What Women Need to Know
Answers to frequently asked questions
Pelvic Organ Prolapse
Q: What is prolapse?
A: Prolapse is a hernia of the vagina that a woman may feel as a bulge or pressure. This is referred to in many different ways. Sometimes it is called a “dropped bladder”, “dropped uterus,” “dropped vagina,” or “dropped rectum.” Your doctor may have also called this a cystocele, rectocele, or enterocele. Prolapse is caused by a weakening of the vaginal tissues. Prolapse is associated with pregnancy and childbirth. However, prolapse can happen in women who have never had children. Prolapse is also associated with repetitive heavy lifting, chronic constipation , chronic cough, and poor tissue.Prolapse symptoms may be worse at different times in the day. Some women notice that they feel more pressure after walking or standing for long periods of time.
Q: What will happen if I just ignore this problem? Will it get worse?
A: Most likely. Prolapse, left untreated, almost always gets worse over time but this is usually a gradual change. “New” prolapse (noticed by a patient or doctor in the early postpartum period) will often get better within the first year after the delivery. This is one exception to the rule.Treatment of prolapse should be based on your symptoms. In rare cases, severe prolapse can cause urinary retention (inability to empty the bladder) that progresses to kidney damage or infection. When this occurs, prolapse treatment is considered mandatory. In most other cases, patients should be the ones to decide when to have their prolapse treated – based on the symptoms they are having.
Q: I have prolapse, but I don’t leak urine. Do I still need bladder testing?
A: Most likely. If you are going to have surgery to correct the prolapse, bladder testing (called urodynamics) usually is done first. That’s because the prolapsed portion of your vagina may be pushing on your urethra and preventing urine leakage. If that is the case, having the prolapse corrected can give you a new problem – urinary incontinence. The best way to tell whether a continence procedure is needed at the time of prolapse surgery is to perform urodynamics while holding the prolapse up in its normal position.
Q: How successful is surgery for pelvic organ prolapse?
A: Many factors affect the outcome of reconstructive surgery. Some of the factors that originally contributed to your pelvic floor problems , such as decreased muscle and nerve function and weak connective tissue, might still exist after the reconstructive procedure has been performed.Pelvic organ prolapse , like a hernia, is the abnormal protrusion of an organ through a weak pelvic floor. Hernias in the pelvic floor are technically more difficult to repair than other hernias because pressure in the pelvic floor from daily activities puts a lot of stress on the surgical repair. As a consequence, some women have a persistence or recurrence of their prolapse after surgery.
It is important to have realistic expectations: some patients cannot be cured. Surgery may result in fewer symptoms, but all of your symptoms may not be relieved. Sometimes surgery for pelvic organ prolapse fails to relieve any symptoms. Discuss the success rates of your particular procedure, or combination of procedures, with your surgeon.
Q: What are the risks with using graft material?
A: Graft material, most often used for prolapse repair, is a medical grade polymer or plastic called polypropylene. This graft material is also used for abdominal and groin hernia repairs. Approximately 90-95% of patients do very well with this material. However, 2-5 % of patients may experience an exposure of the material into the vagina, causing vaginal discharge or spotting, and these patients may require removal of the exposed mesh material. This can either be done in the office or as an out-patient procedure. Other less common complications associated with the mesh grafts include infection which is treated with antibiotics and surgery to remove the graft. Women who smoke tobacco products carry a greater risk for mesh exposure. Currently, women with severe or recurrent prolapse who prioritized retaining sexual function gain the greatest benefit from mesh reinforcement procedures. Every woman has a different risk/benefit profile regarding graft repairs.
Q: What is stress urinary incontinence and is it a common problem?
A: Stress urinary incontinence (SUI) is loss of urine that occurs at the same time as physical activities that increase abdominal pressure (such as sneezing, coughing, laughing, and exercising). These activities can increase the pressure within the bladder, which behaves like a balloon filled with liquid. The rise in pressure can push urine out through the urethra, especially when the support to the urethra has been weakened; this is what we call stress urinary incontinence. Approximately 1 out of 3 women over the age of 45, and 1 out of every 2 women over 65 have SUI.
Q: What are surgical treatment options for stress urinary incontinence?
A: Surgeons have developed different techniques for supporting the bladder back to its normal position. The three main types of surgery are: retropubic suspension and two types of sling procedures.
Retropubic suspension: Uses surgical threads called sutures to support the bladder neck. In this operation, the surgeon makes an incision in the abdomen a few inches below the navel and then secures the threads to strong ligaments within the pelvis to support the urethral sphincter. This common procedure is often done at the time of an abdominal procedure, such as a hysterectomy.
Sling procedures: Performed through a vaginal incision. The traditional sling procedure uses a strip of your own tissue called fascia to cradle the bladder neck. Other slings may consist of donor natural tissue or synthetic material. The surgeon ties both ends of the sling to the pubic bone or ties them in front of the abdomen just above the pubic bone.
Mid-urethral slings: Newer procedures that you can have on an outpatient basis. These procedures use synthetic mesh materials that the surgeon places midway along the urethra. The two general types of mid-urethral slings are retropubic slings, such as the transvaginal tapes (TVT), and transobturator slings (TOT). The surgeon makes small incisions behind the pubic bone or just by the sides of the vaginal opening as well as a small incision in the vagina. The surgeon uses specially designed needles to position a synthetic tape under the urethra. The surgeon pulls the ends of the tape through the incisions and adjusts them to provide the right amount of support to the urethra.
Q: How do I know if a sling is a good option for me?
A: Make this decision in consultation with your doctor. Discuss all of your options and determine which treatment is most appropriate for your specific medical situation. This is a personal choice. Ask your doctor to discuss it with you.
Q: How long is the sling surgery?
A: In most cases, the surgery should last less than 30 minutes. If your doctor recommends, the procedure can be performed under local anesthesia with IV sedation. Sling procedures are frequently outpatient procedures, in which case you may be returning home the same day of surgery. Many times, the sling is part of another procedure and you may need additional surgery to support a prolapsed bladder, uterus or rectum. Your doctor will discuss this with you.
Q: What did the FDA say in its October 20, 2008 Public Health Notice?
A: On October 20, 2008, the FDA issued a Public Health Notification (PHN) regarding potential complications associated with transvaginal placement of surgical mesh to treat pelvic organ prolapse (POP) and stress urinary incontinence (SUI). The PHN provided recommendations and encouraged physicians to seek specialized training in mesh procedures, to advise their patients about the risks associated with these procedures and to be diligent in diagnosing and reporting complications.
Q: What has happened since the 2008 PHN?
A: In July 2011, the FDA issued an update to the October 2008 PHN. In this update, the FDA maintained that adverse events for POP mesh repair are not rare, as previously reported, and questioned the relative effectiveness of transvaginal mesh as a treatment for POP as compared to non-mesh surgical repair.
On September 8 and 9, 2011, the FDA convened an Obstetrics and Gynecology Devices Panel of the Medical Devices Advisory Committee to further address the safety and effectiveness of transvaginal surgical mesh used for repair of POP. The panel recommended to the FDA that slings for the treatment of SUI are properly classified by the FDA with respect to risks and benefits offered. Regarding standard retropubic and transobturator slings, the panel concluded that no additional post-market surveillance studies are necessary. Regarding mini-slings, the panel recommended pre-market studies for new devices and additional post-market studies.
Q: Has the FDA recalled slings?
A: No, the FDA has not recalled slings.
Q: I have a sling implanted for bladder leakage. Should I have it removed?
A: As with all important medical decisions, consult with your physician. There is no need to remove your sling if you are satisfied with your surgery and are not having complications or symptoms. Because a sling integrates with your own tissues, removal may cause complications or symptoms. The FDA recommends you continue with your annual and other routine check-ups and follow-up care. Notify the surgeon if complications develop (persistent vaginal bleeding or discharge, pelvic or groin pain during sex.