Daryl Greebon, MD, FACOG

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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.

Articles

Female urinary incontinence and pelvic or uterine prolapsed are increasing problems as the baby boomer generation ages.

Author | Daryl Greebon, MD, FACOG

Articles

Urinary Incontinence and Uterine Prolapse