Female urinary incontinence and pelvic or uterine prolapsed are increasing problems as the baby boomer generation ages. The underlying cause for these problems is a weakening of pelvic support, or weakening of the floor of the pelvis. It is my belief that women who struggle with this problem probably inherited an underlying tendency for weakness of the collagen, or supportive tissues in the pelvis. If the fibrous tissues, or supporting tissues in the pelvis are weakened, then other life factors such as childbirth, lifting, laughing, sneezing, and others will have an increased effect. This leads to a dropped uterus (uterine prolapsed), a dropped bladder (cystocele), and bulging of the back wall of the vagina (rectocele).
While these problems can occasionally exist one at a time, they often occur together to varying degrees. The result of this is that though a woman may present with symptoms of urinary incontinence, on examination the uterus is often dropped, and the back wall of the vagina is weak as well. Therefore, it is important for women to realize that when they are being evaluated for these kinds of problems, they should be fully evaluated for other problems in the pelvis. It is not uncommon that the reason the bladder is dropped is that the uterus is pushing or dragging it down. Conversely, some women present because the uterus is dropped and causing pressure or pain, but on evaluation, the bladder is dropped too, and if only the uterine problem is addressed and the bladder is not, the result might be to create urinary leakage that was not there before surgery.
There are several kinds of urinary incontinence, and it is important to evaluate which type of incontinence exists before choosing a therapy. However, the type of incontinence relevant for this discussion is urinary stress incontinence which is characterized by a few drops or a “squirt” of urine whenever a woman coughs, sneezes, lifts something, or laughs. Vigorous exercise can produce it. Though the volume of leakage for each episode is small, when this occurs over and over through the course of a day, it can be a very troublesome amount of leakage overall.
Uterine prolapsed can be rather insidious, often not causing many symptoms until it is severe. Sometimes the symptoms increase so gradually that a woman comes to think of them as “normal for this stage of life”. As this progresses, the cervix and uterus can be felt at the vaginal opening, or even protrude all the way outside of the body.
A bulging back wall of the vagina (rectocele) can cause significant pressure discomfort, but can often cause constipation and difficulty initiating a bowel movement.
In women who have severe problems with weak supports in the pelvis, even after hysterectomy, the top of the vagina can come down, and this is termed vaginal vault prolapse. This too can cause pressure and discomfort, and pull the bladder and the back wall of the vagina down with it.
All of these problems require surgical correction. The key point is to find someone who is an experienced vaginal surgeon, and who will adequately repair all of the defects present. Vaginal hysterectomy is not a skill that all gynecologic surgeons are equally good at. In the hands of an accomplished gynecologic surgeon, even a moderately sized uterus can be removed with a vaginal hysterectomy, and in most cases the ovaries and tubes can be removed this way as well. Vaginal hysterectomy provides an easier recovery than an abdominal hysterectomy. In addition performing a vaginal hysterectomy moves right into the other repairs necessary since they too are performed vaginally.
Repair of the bladder can be performed several different ways and may depend on the needs of the patient. There are two components, first is repair of the bladder neck, which is the element important to prevent leakage, the second, is repair of the bulging vaginal wall. These are often referred to as an anterior repair. The older style anterior repair treated both elements, the leakage and the bulging, however this older type of repair did not always hold up very well. For a patient who has a lot of uterine prolapse and minimal cystocele, a vaginal hysterectomy and a conventional anterior repair probably is sufficient.
However, it is often the urinary leakage that causes women to seek surgery, and if there is significant urinary stress incontinence then most people today would perform some form of TVT procedure. TVT stands for tension free vaginal tape, and involves passing a small strip of mesh material underneath the urethra like a sling or hammock to support the neck of the bladder. TVT’s work very well, and provide good long term continence results for most women. If this is the only procedure required it can be done as an outpatient, but it often is done with vaginal hysterectomy or anterior repair. If the bulging of the bladder into the vagina is a major problem, then often, newer mesh repairs are performed. These allow the surgeon to place a strip of mesh underneath the bladder to provide support for the vaginal wall.
A rectocele is a weakness of the back wall of the vagina. This too is often found in conjunction with uterine prolapsed and a cystocele, and should be repaired at the same time. It is not uncommon for an inexperienced gynecologist to take care of the more obvious problems and neglect the rectocele repair only to find that 6 months after the surgery, the rectocele has become a major problem. Rectoceles also can be repaired with different procedures. I would strongly caution against having a transanal or transrectal repair that some colorectal surgeons seem to like. When this is done, stitches are placed in the anterior (front) wall of the rectum to narrow the rectum. This does make the rectocele smaller temporarily, but the problem is that it does not provide any long-term support and seldom is an effective long-term repair. The older rectocele repair procedures were performed vaginally, and involved placing sutures in the muscles and/or fascia to provide some support. Unfortunately the long-term track record with these procedures is not good. The muscle tissue does not like have sutures placed in it, and is not a very strong tissue to begin with, and these do not hold up well long-term. Therefore we come to the newer mesh repairs, which seem to be much more effective at giving some artificial long-term support to the back wall of the vagina.
Thus when these defects of vaginal support, or pelvic floor defects occur, it is not uncommon to need vaginal hysterectomy with TVT, and mesh repair of the cystocele and rectocele. In the hands of a skilled surgeon, the whole operation should take 1.5-2 hours to complete, and should give long-term support.
In the relatively rare event that the top of the vagina comes down after hysterectomy, there are several repairs that can be done. First is a vaginal repair to anchor the top of the vagina to stronger supporting structures through the vagina, or the vaginal vault can be anchored with an abdominal procedure which could require and open abdominal surgery. This procedure is called a Sacrocolpopexy. In today’s world of high technology this procedure can often be done with the DaVinci robot as a robotic sacrocolpopexy.
Since this is a relatively complicated field, and the possibilities for surgical correction have changed rapidly over the last few years, it is important to find an experienced surgeon who regularly and consistently does these procedures, and who is up to date on the benefits and risks of newer technologies.