112016Jan

Pelvic Reconstructive Surgery (Post-Child Birth) with Dr. Heidi Wittenberg

dreamstime_s_27181205Did you know that roughly 50% of women who have given birth experience some type of pelvic prolapse?

Prolapse refers to when a part of your body, such as an organ, moves (slips) forward or down. It often affects women after childbirth because the muscles surrounding your vagina and bowels are weakened from having a baby and prolapse occurs. Not every woman will experience a form of prolapse after giving birth, but for those who do, an effective treatment options are available at the Urogynecology Center of San Francisco (UGCSF) through pelvic floor physical therapy, pessaries or  pelvic reconstructive surgery depending on the type of prolapse.

What are the types of prolapse women can experience post-childbirth?

  • Vaginal Prolapse: Any portion of the vagina can be weakened and fall down.
  • Anterior Vaginal Prolapse (Cystocele): Support underneath the bladder is weakened and the bladder can drop into the vagina.
  • Urethral loss of Support: Stretching or loss of the support ligaments underneath the urethra can cause women to lose urine with coughing, laughing, sneezing, lifting or any physical exertion.
  • Posterior Vaginal Prolapse (Rectocele): Support of the lower rectum is weakened and the rectum pushes against the vaginal wall and bulges into the vagina.
  • Small Bowel Prolapse (Enterocele): Higher in the vagina, weakening can cause small bowel to push and bulge into the vagina near the vaginal apex or roof.

What are the symptoms of vaginal prolapse?

Depending on where the weakening occurs and the severity of the prolapse will determine the symptoms. Generally, a woman can feel vaginal pressure, soreness, possibly lower back pain. This may worsen over the day and be worse at the end of the day or after vigorous activity, as gravity can exacerbate the symptoms.

If the prolapse is anterior or a cystocele, a woman can feel the above vaginal symptoms, but also notice that her urine stream is different, i.e sprays, has difficulty emptying, sometimes having to use fingers to push up the bulge in order to empty, sometimes having improvement of leaking because the bladder is kinking the urethra and therefore masking stress incontinence.

If the prolapse is posterior, like a rectocele or enterocele, then symptoms can feel like the vaginal prolapse symptoms noted above or discomfort when having to have a bowel movement, sometimes having to use fingers to push in the bulge or press in the perineum in order to empty. Sometimes the anal sphincter is damaged and a woman can experience gas or fecal incontinence.

Urethral loss of support shows itself with accidental loss of urine with physical exertions like coughing, laughing, sneezing, lifting, running, playing soccer, etc.

How is prolapse treated at UGCSF?

This depends on which part of the vagina is falling, the severity, and a woman’s symptoms. Initial approach can be pelvic physical therapy to help strengthen the muscles that help support these areas. Inserts called pessaries can temporarily help symptoms and be a way to avoid procedures. A variety of procedures from office to same day surgery procedures are available- via vaginal approach, laparoscopic and robot assisted laparoscopy. The approach is individualized based on:

  • Type or combination of prolapses present
  • Severity of prolapse
  • Types of symptoms the prolapse causes
  • Presence or absence of urinary or fecal incontinence

Examples of minimally invasive approaches are:

  • Vaginal cystocele repair without mesh
  • Vaginal rectocele or enterocele repair without mesh
  • Vaginal apex support via vaginal sacrospinous ligament suspension or laparoscopic abdominal sacrocolpopexy.
  • Urethral support with hammock or midurethral sling.
  • Urethral bulking procedure.
  • Anal sphincteroplasty
  • Anal sphincter supporting muscles: Levatoroplasty
  • Anal sphincter bulking procedure

Depending on type, severity of prolapse and symptoms, a repair can be just one of the above procedures or a combination — the decision is based upon an individualized approach.