Put simply, a vaginal repair is an operation to repair the vagina. It is a very common gynaecological operation. For many it is used to deal with:
- Vaginal prolapse
- Tightening the vagina following childbirth
Whilst you would think of the vagina as a hollow tunnel through which many things pass through ( I mean babies….), in Gynaecology, it is considered to be made up of 3 different compartments:
- The front compartment which supports the bladder and urethra
- The top compartment supporting the womb and bowel
- The back compartment supporting the rectum and anus
A prolapse means that there is loss of support of one or perhaps all of those compartments. This results in the appearance of a vaginal lump and may also be associated with bladder and bowel symptoms like incontinence etc.
A vaginal repair is thus to try to repair the support to the compartment that has prolapsed. There is a wide range of complexity based on the degree of the prolapse and any associated symptoms being present.
For some women, the prolapse can also be associated with a widening of the vagina. Almost always this related to childbearing. There is a significant laxity and sexual intercourse is not as satisfying as previously experienced. Hence the request for “tightening” of the vagina.
Different degrees of severity and the type of prolapse will then determine which variety of vaginal repair operating is performed. Whilst it may involve all three parts of the vagina, it is more commonly related to one or two parts.
The operation involves an anaesthetic. Usually is a general anaesthetic where one is popped off to sleep for a period of time. At times it may be performed under a spinal anaesthetic. Here a needle is inserted into the spine and local anaesthetic is infused. This results in the lower part of your tummy and legs being numb, usually for 3-4 hours. A light sedation is usually given at the same time. Both technique is suitable and the decision is always made by the anaesthetist.
Once the anaesthetic is working, then your legs are placed in a “lithotomy” position. Colloquially speaking, this means that your legs are placed in stirrups. The operation is then performed through the vagina. No cuts are required in your tummy, unless you are also having a concomitant operation for urinary stress incontinence.
A cut is then made in the vagina. This can be on the front or back wall of the vagina. The prolapsing bit, either bladder or bowel/rectum is then pushed back and lots of stitches inserted to pull the muscle and fibrous tissue together. This has the effect of creating an additional layer of support for the organ that has fallen down. If need be, other procedures are taken to strengthen the support. One common one is to cut and adjust the ligaments that hold the womb or vagina up and tighten them as well.
I frequently am asked if a hysterectomy ( removal of the womb) should be performed at the same time. It is a common perception that this should be undertaken as it would results in a better support. Nothing could be further from the truth. The need is based on the severity of the prolapse of the womb itself. It is not uncommon for the womb to be well supported and only the bladder or rectum is falling down. At other times, whilst there is some prolapse of the womb, it is not sufficient to warrant a hysterectomy. Indeed there is an operation I use called a Manchester repair where the womb is retained but the ligaments are cut and readjusted onto the womb itself. This can give a stronger and better repair than taking the womb out. At other times, a hysterectomy may indeed be the right thing to do.
A variation that I commonly undertake is a sacrospinous fixation. This involves a stitch placed at the top of the vagina. It attaches the top of the vagina to a ligament deep inside your pelvic called a sacrospinous ligament. The reason for doing this is that at times, the top of the vagina is till weak and can fall down despite having the back and front walls operated on. So this stitch helps the stabilise the upper part of the vagina.
Whichever type or combination of operation is recommended should depend on the assessment of the type and severity of the prolapse.
Once the operation is completed, I then usually also look into the bladder with a telescope, called a cystoscopy. The bladder is closely approximated to the vaginal wall and the womb. Where surgery is performed on the front wall of the vagina or the womb is removed, the bladder has to se separated off these parts. In doing so, it is possible to damage the bladder. The most common form of damage is to perforate or make a hole into the bladder. Hence, when I undertake such procedures, I always ensure I check the bladder to exclude damage to it.
I then put a large gauze pack in the vagina. The largest tampon you will ever meet! This helps to reduce the risk of bleeding. A catheter is also put into the bladder . Both are in overnight and removed the next day.
Once the catheter is removed, you will have a trial of void. This means , the nursing staff will check to ensure that you are able to empty you bladder well after each time you pass water. This is easily done by checking your bladder with an ultrasound to measure how much urine you have left behind after you pass water. Most will void well and may go home the same day. In this case, you will only need to be in Hospital overnight.
With others, the bladder may not empty well. They will need another catheter put in and left for about 3-4 days. It is then removed and another trial of void performed. Hopefully the bladder will empty well and they would be homeward bound.
In a small proportion however, this may not happen and they may have to go home with a catheter in place, usually for a few weeks. Whilst this can be frustrating, usually it all settles and the bladder starts to empty well.
The reason why retention happens is because there can be swelling under the bladder from the operation. This may prevent good bladder emptying especially in those who have had long standing bladder prolapse. In such women the prolapse may have caused long standing retention of urine which leads to the bladder muscle tone being weak. Thus it may not be able to contract well after the operation to overcome the swelling that occurs. Hence there may be retention occurring. Usually as the swelling settled, the bladder function improves.
There can also be other reasons why your bladder may not work well. Sometimes this can be due to other neurological problems that may pre-exist like diabetes, multiple sclerosis and back problems affecting the nerve supply to the bladder etc. If you have an operation to tighten the bladder sphincter to deal with urinary stress incontinence, it could also be that the tightening is too tight. This brings on other problems of its own.
For most women however, bladder retention is not an issue after the operation. Even in those for whom it is, the retention tends to settle with time and patience.
Whilst the above is the usual process that happens with a vaginal repair, it is possible that other issues may arise that complicate your recovery. I will normally have discussed them with you during our consultation but I will list them as follows:
1 Bladder – trauma
urinary retention – short and long term
increased urinary irritation
2. Rectal damage – only if there is a rectal prolapse that needs to be operated on
6. Sciatica – only of the sacrospinous stitch is required.
7. Recurrence of your prolapse. This risk can be as high as 30%. It cannot be prevented, but it can be minimised.
Despite all this information of bad tidings, for most a vaginal repair is a straightforward procedure. The success rate is high and the recurrence rate is low. For many convalescence can be as short 2-3 weeks. It is important that this is one operation where the long term success is also very much in your own hands. Ensuring you undertake your pelvic floor exercises, avoiding straining , managing your weight are many of the things you can do to achieve this.
These notes reflect my personal opinion and are intended for general advice only. It should not be used for any one individual case. You should consult your own doctor to determine the appropriate management of your own individual situation. No part of these notes can be used or reproduced in any manner without my express consent