications, and pain from surgery can all cause constipation, so if a normal bowel movement does not happen you need to use a laxative, do not delay. Laxatives include Dulcolax tablets or suppositories, Miralax, magnesium citrate and Fleets enema. Stool softeners are not laxatives!  Some doctors will have you take stool softeners (Colace or similar) but these are not a replacement for a laxative if you have not moved your bowels within 2-3 days of surgery. We cannot have you strain hard to move your bowels or you may disrupt the surgery. The mesh used takes about 2 weeks to have strong scarring set up, and before this time the mesh can be loosened.

Vaginal Discharge and Spotting

This is common and can occur for up to 4-6 weeks. The vaginal sutures dissolve and create the discharge. Spotting more than a couple days after surgery does not mean there is active bleeding; instead, it’s usually a blood clot that is draining.

Bladder Overactivity

In the immediate post op period 1-2 weeks, sometimes as long as 4-6 weeks, some patients will feel symptoms of urgency, frequent voiding, and even leakage with the urge to void. This usually means the bladder is irritated from the surgery and most commonly will improve over time. Things you can do to help include avoiding excessive fluid intake (drinking more does not mean you will urinate better), and avoiding caffeine. Caffeine is a potent bladder stimulant and if your bladder is irritable from surgery, the caffeine will make it worse.

In general, we want to hear from you in the first week if you notice difficulty urinating or have a significant change in urgency and frequency. We often see you to check for bladder infection and to make sure your bladder is emptying well.