Vaginal Repair Surgery

Obstetrics & Women & Children’s Group

This leaflet has been designed to give you important information about your prolapse and vaginal repair surgery, and to answer some common queries that you may have.

Introduction Why do I need a prolapse repair? This information is for you if you are about to Prolapses can cause symptoms such as an have, or you are recovering from, an uncomfortable lump or bulge in the , operation for a prolapse of your bleeding and ulceration of the vaginal skin (when the sling of muscles that supports your and bowel / urinary problems. A prolapse bladder, bowel and vagina has slipped or repair may ease these symptoms descended). You might also find it useful to There are different types of vaginal prolapse share this information with your family and which include: friends. This information gives general advice based on women’s experiences and  – a prolapse of the bladder expert opinion. Every woman has different wall into the vagina which may cause needs and recovers in different ways. Your bladder problems such as incontinence own recovery will depend upon: or incomplete emptying  how fit and well you are before your  – a prolapse of the rectal wall operation into the vagina which may cause bowel problems such as incomplete emptying /  the reason you are having a pelvic-floor fecal incontinence repair operation  Enterocele – a prolapse of the top of the  the exact type of repair that you have vagina causing an uncomfortable lump in  how smoothly everything goes and the vagina whether there are any complications What are the alternatives to a Prolapse repairs are sometimes performed at the same time as a hysterectomy (removal of prolapse repair? the ). A separate information booklet There are some non-surgical options to is available for this operation. surgery for a prolapse, especially for less severe prolapses, which you may wish to What is a prolapse? discuss with your doctor: A prolapse occurs when the ligaments and  If you are overweight, weight loss can tissues supporting the womb, rectum and assist in improving the symptoms of a bladder become weak, causing it to drop genital prolapse down from its normal position. Symptoms may include back pain, dragging pain,  Special exercises to strengthen the difficulty passing urine or faeces and seeing pelvic floor can improve symptoms such or feeling a lump or bulge in the vagina. as urinary stress incontinence, sexual A prolapse is often a result of childbirth. function and pelvic discomfort Other causes include stretching of tissues from heavy lifting, chronic cough, obesity and  Hormone replacement therapy (HRT) increasing age. can improve the strength of the pelvic floor ligaments and muscles, bringing an improvement in symptoms and increase the effectiveness of the exercises

are special devices of different Risks shapes and sizes that are fitted into the Complications associated with prolapse vagina. These can effectively hold the repair surgery are uncommon. Women who uterus and / or vaginal walls in the are obese, who have significant pathology, correct position. The must be who have had previous surgery or who have fitted according to the type and degree of pre-existing medical conditions must the prolapse understand that the quoted risks for serious Benefits or frequent complications will be increased. Frequent risks include: Surgical prolapse repair is often the most effective and convenient method of  urinary infection, retention and/or managing a prolapse. frequency What is a prolapse repair?  The type of pelvic-floor repair operation will  postoperative pain and difficulty and/or depend on your symptoms. There are 3 pain with intercourse main types of vaginal prolapse:  wound infection  Anterior vaginal repair – if the front wall Serious risks include: of your vagina has prolapsed (cystocele)  damage to bladder/urinary tract (two  Posterior vaginal repair – if the back wall women in every 1000) of your vagina has prolapsed (rectocele)  damage to bowel (five women in every  Vault fixation – if the top of the vagina 1000) has prolapsed (enterocele) How is a prolapse repair carried out?  excessive bleeding requiring transfusion or return to theatre, (two women in every Prolapse repairs can be carried out under 100) general anaesthetic or regional anaesthetic and may take between 30 – 60 minutes to be  new or continuing bladder problems completed.  pelvic abscess (three women in every An operation for a prolapse of the pelvic floor 1000) is done through your vagina so the scars will  failure to achieve desired cosmetic mainly be out of sight. Prolapses are results repaired by cutting the skin in the vagina and repairing the weakness in the vaginal wall  recurrence of prolapse with stitches.  deep venous thrombosis (blood clot in It may be necessary to remove some of the the leg) and pulmonary embolism (blood excess skin inside the vagina before being clot in the lungs) stitched at the end of the procedure.

Any extra procedures which may become repair and you develop bright red (fresh) necessary during the procedure: vaginal bleeding and are in pain, this may be because small parts of the mesh  blood transfusion: two women in every are coming through your vagina. This 100 undergoing vaginal hysterectomy at occurs in 5 to 20 out of every 100 women the same time as prolapse repair will (5–20%). Treatment is removal of the require a blood transfusion exposed mesh in hospital. This should  repair of bladder and bowel damage not affect the overall success of your which may require a laparotomy (an repair operation through a cut in the abdomen)  a painful, red, swollen, hot leg or When should I seek medical advice difficulty bearing weight on your legs: after a pelvic-floor repair operation? this may be caused by a deep vein thrombosis (DVT). If you have shortness While most women recover well after a of breath, chest pain or cough up blood, pelvic-floor repair operation, complications it could be a sign that a blood clot has can occur – as with any operation. travelled to the lungs (pulmonary You should seek medical advice from your embolus). If you have these symptoms, GP, NHS Direct or NHS 24 or the hospital you should seek medical help where you had your operation, if you immediately experience: You can reduce the risk of clots by:  burning and stinging when you pass  being as mobile as you can as early as urine or pass urine frequently: this you can after your operation may be due to a urine infection. Treatment is with a course of antibiotics  doing exercises when you are resting, for example:  heavy or smelly vaginal bleeding or - pump each foot up and down briskly bleeding which starts again: if you are for 30 seconds by moving your ankle also feeling unwell and have a temperature (fever), this may be because - move each foot in a circular motion for of an infection or a small collection of 30 seconds blood in the vagina. Treatment is usually - bend and straighten your legs – one with a course of antibiotics. If you had a leg at a time, three times for each leg hysterectomy at the time of your repair, the infection or blood collection can be at You may also be given other measures to the top of your vagina, called a vault reduce the risk of a clot developing, haematoma. Again, the treatment is particularly if you are overweight or have usually with a course of antibiotics. other health issues. These may include: Occasionally you may need to be  a daily injection of a blood thinning agent; admitted to hospital for the antibiotics to your doctor will advise you on the length be administered intravenously (into a of time you should take this for vein). Rarely, this collection may need to be drained. If you have had a mesh  graduated compression stockings; the stockings should be worn day and night

until your movement has improved and PLEASE BRING YOUR MEDICINES WITH your mobility is no longer significantly YOU ON THE DAY OF ADMISSION reduced On arrival to the ward you will be shown to a  special boots that inflate and deflate bed. You may stay in your own clothes or put on a nightdress, whichever you prefer. If Information on what will happen you have come in fasting (not eating or when you come in to hospital. Your drinking) for theatre you will be asked to put visit to the Pre-Assessment Clinic: on a theatre gown. A nurse will carry out some routine checks,  You may be given an appointment to such as your temperature, blood pressure attend the Pre-Assessment Clinic. At the and pulse rate and will then arrange for you clinic the nurse will confirm your to see the doctor. The doctor will explain the admission date and time, after checking operation to you, and then ask you to sign that you are medically fit for the the consent form after you have read it operation. The nurse will also arrange carefully. any tests that are necessary, for example, blood tests, an ECG, or x-rays. If you are a smoker, you will have been The nurse may also arrange for you to advised to stop 24 hours before your surgery see an anaesthetist date. The Trust has a non-smoking policy within its grounds.  The nurse will begin the documentation for admission and explain the admission You will be provided with some elastic and ward procedures to you. You will be support stockings to wear whilst in hospital, able to ask the nurse any questions and, and for a period of time when you go home. if necessary, she will contact a doctor to These will help to prevent blood clotting in speak to you. Please note that if there the legs called deep vein thrombosis (DVT). are any problems as a result of this, your The doctor will also prescribe a daily injection operation may be delayed to ‘thin the blood’ as a further precaution to  Failure to attend this clinic could result in prevent blood clotting. These are usually your operation being cancelled given each day that you are in hospital. The doctor will also prescribe any medication that Your admission day you normally take. On the day of your admission please report If you come in the day before theatre, you to: will be able to eat and drink as normal. The nurse will tell you when you have to start  Scunthorpe General Hospital – Ward 19 fasting. If you come in on the day of theatre, – Tel: 01724290108 then you will have been told when to fast  Diana Princess of Wales Hospital – Ward from. You need to fast because if you have B1 – Tel: 01472 875303 food and drink in your stomach when you have an anaesthetic, then you may be sick  Goole District Hospital – Ward 6 – Tel: while you are unconscious. 01724 290040 The anaesthetist will see you on the day of your operation.

On the day of surgery the nurse will check all Information on what happens after the information with you and then you walk prolapse repair surgery up to theatre escorted by a nurse. If you are unable to walk far you will go to the theatre Operation Day on a trolley, escorted by a nurse. After the operation it is usual to expect the During the operation: following for approximately 6 - 24 hours:  Vaginal repair surgery is usually  An oxygen mask performed using a spinal or general  A drip in your arm that may also be anaesthetic. More information on the attached to a pain killing device called a anaesthetic can be found out by Patient Controlled Analgesia System reading the leaflet ‘You and your (PCAS) anaesthetic’ or by speaking to the anaesthetist  A urinary catheter  During the operation a catheter will be  A vaginal pack passed up the urethra into the bladder  A vaginal drain to drain off the urine. This may be left in place after the operation has  If you have had a spinal anaesthetic your finished and will usually be removed legs may feel heavy and numb for up to within 24 hours. A vaginal pack made 4 hours of gauze may be inserted into the Once in bed the nurse will make regular vagina prevent bleeding after the checks on your condition. Your pain level operation which feels like a very large will be checked regularly using a pain scale tampon. A vaginal drain may also be chart of 1-3. It is well known that only the inserted to drain away any blood that patient is aware of how much pain they have. may collect internally. The drain and The most commonly used types of painkillers pack are usually removed after 24 are: hours  Tablets or medicines Recovery:  Suppositories – a drug given in tablet  You will usually wake up in the recovery form into your rectum room near the operating theatre. A  Intramuscular injections – a drug in specially trained member of staff will look solution form drawn up into a syringe and after you. When you wake up you will be injected into your thigh or buttock breathing through an oxygen mask and More rarely you may have the following types this is usually left in place for 2 – 24 of pain killing devices but they are usually hours, depending on the instructions of only necessary following more complex the anaesthetist surgery:  Once the recovery room staff are Patient controlled analgesia (PCA) – the satisfied with your condition, you will be  patient is in control of a drug given from taken back to the ward

a syringe or bag through a tube and If you have a vaginal pack, drain or a cannula into the hand or arm catheter, they will usually be removed within 6 - 24 hours of your operation. The nurses  Epidural – the doctor inserted a fine tube will keep a check on any bleeding into your back (spine) and through this afterwards. If necessary, use sanitary pain relieving drugs can be given. This towels, changed regularly, not tampons. is usually connected to a machine (infusion pump) There is a risk that you may experience problems with emptying your bladder and You may also suffer from feeling or being you may need to be catheterised (have a sick. To help prevent this you will be given tube inserted through the urethra into the injections and you will have an infusion (drip) bladder so that urine can be drained out). in place. Once you feel able to you will be The nurses will monitor how you pass urine allowed to drink some water in the recovery once your catheter has been removed. room or back on the ward. The drip will be removed once you are drinking normally and Day 2 not feeling sick. You may take a bath or shower and should It is important to tell your nurse about any be as active as possible by taking short pain and / or nausea as soon as possible. walks. Eating may depend on the instructions of the doctor, but this is usually the same day of Going Home your operation. You will be able to choose your own meals. The doctor will visit the ward daily to check on your progress and issue any instructions You will be able to get out of bed later in the to the nurses. The usual length of stay for a day, or the day after surgery, depending on prolapse repair is between 1-3 days. By the how you feel. Once you are allowed up, it first or second day, most women feel well will help to have regular walks around the enough to go home. ward. When you are ready to go home the doctor Day 1 will arrange for a discharge letter to be given to you and your GP. Medication which you On the day after your operation you will be will need to take home will be prescribed to allowed to wash yourself. After that you will you and a sick note if required. Please make be encouraged to have a bath or shower sure you have some simple pain killers such daily. You will be encouraged to wear as Paracetamol and Ibuprofen at home ready comfortable day clothes instead of night wear for when you are discharged. during the day. Stitches – Your stitches will not need to be You may also have pain from your wound removed as they are dissolvable. You may and ‘wind’ pain. Wind pain can be quite notice a stitch or part of a stitch coming away uncomfortable. This is quite normal as the after a few days or maybe after a few weeks. bowel begins to start working. The nurse will This is normal and nothing to worry about. It give pain killers if required to relieve this. usually occurs with the stitches on the Walking around or taking warm baths may surface of your skin. also help.

Passing urine – If you have had an anterior sexual satisfaction. It is important for you to vaginal repair, you may notice a change in get these muscles working properly after the flow of your urine and that passing urine your operation, even if you have stitches. To is slower and takes longer. identify your pelvic-floor muscles, imagine Vaginal bleeding – You can expect to have you are trying to stop yourself from passing some vaginal bleeding for 2 to 3 weeks after wind or you could think of yourself squeezing your operation. This is like a light period and tightly inside your vagina. When you do this is red or brown in colour. You should use you should feel your muscles ‘lift and sanitary towels rather than tampons, as squeeze’ gentle tightening in your lower using tampons could increase the risk of abdominal muscles. This is normal. Women infection. used to be told to practice their pelvic-floor muscle exercises by stopping the flow of Helping your bladder to function – To help urine midstream. This is no longer your bladder to function, make sure the fluid recommended, as your bladder function you drink is mainly water. You should limit could be affected in the longer term. You your intake of caffeine (found in tea, coffee can begin these exercises gently once your and some fizzy drinks) as this will irritate your catheter has been removed and you are able bladder. Make sure you drink small amounts to pass urine on your own. You need to of fluid at regular intervals throughout the practice short squeezes as well as long day. Drinking less frequently can make your squeezes: urine concentrated and this can also irritate your bladder.  Short squeezes are when you tighten your pelvic-floor muscles for one second Washing and showering – You should be and then relax able to have a shower or bath the day after your operation. Don’t worry about getting  Long squeezes are when you tighten your scars wet – just ensure that you pat your pelvic-floor muscles, hold for them dry with clean disposable tissues or let several seconds and then relax them dry in the air. Keeping scars clean and Start with what is comfortable and then dry helps healing. gradually increase – aiming for ten long Cervical screening (smears) – If you are squeezes, up to 10 seconds each, followed still on the cervical screening programme, by ten short squeezes. You should do you should continue to have screening pelvic-floor muscle exercises at least three (smears) after your repair. If you have also times a day. At first you may find it easier to had a hysterectomy, you should check with do them when you are lying down or sitting. your GP or gynaecologist if you need to As your muscles improve, aim to do your continue to have screening (smears). exercises when you are standing up. It is very important to tighten your pelvic-floor A pelvic-floor muscle exercise – Your muscles before you do anything that may put pelvic-floor muscles span the base of your them under pressure, such as lifting, . They work to keep your pelvic organs coughing or sneezing. Make these exercises in the correct position (prevent prolapse), part of your daily routine for the rest of your tightly close your bladder and bowel (stop life. Some women use triggers to remind urinary or anal incontinence) and improve themselves such as, brushing their teeth,

washing up or commercial breaks on smaller parts, such as ironing a couple of television. Straining to empty your bowels items of clothing at a time and taking rests (constipation) may also weaken your pelvic- regularly. You can also try sitting down while floor muscles and should be avoided. If you preparing food or sorting laundry. For the suffer from constipation or find the pelvic- first month you should restrict lifting to light floor muscle exercises difficult, you may loads such as a 1 litre bottle of water, kettles benefit from seeing a specialist women’s or small saucepans. You should not lift health physiotherapist. heavy objects, such as full shopping bags or children, or do any strenuous housework like Keep your bowels working – It is important vacuuming, until 4 to 6 weeks after your to avoid straining to have your bowels open operation, as this may affect how you heal to avoid a prolapse returning. Your bowels internally. Try getting down to your children may take time to return to normal after your rather than lifting them up to you. If you feel operation. Your motions should be soft and pain you should try doing a little less for easy to pass. You may initially need to take another few days. laxatives to avoid straining and constipation. If you do have problems opening your Driving – You should not drive for 24 hours bowels, it may help to place a small footstool after a general anaesthetic. It usually takes under your feet when you are sitting on the between 2 – 4 weeks before you will be toilet so your knees are higher than your ready to drive again. Each insurance hips. If possible, lean forwards and rest your company will have its own conditions for arms on top of your legs to avoid straining. when you are insured to start driving again. Check your policy. Before you drive you Stop smoking – Stopping smoking will should be: benefit your health in all sorts of ways such as lessening the risk of a wound infection or  free from the sedative effects of any chest problems after your anaesthetic. If you painkillers have a persistent cough it may increase the  able to sit in the car comfortably and chance of the prolapse returning. If you are work the controls unable to stop smoking before your operation, you may need to bring nicotine  able to wear the seatbelt comfortably replacements for use during your hospital  able to make an emergency stop stay. You will not be able to smoke in hospital. If you would like information about a  able to comfortably look over your smoking cessation clinic in your area speak shoulder to manoeuvre with the nurse in your GP surgery. Having sex – You should usually allow 4 to 6 weeks after your operation to allow your Getting back to normal scars to heal. It is then safe to have sex – as Around the house – While it is important to long as you feel comfortable. If you take enough rest, you should start some of experience any discomfort or dryness, you your normal daily activities when you get may wish to try a vaginal lubricant. You can home and build up slowly. You will find you buy this from your local pharmacy. are able to do more as the days and weeks Returning to work – Some women are fit to pass. It is helpful to break jobs up into work after 2 to 3 weeks and will not be

harmed by this if there are no complications Alternatively you can email: from surgery. Others may be advised to take [email protected] up to 6 weeks off work. It is best to ask your Gynaecologist for advice on this. A sick note Northern Lincolnshire and Goole NHS can be issued from the ward before you go Foundation Trust home. Diana Princess of Wales Hospital Scartho Road Reference Section Grimsby RCOG 2009 Vaginal surgery for prolapse. 01472 874111 Consent Advice Number 5. Scunthorpe General Hospital http://www.rcog.org.uk/files/rcog-corp/CA5- Cliff Gardens 15072010.pdf. Accessed 19.1.12. Scunthorpe RCOG 2010 Information for you after a pelvic 01724 282282 floor repair. Goole & District Hospital http://www.rcog.org.uk/files/rcog- Woodland Avenue corp/PelvicFloorRecoveringWell0710.pdf. Goole Accessed 19.1.12. 01405 720720 Contact details for Further www.nlg.nhs.uk Information Date of issue: November, 2013 If you need further information please contact Review Period: November, 2016 your consultant's secretary via the hospital Author: Advanced Nurse Practitioner switchboard. Gynaecology Concerns and Queries IFP-517 v1.1 If you have any concerns / queries about any © NLGHT 2013 of the services offered by the Trust, in the first instance, please speak to the person providing your care. For Diana, Princess of Wales Hospital Alternatively you can contact the Patient Advice and Liaison Service (PALS) on (01472) 875403 or at the PALS office which is situated near the main entrance. For Scunthorpe General Hospital Alternatively you can contact the Patient Advice and Liaison Service (PALS) on (01724) 290132 or at the PALS office which situated on C Floor.