Many women in the menopausal and perimenopausal
age range, require surgery for pelvic support defects
such as cystocoele (bladder dropping), rectocoele
(rectum protruding), bladder neck dropping (stress
incontinence), and uterine or post hysterectomy vaginal
vault prolapse. There is not much information about
these subjects in the usual health media so it is
difficult for women to know what to expect as far
as success rates, complications and recovery in general.
At a recent meeting of the Society of Gynecologic
Surgeons, some of the scientific papers provided answers
to questions that women may have about these subjects.
How often do normal perimenopausal women lose urine
with cough, sneeze or increase in abdominal pressure?
In one study by Robinson D et al., women aged 45-55
who did not present for incontinence or evaluation
of pelvic relaxation, were questioned to see how often
they had episodes of urinary loss with intraabdominal
straining. Some degree of urinary loss was reported
by 2/3's (66%) but daily loss was only reported by
8%.
Frequency of urinary loss Incidence (%)
None 38.0%
Less than once per month 23.0%
Several times per month 13.0%
Several times per week 17.0%
Daily loss 8.0%
What degree or amount of pelvic relaxation is normal
in the perimenopause?
Robinson D et al. also measured the degree of vaginal
and uterine prolapse in these asymptomatic, perimenopausal
women aged 45-55. She found that only 3% had a degree
of prolapse for which surgeons might recommend surgical
repair depending upon symptoms.
Degree of uterine or vaginal prolapse Incidence (%)
None 81%
Mild (Stage 1) 16%
Moderate (Stage 2) 3%
Severe (Stage 3) 0%
Complete/Total (Stage 4) 0%
What symptoms are caused by a rectocoele?
In a study by Kenton K et al, of 46 women undergoing
rectocoele repair, preoperative symptoms that were
felt to be due to the herniation of rectal tissue
included protrusion of rectal tissue from the vagina,
difficult defecation (bowel movement), constipation,
dyspareunia (pain with sexual relations), and manual
evacuation or the need to put fingers in the vagina
and push down on the rectal protrusion in order to
have a bowel movement.
Rectocoele symptom Incidence (%)
Protrusion 85%
Difficult defecation 52%
Constipation 46%
Dyspareunia 26%
Manual evacuation 24%
How well does rectocoele support surgery decrease
symptoms.
In the same study from Kenton K et al, they looked
at how well the initial presenting symptoms improved
when remeasured at one year after the surgery. Basically,
protrusion and painful sexual relations resolved by
90%, but difficult defecation, constipation and the
need for manual evacuation only improved by 35-55%.
Rectocoele symptom Preoperative(%) Postoperative
(%)
Protrusion 85% 9%
Difficult defecation 52% 22%
Constipation 46% 26%
Dyspareunia 26% 2%
Manual evacuation 24% 15%
Can bladder repair surgery be too tight to void afterwards?
Any time the bladder is suspended to attempt to reduce
urinary leakage with stress of the intraabdominal
pressure, there is always the risk that voiding will
go to the opposite extreme, i.e., difficulty or being
unable to void at all. How often this occurs as a
complication of surgery depends upon the type of surgery
performed and how the tissues heal. This problem can
occur as high as 5% of the time. Sometimes it can
be due to just "being too tight", i.e.,
compressing the urethra shut during voiding. At other
times, it can be due to a bladder that just does not
contract well or its contraction during voiding is
not coordinated with relaxation of the urethra.
Urodynamic studies (uroflow and cystometrogram) are
used to diagnose which is the main problem but if
it turns out that the support is just "too tight",
the question becomes as to how the problem should
be fixed. Should sutures just be cut either from the
vaginal side or from the abdominal side? If the sutures
are cut, does there need to be some sort of repair
done again so that the stress incontinence does not
just recur? Steele AC et al, reported that in their
hands the abdominal approach to take down the scarring
worked best because they had previously seen patients
that had attempts at vaginal take down that did not
improve the problem. All of their patients underwent
abdominal incision for take down (retropubic vesicourethrolysis)
and that successfully treated the voiding dysfunction
without having to "resuspend" the urethra.
In their patients with voiding dysfunction that had
weak bladder muscles, most of them improved with just
physical therapy and self-catheterization over several
weeks rather than having to have repeat surgery. While
voiding problems after anti-incontinence surgery are
not common, they can be sucessfully treated.
How successful is repair surgery for stress incontinence?
Different surgeons and different procedures can result
in widely different "cure" rates for stress
urinary incontinence. Surgeons also know that the
cure rates depend on how long after the surgery you
check them. Success will always be greater at one
year than at five years and even lower at 10 years.
This change in success is often due to aging effects
that make tissues weaker over time. Surgeons would
like to let women know what to expect, however. How
likely is it that the surgery is going to cure the
problem for a "very long time"?
Tamussino KF, looked five year follow-up results
after anti-incontinence surgery. The cure rates varied
from 50-60% for vaginal procedures (anterior repair
alone or anterior repair with needle suspension) to
80% for the abdominal surgical approach (Burch retropubic
urethropexy). These were overall results. They did
note, however, that with just mild stress incontinence,
the vaginal procedures alone had an 80% 5-year cure
rate. Thus they felt the vaginal procedures still
have a role in some cases, especially if the urinary
loss is mild.
|
