INFORMATION FOR PATIENTS Posterior vaginal wall prolapse repair and repair of perineum We advise you to take your time to read These muscles, together with their this leaflet. If you have any questions surrounding tissue, are responsible for please write them down on the sheet keeping all of the pelvic organs (bladder, provided (towards the back) and we can uterus, vagina, and rectum) in place and discuss them with you at our next functioning correctly. meeting. It is your right to know about the operations being proposed, why they are Prolapse occurs when the pelvic floor being proposed, what alternatives there muscles, their attachments or the vagina are and what the risks are. These should have become weak. This usually occurs be covered in this leaflet. because of the damage of childbirth but is most noticeable after the menopause This leaflet details what a posterior when the quality of supporting tissue vaginal wall prolapse is, what alternatives deteriorates. are available within our Trust, the risks involved in surgery and what operation With straining, for example on passing a we can offer. motion, the weakness described above allows the rectum (back passage) to What is a posterior vaginal wall bulge into the vagina and sometimes prolapse? bulge out of the vagina (rectocele). Posterior means towards the back, so a A large rectocele may make it very hard posterior vaginal all prolapse is a to have a bowel movement, especially if prolapse of the back wall of the vagina. you have constipation. Posterior vaginal wall prolapse is called a Some women have to push the bulge rectocele, which describes the structure back into the vagina or support the bulging into the vagina - the rectum. perineal area (the area between the anus and the vagina) with their fingers in order The pelvic floor muscles form a ‘sling’ or to complete a bowel movement. ‘hammock’ across the opening of the pelvis. Some women have to insert a finger in If however, the prolapse permanently the back passage to facilitate evacuation protrudes through the opening to the of their bowel, this is called digitation. vagina and is exposed to the air, it may become dried out and eventually ulcerate. If a woman has difficulty in emptying the Even if it is not causing symptoms in this back passage or has to use her fingers to situation it is probably best to push it back achieve bowel emptying, a special x-ray with a ring pessary (see below) or have test to assess bowel emptying may be an operation to repair it. needed in planning the surgical approach. Pelvic floor exercises (PFE) The x-ray will involve inserting a special The pelvic floor muscle runs from the paste in the back passage and taking x- coccyx at the back to the pubic bone at rays while trying to evacuate the paste the front and off to the sides. This muscle from the back passage. supports your pelvic organs (uterus, vagina, bladder and rectum). Any muscle Some women find that the bulge causes in the body needs exercise to keep it a dragging or aching sensation. strong so that it functions properly. This is more important if that muscle has been The diagram bellows shows the rectum damaged. bulging through the posterior (back) vaginal wall (in standing women). PFE can strengthen the pelvic floor and therefore give more support to the pelvic organs. These exercises may not get rid of the prolapse but they make you more comfortable. PFE are best taught by an expert who is usually a physiotherapist. These exercises have no risk and even if surgery is required at a later date, they will help your overall chance of being more comfortable. Types of pessary Ring pessary This is a soft plastic ring or device which is inserted into the vagina and pushes the Alternatives to surgery prolapse back up. This usually gets rid of the dragging sensation and can improve Do nothing urinary and bowel symptoms. It needs to If the prolapse (bulge) is not distressing be changed every 6-9 months and can be then treatment is not necessarily needed. very popular - we can show you an example in clinic. Other pessaries may be used if the ring pessary is not suitable. Page 2 of 7 Some couples feel that the pessary gets DVT can occur more often with major in the way during sexual intercourse, but operations around the pelvis and the risk many couples are not bothered by it. increases with obesity, gross varicose veins, infection, immobility and other Shelf pessary or gellhorn medical problems. The risk is significantly If you are not sexually active this is a reduced by using special stockings and stronger pessary which can be inserted injections to thin the blood (heparin). into the vagina and again needs changing every 6 months. Specific risks of this surgery General risks of surgery Damage to local organs This can include bowel and blood Anaesthetic risk vessels. This is a rare complication but This is very small unless you have requires that the damaged organ is specific medical problems. This will be repaired and this can result in a delay in discussed with you. recovery. It is sometimes not detected at the time of surgery and therefore may Haemorrhage require a return to theatre. If the rectum There is a risk of bleeding with any (back passage) is inadvertently damaged operation. The risk from blood loss is at the time of surgery, a temporary reduced by knowing your blood group colostomy (bag) may be required but this beforehand and then having blood is exceptionally rare. available to give you if needed. It is rare that we have to transfuse patients after Prolapse recurrence their operation. If you have one prolapse, the risk of having another prolapse sometime during Infection your life is 30%. This is because the There is a risk of infection at any of the vaginal tissue is weak. wound sites. A significant infection is rare. The risk of infection is reduced by our Pain policy of routinely giving antibiotics with You may have general pelvic discomfort. major surgery. This usually settles with time but occasionally pain on intercourse may Deep vein thrombosis (DVT) occur and can sometimes be permanent. This is a clot in the deep veins of the leg. The overall risk is at most 4-5% although Reduced sensation during intercourse the majority of these are without Sometimes the sensation during symptoms. Occasionally this clot can intercourse may be less and occasionally migrate to the lungs which can be very the orgasm may be less intense. serious and in rare circumstances it can be fatal (less than 1% of those who get a clot). Page 3 of 7 Change in bowel function During the operation: Occasionally, patients can become The legs are placed in stirrups constipated after the operation but often (supported in the air). bowel function is improved. The back vaginal wall is infiltrated with local anaesthetic. Posterior vaginal wall prolapse repair A horizontal cut is made where the Following the operation you are likely to back wall of the vagina meets the skin feel more comfortable. Intercourse may just outside the vagina. be more satisfactory. Opening your A vertical cut is then made in the back bowels may be easier, but this cannot be wall of the vagina, over the area of the guaranteed. bulge – see figures 1 and 2. The vaginal skin is then separated Before the operation from the rectum (lower bowel). Stitches (2 or 3) are placed in tissue at It is recommended that you take a either side of the rectum. medication to soften your motions for at These stitches are then tied in the least three days before the operation. centre thus bringing the tissue into the This will help to reduce the risk of you middle so that the rectum is held getting constipated after the operation behind them and thus supported. This and could mean you get home earlier. then stops the rectum bulging into the Magnesium sulphate, Lactulose or back vaginal wall – see figure 3. Movicol would be suitable and you can Sometimes a perineorrhaphy, which is obtain these from your GP or local a surgical repair of the perineum (the pharmacist. If you are post-menopausal skin and muscle between the front and your gynaecologist may recommend back passage), will be performed. This oestrogen cream. can improve the prolapse repair but can result in tightening of the vaginal How the operation is performed entrance and pain during sexual intercourse. The operation can be done with a spinal Any excess vaginal skin is trimmed or general anaesthetic. You may have a and then the vaginal skin closed with choice of which anaesthetic is used. A stitches – see figure 4. spinal anaesthetic involves an injection in A vaginal pack (ribbon gauze to apply the lower back, similar to what we use pressure) may then be inserted into when women are in labour or for a the vagina which is removed the Caesarean Section. The spinal following morning. A catheter may also anaesthetic numbs you from the waist left in the bladder overnight. down; this removes any sharp sensation but a pressure sensation will still be felt. A general anaesthetic will mean you will be asleep (unconscious) during the entire procedure. Page 4 of 7 Figure 1: Diagram showing back Figure 4: Diagram showing the excess (posterior) vaginal wall protruding through vaginal skin cut away and vagina. the vaginal skin closed with stitches. Figure 2: Diagram showing vertical and horizontal incisions in posterior vaginal After the operation - in hospital wall.