Pelvic Reconstructive Surgery for Pelvic Organ Prolapse
Patient Information, Treatment, and Anticipated Recovery Plan
One or more of the pelvic organs can lose their support and fall out of place. Women with
prolapse may experience pelvic pressure, a sense of a “lump” protruding through the vagina,
problems having a bowel movement, low back pain, and problems having intercourse. Pelvic
organ prolapse may be caused by vaginal childbirth, menopause, chronic coughing or straining,
heavy lifting, or obesity.
Of significance, prolapse often causes problems with urination. Women who may have once
experienced urinary incontinence (a condition common with prolapse) often notice an
“improvement” as their prolapse worsens. This is due to the functional “kinking” of the urethra
caused by the occluding nature of the prolapse. Severe prolapse may not only affect urinary
continence, but also may obstruct the ability to empty the bladder.
In a normal pelvis, the pelvic muscles support the reproductive, urinary, and digestive organs. If
these muscles stretch, weaken, or tear, the pelvic organs fall out of place (prolapse). The
prolapse may mild or severe. It may involve more than one of the three pelvic organ systems
mentioned above. The main types of prolapse are mentioned below:
Once you and your health care provider have decided on pelvic reconstructive surgery, you will
want to understand what needs to be repaired. There are several types of surgery for pelvic organ
prolapse. The goal of each type of surgery is to repair the problem and relieve your symptoms.
The surgery may include one or more repairs, depending on your problem.
The surgeon reaches your pelvic organs through the vagina or the abdomen. An incision may be
made in the vaginal wall. If incisions are made on the abdomen, they can be up and down or
across. The method of surgery may affect your recovery.
Once the pelvic organ prolapse is repaired, the urethra may no longer be occluded. This may result in
the “unmasking” of the hidden urinary incontinence problem that so often coexists with prolapse.
Urinary incontinence surgery may be needed to help reduce prolapse related urinary leakage.
Bulking
agent
A transurethral bulking agent injects material into the urethra and helps to close the urethra
during activities that cause urine leakage. An incontinence sling is placed vaginally under the
urethra to recreate a hammock of support that kinks the urethra closed during activities that
cause urine leakage. A retropubic urethropexy uses an abdominal incision to resuspend the
bladder neck to ligaments adjacent to the back of the pubic bone.
If prolapse or incontinence is severe or recurrent, biologic or synthetic material may need to be
used for the repair. If necessary, this will be discussed before surgery.
You may stay in hospital for 1 night or longer. Or, you may go home the same day. The length
of stay depends on the nature of your surgery. You will have an intravenous line to provide
fluids. Medication to relieve pain and nausea will be available throughout your hospital stay.
It may be hard for you to urinate for a few days or weeks. Sometimes, up to 40% of women
cannot urinate efficiently after surgery due to swelling or anesthesia. This may last a few hours
to a few weeks.
You may be required to use a catheter in your bladder to help it drain. One kind of catheter,
called a Foley catheter, may be placed into the bladder through the urethra. This is usually
reserved for large pelvic reconstructive surgeries and delayed recovery. Most patients learn how
to use a catheter intermittently to empty their bladder. This is called self intermittent
catheterization. It is an easy technique to learn and helps to lessen the threat of urine infection.
A third kind of catheter is called a suprapubic catheter (SPC). This catheter is place through a
small incision in the abdomen. A SPC is good for elderly patients who may not be able to insert
a catheter or who are obese. Other tubes may help drain fluid from your incision.
All in-patient surgical procedures are performed at St. Luke’s Hospital or St. Vincent’s Hospital
unless your insurance requires you go elsewhere. A surgical consent must be signed in the office
prior to having your procedure scheduled.
You may stay in hospital for 1 night or longer. Or, you may go home the same day. The length
of stay depends on the nature of your surgery. You will have an intravenous line to provide
fluids. Medication to relieve pain and nausea will be available throughout your hospital stay.
After surgery, give your self a chance to adjust and recover. Some women feel fine within a
month. Many need a little extra time. It may take several weeks to urinate normally thus,
requiring help from a catheterization plan at home.
If pain and bleeding have been a problem, you may feel better and have more energy as your
body heals. Once you have fully recovered, you can focus on enjoying your life.
Before Surgery
* For surgery scheduled at St. Luke’s Hospital, pre-admission testing will be scheduled for
you. Your tests may include blood work, a urinalysis, chest x-ray, electrocardiogram and a
pregnancy test.
* If MRSA positive, please refer to the MRSA protocol below to obtain appropriate preoperative therapies to use before your surgery.
* The anesthesiologist will talk with you at the time of your testing regarding the specific type
of anesthesia that will be administered. Inform the anesthesiologist if you wear dentures, or
have a family history of anesthetic complications. He/she or one of the personnel in the outpatient testing will tell you what time to report to the out-patient admitting office the day of
your scheduled surgery.
* Do not bring jewelry or valuables with you to the hospital.
* Stopping smoking before surgery if strongly encouraged.
One Day Prior to Surgery
* Please refer to the bowel prep protocols attached. Please Follow a Clear Liquid Diet
beginning at 4:00 PM the day before surgery. You may have Jello, broth, coffee,
popsicles, tea, soda, Kool-Aid and juices (except orange). ABSOLUTELY NO FOOD,
LIQUID OR MEDICATION SHOULD BE TAKEN BY MOUTH AFTER MIDNIGHT
OF THE DAY PRIOR TO SURGERY. Please let Dr. Croak and the anesthesiologist
know if you take any medicines daily, or have a chronic illness.
After Surgery
* For procedures requiring an overnight stay, the length of your hospital stay can vary, but is
typically is 1-3 days. Please understand that with healthcare reform, Medicare and many
private insurers will now only allow a one night in the hospital for most surgical procedures.
* Perform breathing exercises every hour while awake in the hospital to keep lungs clear of
excess fluid; walking with assistance later in the day of surgery can help prevent blood clot
formation
* If necessary, perform the catheterization plan specific to you surgery.
* Normal activities, including sex, can be resumed in 6 weeks in most cases; meanwhile, do
not place anything in the vagina
* Resume physical activities slowly; take showers instead of baths for 6 weeks
* To avoid constipation eat fruits, vegetables & whole-grain foods. Drink 8 glasses of fluid
daily.
* You can drive after 1-2 weeks if you feel up to it, have discontinued narcotic pain meds, and
can press on the brake quickly without pain
* Do not lift more than 15 lbs until after your 6-week appointment; when you can return to
work depends on your responsibilities
* You will be seen in the office at 1 & 6 weeks postoperatively, and as needed
* Please call the office with any questions or concerns at 419.893.7134
* Notify your Dr. if you notice fever or chills, heavy vaginal bleeding or foul vaginal
discharge, redness, bleeding or discharge at the incision site, pain or swelling in your
legs, shortness of breath or chest pain, severe abdominal or pelvic pain
Taken from www.fda.gov Medical Devices Safety Alerts & Notices (07/13/2011)
Information on Surgical Mesh for Pelvic Organ Prolapse and Stress Urinary Incontinence: FDA wants to inform
you about the complications that can occur when surgical mesh is used to treat Pelvic Organ Prolapse (POP) and
Stress Urinary Incontinence (SUI), and provide you with questions to ask your surgeon before having these
procedures. This is part of our commitment to keep healthcare professionals and the public informed about the
medical products we regulate.
FDA has received reports of complications associated with the placement of mesh through an incision made in the
wall of the vagina. Although rare, these complications can have serious consequences. The reports have not been
linked to a single brand or model of mesh.
The most frequent complications included erosion through the vagina, infection, pain, urinary problems and
recurrence of the prolapse and/or incontinence.
In some cases, erosion of the mesh and scarring of the vagina led to discomfort and pain, including pain during
sexual intercourse. Some patients needed additional surgery to remove the mesh that had eroded into the vagina.
Other complications included injuries to nearby organs such as the bowel and bladder, or blood vessels.
Background: A pelvic organ prolapse (POP) occurs when a pelvic organ, such as your bladder, drops (“prolapses”)
from its normal position and pushes against the walls of your vagina. This can happen if the muscles that hold your
pelvic organs in place become weak or stretched from childbirth or surgery. More than one pelvic organ can drop at
the same time. Organs that can be involved in a pelvic organ prolapse include the bladder, the uterus, the bowel and
the rectum. Pelvic organ prolapse can cause pain or problems with bowel and bladder functions or interfere with
sexual activity. Stress urinary incontinence (SUI) is a type of incontinence caused by leakage of urine during
moments of physical stress.
Talking to your doctor: Before having an operation for POP or SUI, be sure to let your surgeon know if you’ve had
a past reaction to mesh materials such as polypropylene. Questions you should ask the surgeon before you agree to
surgery in which mesh will be used:
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What are the pros and cons of using surgical mesh in my particular case? Can my repair be successfully
performed without using mesh?
If a mesh is to be used, what’s been your experience with implanting this particular product? What
experience have your other patients had with this product?
What’s been your experience in dealing with the complications that might occur?
What can I expect to feel after surgery and for how long?
Are there any specific side effects I should let you know about after the surgery?
What if the mesh doesn’t correct my problem?
If I have a complication related to the mesh, can the mesh be removed and what could the consequences
be?
If a mesh is to be used, is there patient information that comes with the product, and can I have a copy?
Reporting complications to the FDA: In order to help FDA learn more about possible problems with surgical mesh,
it is important that both physicians and patients report complications that may be associated with this product.
You can report any problems to the FDA's MedWatch Adverse Event Reporting program either online, by mail or
FAX.
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Online : MedWatch Online Voluntary Reporting Form (3500)5
Mail : use postage-paid FDA form 3500 available at: MedWatch Forms6
Mail to MedWatch 5600 Fishers Lane, Rockville, MD 20852-9787
FAX: 1-800-FDA-0178
Related Links
FDA Public Health Notification: Serious Complications Associated with Transvaginal Placement of Surgical Mesh in Repair of
Pelvic Organ Prolapse and Stress Urinary Incontinence
MRSA SCREEN PROTOCOL
(For patients with a positive result only)
IF you have tested positive for Methicillin Resistant Staph Aureus (MRSA), the
following protocol will be used to decrease the amount of bacteria present and help
prevent an infection with surgery.
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Bactroban ointment in both nostrils, twice a day for 10 days before surgery
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Cipro 500 mg by mouth twice daily for 2 days before surgery
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Povidone/Iodine douche 1-3 days before surgery (available at Buderer’s Pharmacy in
Perrysburg)
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Chlorhexadine (or similar) shampoo/wash the day before surgery (available at Buderer’s
Pharmacy in Perrysburg)
PRE-SURGERY BOWEL PREP INSTRUCTIONS
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May have regular diet up until 4:00 PM day before surgery
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At 4:00 PM, begin a clear liquids diet AND take one (1) Ducolax laxative tablet
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At 6:00 PM, use one (1) Fleets enemas according to instructions
Examples of Clear Liquids: Water, clear fruit juices (apple or white grape), chicken/beef
bouillon cubes, jello (NO RED OR PURPLE), popsicles ( NO RED OR PURPLE), Gatorade
(Light color only), clear soft drinks (7-UP, Sprite, Vernors), coffee/tea without cream (sugar is
Ok). No milk, milk products or orange juice.
*** ABSOLUTELY NOTHING BY MOUTH AFTER MIDNIGHT ***
STOP Plavix/Aspirin, Aspirin by-products 1 week prior to your surgery.
STOP Coumadin 5 days prior to your surgery.
PLEASE CONSULT the physician who ordered the Plavix and Coumadin before you stop
taking.
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NEWER ANTICOAGULANTS (I.E. PRADAXA, EFFIENT) MAY REQUIRE A LONGER
DISCONTINUANCE RATE PRIOR TO SURGERY DUE TO HEAVY BLEEDING RISK
PELVIC RECONSTRUCTIVE SURGERY AND DISABILITY
Pelvic prolapse is a condition that may be caused by vaginal childbirth, menopause, chronic coughing or
straining, heavy lifting, or obesity. It is a condition that often takes many years to present itself as a
condition of moderate to severe bother, thus patients with prolapse may choose to delay a visit until their
problem is severe. A delay in seeking help often has caused extreme and permanent pelvic floor
dysfunction from their prolapse including but not limited to urinary of fecal incontinence, pain, weak
tissue, and poor neurological function.
Many women with chronic health problems including but not limited to obesity, diabetes, smoking, joint
replacements, and prior pelvic surgery are prone to prolapse. In addition, women with jobs requiring
heavy labor, lifting, or standing for long periods tend to get prolapse. By the time many patient seek help
for their prolapse problem, they may experience more severe symptoms requiring more complex surgery
that involves longer surgical recuperation.
The fact of the matter is that Dr. Croak will try his BEST to repair a prolapse, but sometimes the
patient’s conditions and poor pelvic health will not allow for the most optimal healing. Recurrent
prolapse is always possible and is more likely to occur in patients with the problems mentioned
above.
To help prevent recurrent prolapse after a surgery, Dr. Croak may give recommendations including but
not limited to limiting heavy lifting, maintaining regular bowel function, optimizing weight loss and
exercise, and improving overall pelvic floor health.
It is impossible for Dr. Croak to control what people do in their daily lives or for him to list the
hundreds of activities that people may do that cause strain to the pelvic floor. Just as a person with
common sense would not cross a busy intersection into oncoming traffic, a postoperative patient should
not do activities that strain a repair such as skydiving, waterskiing, or dead-lifting.
THESE ARE NOT RESTRICTIONS – THEY ARE RECOMMENDATIONS.
The reason Dr. Croak does not give out restrictions is because many patients are employed by
companies that will not allow their employees back to work with a restriction in place. This is their
way to escape responsibility towards protecting their employee’s health after a pelvic surgery. If an
employed patient is put in the position of jeopardizing their repair, they should ask for assistance in
performing that particular job or be switched to another position.
Dr. Croak understands that a patient must return to work to make a living, but he does not have the means
or staff to place restrictions on patients or pursue lengthily disability claims.