INFORMATION FOR PATIENTS Sacrohysteropexy for uterine prolapse We advise you to take your time to read If you have had a hysterectomy then the this leaflet. If you have any questions term ‘vault' is used to describe the area please write them down on the sheet where your womb would have been provided (towards the back) and we can attached to the top of the vagina. discuss them with you at our next meeting. It is your right to know about the Figure 1: A diagram, sideways on, operations being proposed, why they are showing the normal anatomy (dotted line) being proposed, what alternatives there and a prolapsing vaginal apex(continuous are and what the risks are. These should line). be covered in this leaflet. This leaflet describes what an apical vaginal prolapse is, what alternatives are available within our Trust, the risks involved in surgery and what operation we can offer. What is prolapse of the uterus/vaginal apex? A prolapse is where the vaginal tissue is weak and bulges downwards into the vagina itself. It is often accompanied by a posterior vaginal wall prolapse, either a high In severe cases it can even protrude posterior vaginal wall prolapse called an outside the vagina. Apical vaginal enterocele, or a low posterior vaginal Wall prolapse is a prolapse arising from the prolapse called a rectocele, or sometimes top of the vagina. The apex is the both. deepest part of the vagina (top of it/ roof) where the uterus (womb) usually is The pelvic floor muscles are a series of located. muscles that form a sling or hammock across the opening of the pelvis. These muscles, together with their Pelvic floor exercises (PFE) surrounding tissue, are responsible for The pelvic floor muscle runs from the keeping all of the pelvic organs (bladder, coccyx at the back to the pubic bone at uterus, and rectum) in place and the front and off to the sides. This muscle functioning correctly. supports your pelvic organs (uterus, vagina, bladder and rectum). Any muscle Prolapse occurs when the pelvic floor in the body needs exercise to keep it muscles or the vagina have become strong so that it functions properly. This is weak. more important if that muscle has been This usually occurs after the trauma of damaged. childbirth but is most noticeable after the PFE can strengthen the pelvic floor and menopause when the strength of therefore give more support to the pelvic supporting tissue deteriorates. organs. These exercises may not get rid of the prolapse but they make you more With straining, for example, on passing a comfortable. PFE are best taught by an motion, the weakness described above expert who is usually a physiotherapist. allows the apex of the vagina to bulge These exercises have little or no risk and downwards and the rectum (back even if surgery is required at a later date, passage) to bulge into the vagina and they will help your overall chance of being sometimes bulge out of the vagina. Some more comfortable. women have to push the bulge back into the vagina with their fingers in order to Types of pessary empty their bladder or complete a bowel movement. Some women find that the Ring pessary bulge causes a dragging or aching This is a soft plastic ring or device which sensation. is inserted into the vagina and pushes the prolapse back up. This usually gets rid of Alternatives to surgery the dragging sensation and can improve urinary and bowel symptoms. It needs to Do nothing be changed every 4-6 months and can be If the prolapse (bulge) is not distressing very popular; we can show you an then treatment is not necessarily needed. example in clinic. Other pessaries may be If, however, the prolapse permanently used if the ring pessary is not suitable. protrudes through the opening to the Some couples feel that the pessary gets vagina and is exposed, it may become in the way during sexual intercourse, but dried out and eventually ulcerate. Even if many couples are not bothered by it. it is not causing symptoms in this situation it is probably best to push it back Shelf pessary or gellhorn with a ring pessary or have an operation If you are not sexually active this is a to repair it. stronger pessary which can be inserted into the vagina and again needs changing every 4-6 months. Page 2 of 7 General risks of surgery Specific risks of this surgery Anaesthetic risk Damage to local organs This is very small unless you have This can include bowel, bladder, ureters specific medical problems. This will be (pipes from kidneys to the bladder) and discussed with you. blood vessels. This is a rare complication but requires that the damaged organ is Haemorrhage repaired and this can result in a delay in There is a risk of bleeding with any recovery. It is sometimes not detected at operation. the time of surgery and therefore may The risk from blood loss is reduced by require a return to theatre. knowing your blood group beforehand and then having blood available to give If the bladder is inadvertently opened you if needed. It is rare that we have to during surgery, it will need catheter transfuse patients after their operation. drainage for 7-14 days following surgery. Infection If the rectum (back passage) is There is a risk of infection at any of the inadvertently damaged at the time of wound sites. A significant infection is rare. surgery, this will be repaired, however, The risk of infection is reduced by our inserting the mesh may be delayed till a policy of routinely giving antibiotics with later date. This will require another major surgery. operation, and in rare circumstances, a temporary colostomy (bag) may be Deep vein thrombosis (DVT) required. This is a clot in the deep veins of the leg. The overall risk is at most 4-5% although Prolapse recurrence the majority of these are without If you have one prolapse, the risk of symptoms. Occasionally this clot can having another prolapse sometime during migrate to the lungs which can be very your life is 30%. This is because the serious and in rare circumstances it can vaginal tissue is weak. The operation may be fatal (less than 1% of those who get a not work and it may fail to alleviate your clot). symptoms. DVT can occur more often with major Pain operations around the pelvis and the risk General pelvic discomfort, this usually increases with obesity, gross varicose settles with time, and tenderness on veins, infection, immobility and other intercourse due to vaginal tethering or medical problems. The risk is significantly mesh erosion. Occasionally pain on reduced by using special stockings and intercourse can be permanent. injections to thin the blood (heparin). Page 3 of 7 Mesh exposure/extrusion More recently we have been performing This occurs when the plastic mesh pokes the same operation in women who still through the vagina (incidence of around have a uterus, and pulling the cervix/ 10%). This may require a repeat uterus up toward the backbone. There operation to trim the mesh and in severe are some benefits in leaving the womb cases may compromise the operation. behind if it is still present: Infection of mesh 1. Reduced operating time. The mesh and/ or the tissues attached to 2. Reduced risk of damage to local it (vagina and back bone) may get organs. infected. This is usually treated by 3. Reduced risk of bleeding. antibiotics and in rare cases, by removing the mesh. The cervix is a much tougher tissue to place surgical sutures than the vagina so Change in bladder and bowel function the operation may be more robust. As we Changing the axis of the vagina might have only started leaving the uterus interfere with the voiding/continence behind during these operations more mechanism leading to voiding recently we cannot be sure at this dysfunction, or worsening or new urinary moment of the long term results. It can incontinence. If you experience this, involve a cut on the abdomen (tummy) please let us know as this can be treated. and or can be done through keyhole Some patients experience worsening surgery. constipation following surgery. This may resolve with time. It is important to try to Before the operation avoid being constipated following surgery to reduce prolapse recurrence. It is recommended that you take a medication to soften your motions for at Reduced sensation during intercourse least three days before the operation. Sometimes the sensation during This will help to reduce the risk of you intercourse may be less and occasionally getting constipated after the operation the orgasm may be less intense. and could mean you get home earlier. Magnesium sulphate, Lactulose or The operation - sacrohysteropexy Movicol would be suitable and you can obtain these from your GP or local In this operation the cervix (neck of the pharmacy. womb) is lifted upwards toward a prominent part of the back bone (the How the operation is performed – sacral promontory) using a piece of sacrohysteropexy synthetic mesh. These kinds of operations using a plastic mesh to pull up The operation is done under general the vagina toward the backbone have anaesthetic. A general anaesthetic will been performed for a long time and are mean you will be asleep (unconscious) generally successful (90%). during the entire procedure. Page 4 of 7 During the operation: The legs are placed in stirrups (supported in the air). A horizontal (sideways) or a vertical (up and down) incision is made in the lower abdomen (tummy).