Factors That Predict Success And Failure Of Pessary Use
Using the Pelvic Floor Disorders Impact Questionnaire , Komesu et al.7 established that a prolapse subscale score that fell to 50% of baseline at 2 months, best predicted continued pessary use. Older women have also been found to be more likely to continue pessary usage.4, 24 However, others have shown that a desire for surgery and stage IIIIV posterior vaginal wall prolapse are both associated with discontinued pessary use and subsequent pelvic reconstructive surgery.4
Previous hysterectomy,5 increased parity,5 a short vaginal length17 and wide vaginal introitus17 which can occur after prolapse surgery and hysterectomy and SUI,25 were risk factors for pessary failure. Wu et al.3 in a prospective study of women with symptomatic POP who opted for pessaries, found that 58% of the women who complained of concomitant UI chose surgery for treatment of both their prolapse and SUI symptoms.
Pelvic Organ Prolapse After Hysterectomy
After a vaginal hysterectomy, many women are at risk of prolapse developing. The pelvic organs may become unsupported and slip and descend or herniate into the vaginal region. If you are experiencing increased pelvic pressure after your hysterectomy, it may be best to consult your doctor for a proper diagnosis, as this may be a sign of prolapse.
It may be helpful to understand how this happens and why you may be at a higher risk of prolapse after having a hysterectomy. Each of the organs located in the pelvic region are all supported and attached to the pelvic wall by the same ligaments, muscles, and tissues. If the uterus and cervix are removed, support structures must be added in order to maintain the normal support that was previously there. This may actually leave the pelvic area less secure and more vulnerable to prolapse.
If prolapse does present post-hysterectomy, there are a few that are more prone to occur. These include:
We understand that this may sound frightening. However, it is important to understand the risk of undergoing a procedure if you have any pre-existing pelvic floor issues. This is one of the greatest risks of developing a prolapse after a hysterectomy.
Degree Of Bother By Symptoms Is A Key Factor
In older patients, whether and how to treat POP depends on their functional status, the degree to which they are bothered or inconvenienced by the condition, and their personal preference.
If an elderly woman has anatomic POP but lacks bothersome symptoms, the condition rarely requires treatment. Conversely, POP symptoms may cause depression and poor self-image and impair participation in social activities. Associated bladder, bowel or sexual symptoms can also take their toll. And quality of life may be impacted regardless of the stage of prolapse. Vaginal bulge causing discomfort and/or bleeding, difficulty voiding and/or defecating, recurrent urinary tract infections and POP-associated low back pain are all symptoms that may warrant treatment.
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Understanding Pelvic Organ Prolapse
The main cause of pelvic organ prolapse is pregnancy and childbirth, especially vaginal childbirth. Other causes can include aging and obesity. This problem also runs in families.
The following videos show the different types of prolapse that can occur. Prolapse happens in stages. Mild cases are those in which the organs have dropped only a short distance. Severe cases are those in which the organs have dropped a greater distance. Sometimes several organs can be affected at once. There also are videos showing treatment with pessaries.
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How To Deal With Changes After A Hysterectomy
A hysterectomy that also involves the removal of ovaries results in the permanent cessation of a womans menstrual cycle. This condition is known as surgical menopause or surgery-induced menopause. Hormonal changes also take place during menopause for which the doctor may recommendhormone replacement therapy .
Menopause results in a decrease in the estrogen hormone that gives rise to signs and symptoms of menopause. HRT aims at making up for the loss of estrogen by replacing it with synthetic estrogen.
If you experience vaginal dryness and pain during sex, you can use a vaginal lubricant just before performing the carnal act.
You may feel depressed or stressed due to the loss of one or more of your reproductive organs. You can relax and destress yourself by indulging in massage therapy, deep breathing, meditation, and yoga.
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Pros Of Bladder Suspension Surgery
1. Less Urine LeakageWhen the procedure is effective, urine leakage is not only reduced but almost nonexistent. This means that you can return to your normal activities and not have to be self-conscious when you are on-the-go. Urine leakage can impact your emotional and mental state negatively, but bladder suspension surgery can help you get your life back.
2. Treats All Types of Stress IncontinenceNo matter what your cause of stress incontinence is, this can be an effective surgical procedure. Those people dealing with urine leakage caused by menopause, child birth, surgery or muscle problems are great candidates for this type of surgery. It is almost 90% effective, which makes it the superior treatment option to Kegal exercises or medication.
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Will Sex Be Better If You Have Surgery
To answer this, a recent American study questioned a group of women before and after surgery to repair a prolapse or incontinence. About half of these women were sexually active. Before surgery, 82% of the sexually active women reported being happy with their sex lives, and after surgery, 89% of the women felt happy with their sexual relationship.
However, a study brought out a number of interesting findings. For one, the frequency of intercourse did not change following surgery. And two, while only 8% of the women had pain with intercourse before surgery, 19% noted pain with intercourse after surgery. About one quarter of the women who had a repair of a bulging rectum developed pain with intercourse. About one third of the women who had repair of a rectocele and a bladder suspension had painful intercourse. Unfortunately, the researchers did not ask these women why they were more satisfied with their sex lives even though more of them had painful intercourse.
Another study performed in Sweden may shed some light. This study found that one third of women noted an increased interest in sex after incontinence surgery, and one half of their male partners were more interested in sex. It could be that knowing the repair for the prolapse or incontinence had been addressed was enough to make the couples feel better about sex.
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As Pop Worsens You May Notice:
- The feeling of sitting on a ball
- Difficulty starting to urinate or a weak or spraying stream of urine
- Urinary frequency or the sensation that you are unable to empty the bladder well
- Lower back discomfort
- Urinary leakage with intercourse. Though unusual, severe prolapse can block the flow of urine and cause recurrent urinary tract infections or even kidney damage.
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Developer Declaration Of Interests
Mr AM El Naqa: Mr El Naqa has received educational sponsorship to attend educational meetings/sponsorship from Astellas. He has received consultancy fees for attending one Astellas Advisory Board meeting in 2013. Mr El Naqa is a member of the British Society of Urogynaecology, the International Urogynaecological Association and the International Continence Society.
Miss KL Guerrero: Miss Guerrero has received educational sponsorship/speaker fees from Gynecare, Astellas, Pfizer, Allergan and AMS. She has attended one Advisory Board meeting for Allergan in 2013. Miss Guerreros unit is a centre for the CAPTURE registry, a multinational database project funded by AMS. Miss Guerrero is a member of the Scottish Government transvaginal mesh Short Life Working Group and Independent Review. She is a member of the Research and Meetings subcommittees of the British Society of Urogynaecology.
Mr MS Abdel Fattah: The University of Aberdeen received a research grant from Coloplast to fund a research project for Mr Abdel Fattah in 2009. He has received travel grants to attend scientific conferences from Lilly, Astellas and Coloplast. He is the Chairman of the Scottish Pelvic Floor Network and the Chief Investigator of the National Institute for Health Research -funded SIMS Study. He is a member of the Short Life Working Group on transvaginal mesh in Scotland and research committees in the British Society of Urogynaecology and the International Urogynaecological Association.
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How To Prevent Prolapse After Hysterectomy
Resting and Moving About Safely Post-Op
The way you move during your early postoperative recovery affects the load on your pelvic floor after your hysterectomy.
The way you move and engage your muscles during your post-op recovery can affect your pelvic floor after a hysterectomy. It is important that you use techniques that reduce pelvic floor load when you are:
- Rising out of bed or getting into bed
- Moving while in bed
- How you cough or sneeze
- And trying to use the restroom without straining
Avoiding Heavy Lifting
As with any surgical procedure, it is important to not engage in heavy lifting. This can cause additional strain on the pelvic floor. Being cautious when lifting may help reduce the risk of developing prolapse.
Choosing Pelvic Floor Friendly Exercises
Once you have recovered and are at a point when physical therapy and exercise are encouraged, it is important to consider a restorative program that can help you strengthen your core and pelvic region without adding any unnecessary stress and strain.
Indications And Contraindications For Pessary Use
POP remains the most common indication for pessary use. Physicians generally offer pessaries as a first-line option for women with POP who desire nonsurgical management, future pregnancy, have early-stage prolapse, or are too frail for surgery. Additionally, pessaries are a valid option for patients with stress incontinence worsened by strenuous physical activity. In women presenting with pelvic pain, back pain, and pressure thought to be due to POP, pessaries offer an opportunity to simulate postsurgical conditions and aid in patient expectations regarding symptom reduction.
There are very few contraindications to pessary use, which allows clinicians to offer pessaries to almost all patients presenting with prolapse and incontinence. Pessaries should not be placed in patients with evidence of an active pelvic infection or severe ulceration, allergy to both silicone and latex, or those patients who are noncompliant and unlikely to follow up.
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Caring For The Device
Pessaries can fall out if you strain. If you can, try not to bear down during bowel movements. If the pessary does fall out, you can reinsert it after you clean it.
Many women find insertion easier when they are standing up with one foot resting on a stool. Its important to use plenty of water-based lubricant for insertion.
If you arent comfortable removing and reinserting your own pessary, your doctor will set up follow-up visits for you to come and it done in the office. Frequency of visits can range from monthly to every three months, depending on your needs.
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Treatment Of Vaginal Prolapse
In patients with a mild cystocele, treatment using a ring with support, a dish with support, a Hodge with support or a donut pessary will suffice. To manage a large prolapse of the anterior vaginal wall, the Gellhorn pessary may be the best choice, although insertion and removal can be difficult. Inflatable and cube pessaries are also useful in patients with a larger cystocele. In patients with rectoceles and enteroceles, the use of a Gellhorn, donut, inflatable or cube pessary is usually required to provide the necessary support.
Pessary Maintenance And Follow
Women who are able to remove and reinsert the pessary on their own will have the choice to remove it weekly, possibly even nightly, for cleaning. Patients who are sexually active may prefer to remove the pessary prior to intercourse. However, this is not mandatory for those using a support pessary. Follow-up visits for these patients may be every 6 months. There is, however, no consensus on the follow-up regimen for patients using pessaries. This strategy is likely to be different depending on the patients ability to remove and insert the pessary, the extent of prolapse, and the health of the vaginal epithelium. When the pessary cannot be removed regularly by the patient, visits at 2- to 3-month intervals have been widely adopted.
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Choosing Pelvic Floor Friendly Exercises
Regular exercise keeps your body strong and helps you reduce the overall load on your pelvic floor during your everyday activities e.g. carrying shopping.
Minimise the load on your pelvic floor by choosing low impact exercises, avoiding intense core abdominal exercises and choosing pelvic floor safe strength training exercises and techniques.
Factors That May Cause Urinary Incontinence Are:
- Being overweight. When you carry around too much weight, it will put extra pressure on the bladder. Over time the muscles will weaken, and you will have problems holding your urine.
- Chronic constipation. When you have to strain each time you have a bowel movement, your pelvic muscles will get weaker from the continued pressure. This can cause urinary incontinence as well.
- Menopause. Commonly, muscle mass decreases as part of the aging process, and so do the pelvic muscles as a woman ages. When the pelvic floor loses its strength, it can often not handle the increased abdominal pressure when a woman coughs, sneezes, or lifts something heavy.
- Gynecology Surgery. Surgeries that affect the reproductive organs, like removing the uterus, can injure nerve tissues and the pelvic floor muscles. When the pelvic floor loses its muscle tone, women may experience urinary incontinence.
Shortly after a hysterectomy, you may have temporary urinary incontinence. Postoperative urinary tract infections may cause short-term loss of bladder control. Usually, this resolves itself when the infection has healed. Read more about bladder problems after a hysterectomy.
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Benefits Of Using A Pessary
A pessary is an easy alternative to several critical treatments and is often recommended by doctors. It has a host of benefits:
- Easy maintenance: A pessarys primary benefit is that it is a low maintenance option. Once you find one that fits well, and learn how to use it properly, you can wear, remove, wash, and change it all by yourself.
- Cost-effective: A pessary device is more affordable than many expensive treatments and surgeries.
- Does not require time-off/bed rest: Unlike surgeries, another excellent benefit of pessaries is they do not require you to take time off from work or your other personal responsibilities. You may need to take some time to get comfortable with it, sure, but you wont need to be completely out of commission during that time.
Effectiveness Of Pessary Use
Most studies demonstrate a remission in prolapse symptoms after successful pessary insertion.21 Bai et al.22 showed that 70% of users were satisfied or very satisfied with pessary usage and attributed their satisfaction to the remission of prolapse symptoms. Using a validated questionnaire, Fernando et al.5 showed a significant improvement of the symptom of awareness of a vaginal lump in 71% in patients fitted with the pessary 4 months after insertion. Clemons et al.23 reported a significant resolution of nearly all prolapse symptoms from baseline to 2 months: bulge , pressure , discharge , and splinting . In a prospective study by Wu et al.,3 56% of women with symptomatic POP had a pessary fitted successfully. Seventy seven per cent and 64% of those fitted were satisfied with their pessary at 6 months and 2 years after fitting, respectively.
Pessaries may prevent prolapse progression. Handa et al.,2 in a small series of patients comparing prolapse stage from the time of fitting to follow-up at 1 year, have shown that pessaries may improve the degree of prolapse after 1 year of usage. These findings attribute a therapeutic role for the vaginal pessary in addition to its traditional role in improving symptoms.
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Why Does Prolapse Happen
Prolapse is caused by weakening of tissues that support the pelvic organs. Although there’s rarely a single cause, the risk of developing pelvic organ prolapse can be increased by:
- your age prolapse is more common as you get older
- childbirth, particularly if you had a long or difficult labour, or gave birth to multiple babies or a large baby up to half of all women who have had children are affected by some degree of prolapse
- changes caused by the menopause such as weakening of tissue and low levels of the hormone oestrogen
- being overweight, obese or having large fibroids or pelvic cysts which creates extra pressure in the pelvic area
- previous pelvic surgery such as a hysterectomy or bladder repair
- repeated heavy lifting and manual work
- long-term coughing or sneezing for example, if you smoke, have a lung condition or allergy
- excessive straining when going to the toilet because of long-term constipation
Certain conditions can also cause the tissues in your body to become weak, making a prolapse more likely, including:
- joint hypermobility syndrome where your joints are very loose
- an inherited condition that affects the blood vessels, eyes and skeleton
- Ehlers-Danlos syndrome a group of inherited conditions that affect collagen proteins in the body