http://drdarylgreebonmd.com | 972-379-2416 When urinary incontinence or uterine prolapse symptoms are mild, surgery is to be avoided if possible and conservative measures such as avoiding heavy lifting, managing fluid intake, and using stool softeners can help mitigate the symptoms and delay the need for surgery. Unfortunately, the physical stresses and activities of life almost always cause progression of these problems, so that most women who have these disorders eventually need surgery

1. Facts About Urinary Incontinence and
Uterine Prolapse – The Solution
Daryl Greebon, M.D.
In part one of this discussion, we discussed disorders referred to as Pelvic Floor Disorders,
or as Disorders of Pelvic Support. These disorders include Urinary Stress Incontinence
(Urinary leakage), Prolapsed Uterus (Dropped Uterus), Cystocele (Dropped Bladder),
Rectocele (Bulging of the back wall of the vagina), Enterocele (A form of internal hernia),
and Vaginal Vault Prolapse (Dropped vagina after hysterectomy). We discussed some of
the causes and the symptoms associated with Pelvic Floor Disorders. In this portion of
the discussion, I would like to discuss the potential solutions to these problems.
For the most part, the treatment of all of these disorders is surgical. When uterine
prolapse or urinary incontinence symptoms are mild, surgery is to be avoided if possible
and conservative measures such as avoiding heavy lifting, managing fluid intake, and
using stool softeners can help mitigate the symptoms and delay the need for surgery.
Unfortunately, the physical stresses and activities of life almost always cause progression
of these problems, so that most women who have these disorders eventually need surgery.
For elderly women who are not sexually active and not good surgical candidates because
of other medical problems, the use of a pessary (a plastic or rubber device that fits into the
vagina to hold the uterus and bladder in better position) can be used. However these are
not adequate for anyone who is sexually active, or has moderate physical activity.
We will discuss now the various procedures necessary to correct pelvic organ prolapse.
Because there are often multiple problems (uterine prolapse, cystocele, rectocele) more
than one procedure is often required.
Hysterectomy – When there is a Prolapsed Uterus (dropped uterus), usually a vaginal
hysterectomy is required. The tubes and ovaries can be removed vaginally as well for
those postmenopausal women who need to have the ovaries out. Occasionally, vaginal
repairs listed below may be done in association with and abdominal hysterectomy, or a
DaVinci Robotic Hysterectomy.
TVT – Tension Free Vaginal Tape. This is a procedure to repair the bladder neck. This
does not take care of significant bulging of the vagina, but is all about control of urinary
leakage. Needles are passed either behind the pubic bone, or around the lateral pelvic
bones and into the space between vaginal wall and bladder. A 1 cm. wide mesh tape is
threaded through the needle and the needle is pulled out . In this way, the vaginal tape is
anchored in place and lays without tension beneath the urethra so that when the woman
coughs or sneezes the urethra is compressed against the mesh and the resulting fibrous
tissue that is laid down around the mesh. This compression prevents urinary leakage.
Anterior Repair – (Also medically known and Anterior Colporraphy). This is a repair of
the anterior or front wall of the vagina beneath the bladder. This is done to correct the
extensive bulging of a large cystocele. An incision is made in the vaginal wall, the vaginal
tissue is then separated from the underlying bladder. In the older type of Anterior

2. Repair, suture is used to pick up some bladder wall on one side, then on the other, and
when this suture is tied, it pulls the tissue together and lifts and supports the bladder.
Unfortunately, when women have weak connective tissue to begin with, the tissue which
is used for support is often not as strong as we might like, and therefore, with
conventional old-style anterior repairs, the failure rate is higher. To avoid this problem,
newer procedures have been developed which use a mesh material, like a loose weave
thin cloth, which can be placed beneath the bladder to provide support. In today’s world,
these surgeries are often done with kits, which provide conveniently shaped pieces of
mesh with “arms” of mesh material that can be passed thru tissue with a needle much like
the TVT described above. The arms help anchor the mesh is place long term, and seem
to give better long-term results. The primary problem with placing mesh material in the
vagina is the possibility of erosion such that the vaginal tissues do not heal completely
over the mesh graft, or the possibility of pain with intercourse if this mesh is used in
women prior to menopause.
Posterior Repair – (Posterior Colporrhaphy) This procedure is a repair of the back wall
of the vagina over the rectum. The description of this procedure would be identical to
the description above of an Anterior Repair. The vaginal wall is opened, the vaginal
tissues are dissected off of the underlying rectum, and then either sutures are placed to
obliterate the defect and provide support, or mesh materials are used as described above
to provide better long-term support.
Vaginal Vault Suspension – This is a procedure to lift or elevate the vaginal vault (top of
the vagina after hysterectomy). Some doctors try to accomplish this simply by doing a
good anterior and posterior repair. If there is significant vault prolapse, I do not believe
that this is adequate to prevent recurrence. There are however, additional procedures
that can be done, some vaginally and some abdominally to support the top of the vagina
when necessary. Sometimes the top of the vagina is anchored with sutures to the
sacrospinous ligament, or high up on the uterosacral ligament. These are both strong
structures which can give a better chance of long-term support, and both of these can be
done vaginally. Each procedure has its relative strengths and weaknesses.
Traditionally the “gold standard” procedure for repair of vaginal vault prolapse is the
Abdominal Sacrocolpopexy. This requires an abdominal incision, and the 4 – 6 week
recovery attendant with an abdominal incision. This procedure uses a 3cm. piece of
mesh material sewn to the top of the vagina with multiple stiches. The other end of the
mesh is attached to the sacrum internally. Fortunately, today this procedure can usually,
though not always be done as a Davinci Robotic Sacrocolpopexy. Using robotic surgery,
it is possible to attach mesh both to the top of the vagina, and to the sacrum using
laparoscopic techniques. This means less pain, quicker recovery, and easier return to
work than the traditional open operation, and still gives the “gold standard” result.
There obviously are nuances about when these procedures should be applied and in what
combination. Results with many of these procedures are directly dependent on the
surgeons skill and experience. For instance, a talented and experienced surgeon can
usually do a vaginal hysterectomy in 30-45 minutes and do vaginal hysterectomy with
anterior repair and posterior repair and TVT in about 2 hours, whereas an inexperienced

3. or less expert surgeon can take 2.5 to 3 hours for vaginal hysterectomy alone. While the
time one takes to do a surgery is not a direct measure of quality, long operating times
often suggest that the surgeon was either struggling or uncomfortable doing the case. The
message is to make sure as much as possible that your surgeon knows and has considered
all of the surgical choices available to you, and that he/she is choosing the best surgery for
you, and that he/she is skilled at performing these operations.
I hope that this two part discussion has been helpful in understanding the problems of
Pelvic Relaxation or Pelvic Support Disorders, and it is my sincere hope that this
information serves you well if you or a loved one are having problems in these areas or
are contemplating surgery in the near future.