Frequently Asked Questions at the Center for
Advanced Gynecologic Surgery
Questions about incontinence
Q: Why can’t I control my urine when I cough, sneeze, or lift?
A: The continence mechanism works in two ways. First, it requires good support for the urethra. Increased abdominal pressure occurs with coughing, sneezing and lifting. This increased abdominal pressure is transmitted to the pelvic organs. The urethra should have strong support from ligaments, tendons, and muscles so that it remains in the proper position during exercise, coughing, and straining. If the anterior wall of the vagina is well supported, there is resistance against which the urethra can push. For example, if a garden hose was placed in soft mud, you could step on it and it would just sink in the mud, and water could continue to flow through it. However, if the garden hose was against concrete and you stepped on it, the surface under the garden hose would be firm enough for the pressure from above to stop the flow of water.
Secondly, the work of a sphincter muscle around the urethra can squeeze the urethra closed.
Patients with stress urinary incontinence (SUI) will report leakage with coughing, sneezing, laughing, and lifting heavy objects, bending over, and other physical activities, such as playing tennis. The leakage tends to be drops or small amounts of urine that spurt out quickly.
In stress urinary incontinence, the urethra may be abnormal from either of these two basic problems. First, the urethra may be poorly supported. These structures can be injured or weakened by childbirth, pelvic surgery, obesity, frequent prolonged straining, and strenuous exercise (such as weight lifting, long distance running, high impact aerobics, etc). This common condition may be associated with aging. The second cause of SUI is poor urethral sphincter function, or intrinsic sphincter deficiency (ISD).
Q: What can be done to treat this stress urinary incontinence?
A: Correct diagnosis must be established prior to advising any specific treatment options. Diagnosis is made after initial consultation and diagnostic testing, if required. Please, contact you doctor for appropriate evaluation prior to initiation of any therapies. Evaluation starts with meticulous history taking followed by thorough urogynecologic/pelvic exam. Additional tests may include urine analysis, culture and urine cytology. You may require urodynamic testing and/or cystoscopy to understand your problem better and offer you the most appropriate treatment plan. These may include diet changes, fluids management, behavioral modifications, pelvic floor muscles exercises and other physical therapies to help you to control urine. Certain medications and/or surgery may be beneficial depending on the specific situation.
Treatment may vary considerably depending on the patient’s specific problems.
If the urethra is poorly supported, a number of procedures may be considered. Sling procedures provide the best success rate in surgical correction of stress urinary incontinence. Sling procedures are a number of conceptually similar procedures where supportive material is brought from underneath and along the sides of the urethra to the anterior abdominal wall, to provide a support for the urethra. The are different types of supportive materials available, varying from the patient’s own tissue, synthetic mesh, cadaveric (from another human body) or porcine materials (from a pig).
Today, frequently physicians use a synthetic mesh because it is permanent and it will never go away. With any surgery, there are risks of infection. However, newer meshes recently introduced have very low rates of infection, erosions or rejections. Use of the synthetic polypropylene mesh in the form of a “tape” mainly replaced all other techniques due to its effectiveness and low complications rate. It is surgically placed under sterile conditions. It is knitted from several threads, where each filament is solid, not braided, so that it is less likely to potentiate an environment upon which bacteria can grow. Between each filament, there is enough space where it is possible for the immune system cells to fight the growth of bacteria. This space, or pore size, also allows small blood vessels, or capillaries, to grow through the tape.
These minimally invasive surgeries with very high success rates and longevity of results, known as “Tension free procedures”. It is called tension-free because it is not sutured to any ligament or attached to any bone. The material itself grips into the tissue. In addition, it creates an environment for the patient’s own collagen to form around it and produce supportive scarring.
For intrinsic sphincter deficiency, paraurethral injections of a bulking agent can be considered. This surgical procedure involves injecting a medicated substance such as bovine collagen or carbon beads around the urethra (paraurethral). Bovine collagen (obtained from a cow) is highly processed and sterile. This treatment allows the urethra to close more effectively during times of increased abdominal pressure, preventing the leakage of urine. This procedure is done using local or general anesthesia as an outpatient procedure.
Questions about the repair of pelvic organ prolapse
Q: Why is my bladder falling into the vagina?
A: The bladder does not have its own support. It is intimately connected to the vagina. The vagina is stretched between the two sidewalls of the pelvis. The uterosacral ligament supports the apex of the vagina and the cervix. These structures can be injured or weakened by childbirth, pelvic surgery, obesity, frequent prolonged straining, and may be attenuated with aging. Sometimes the quality of the patient’s tissues is inadequate to provide sufficient long-term support. A cystocele is the prolapse of the anterior (top) wall of the vagina, when the bladder descends into the vaginal space. If ignored, or when treatment is delayed, pelvic organ prolapse usually gets worse. Prolapse and incontinence can occur together. . [There are various types of pelvic organ prolapse, or the displacement of an organ from its normal position. The Advanced Gynecologic Surgery Center is specialized in the surgical treatment of all types of pelvic organ prolapse. Please see glossary for descriptions of organ prolapse (see uterine prolapse, cystocele, rectocele, enterocele and etc.).
Q: How do you surgically repair pelvic organ prolapse?
A: The goal of pelvic reconstruction is to restore your own anatomy to facilitate normal function. There are a number of different surgical treatments to repair pelvic organ prolapse. None of the procedures are successful 100% of the time. Anterior and posterior colporrhaphy is a plication, or folding, of the anterior or posterior walls of the vagina, respectively, in order to strengthen these walls. Colporrhaphy results rely on the patient’s own tissues, which are already weak.
Surgeons trained to use reinforcing materials can connect them to the pelvic sidewalls to support prolapsed organs. There are various reinforcing materials. Allografts (biologic products – cadaveric or animal origin) represent collagen matrix, which promotes your own tissue growth upon it, but the body can reabsorb this. Grafting materials must be cut to fit your own anatomy. Sometimes they may produce scarring and change the dimension of the vaginal lumen.
Q: What type of surgical approach do you prefer for the repair of pelvic organ prolapse?
A: The surgical approach depends on the patient’s specific problems. As the patient’s condition indicates, we can use vaginal, abdominal or laparoscopic approach. Most commonly, we use a vaginal or laparoscopic approach for the repair of pelvic organ prolapse, instead of an abdominal. “Why break the ceiling to fix the floor”.
Questions about anal reconstruction
Q: Will you make an episiotomy incision with the anal reconstruction surgery?
A: Not an episiotomy, per se, but you will have a suture line in the area between the vagina and anus (perineal body). Sometimes it situation require to make an incision to get to the anal area to operate. A perineoplasty includes the repair of this incision. The perineal body area is very sensitive, and most of the discomfort from anal reconstruction will come from this area. Sitz baths and warm, moist heat applied to this area will diminish the discomfort after surgery. In addition, pain medication will relieve this discomfort.
Q: When you repair the anus, how can I pass stool?
A: You will take stool softener medication. The first three weeks after surgery, you will also take mineral oil, one tablespoon each day, and you will be on a low fiber low residue diet. After your body has had time to begin to form scar tissue (healing), which takes about three weeks, you will change your diet to a fiber rich diet. This will keep the stool formed, but soft, and you should be able to pass it. Never strain, and notify as if 36 hours have passed since your last bowel movement. You may take any laxative that has worked for you in the past.
General pre-operative questions
Q: I take aspirin. Should I stop this before surgery?
A: Stop taking the aspirin ten days before surgery. [Please refer to treatment page, pre-operative preparation section.]
Q: What kind of anesthesia will I have?
A: The type of anesthesia is influenced by the type of surgery, your medical and surgical history. You and the anesthesiologist can discuss your preferences.
General questions regarding post-operative recovery period
Q: What can I expect during recovery from pelvic reconstruction surgery?
A: Most patients leave the hospital after they meet the discharge criteria. [Please refer to treatment page.] The recovery period after surgery lasts an average of 6-8 weeks. Before leaving a hospital, patients will receive preprinted “Discharge Instructions”, “Bladder Catheter Instructions” and “Dietary Instructions” as needed. To assure success of the operation, patients should adhere to postoperative discharge instructions, which describe all the important aspects of the recovery process.
Do not lift anything heavier than 10 lbs. for at least 8 weeks. After surgery, tissue becomes inflamed. The reinforcing sutures are strong, but it takes 2-4 months for scar tissues to form around the sutures and reinforce the surgical repair. Any increase in the abdominal pressure can pull the sutures through the tissue, like a wire through the butter. This would undo the surgical repair.
After reconstructive surgery for prolapse or urinary incontinence, many patients will temporarily require a tube to drain the bladder (catheter). They may leave the hospital with a catheter in place. Catheters are not a complication, but part of a routine recovery process. This is needed because of urethral edema (swelling) and temporary changes in the voiding mechanism.
Unless required sooner, the first follow up visit with your doctor will be about two weeks after surgery, then as frequently as needed.
Q: How will vaginal surgery affect sexual intercourse after surgery?
A: Vaginal intercourse should be postponed until about 6-8 weeks after surgery and as advised by your doctor. After you have healed completely, you should be able to resume intercourse as before surgery. Once prolapse and incontinence are treated and the recovery period is complete, many women notice improvement.