Vaginal hysterectomy for uterine prolapse

Women and Children – Obstetrics and Gynaecology

About this leaflet

We advise you to take your time to read this leaflet, any questions you have please write them down on the sheet provided (towards the back) and we can discuss them with you at our next meeting.

It is your right to know about the operations being proposed, why they are being proposed, what alternatives there are and what the risks are. These should be covered in this leaflet.

This leaflet firstly describes what a vaginal hysterectomy is, it then goes on to describe what alternatives are available within our trust, the risks involved in surgery and finally what operation we can offer.

What is uterine prolapse

• The uterus is the medical name for the womb. It includes the neck of the womb (cervix) from where the smear test is taken.
• After the menopause (the change) periods stop and the womb is no longer needed for babies. As hormone levels fall at this time, the womb usually gets a bit smaller.
• The womb normally sits in the pelvis which is the place between the hip bones at the bottom of the abdomen (tummy). The pelvic bones form a strong circle and have a sheet of muscles forming a hammock between them – these muscles are the pelvic floor muscles.
• The pelvic floor muscles support the womb, the top of the vagina (front passage), the bladder and the rectum (back passage). If this muscle sheet is weak, the organs it supports can sag down with gravity.
  Having babies and getting older may weaken the pelvic floor muscles.
• This sagging forms bulges into the vagina because the walls of the vagina are stretchy. This sagging is called prolapse.
• When the womb is sagging it is called uterine prolapse. Sometimes the womb sags so much that the neck of the womb pokes out of the vaginal opening.
• Uterine prolapse can cause you to have a lump in the vagina that you can see or feel. The lump is often smaller first thing in the morning but gets bigger during the day when you are on your feet.
  The lump can be uncomfortable and it may get in the way of having sex or putting in tampons. If the lump pokes out, it can rub on your underwear and get sore and sometimes gets in the way of the bladder emptying properly.

Types of pessary

Ring pessary

This is a soft plastic ring or device which is inserted into the vagina and pushes the prolapse back up. This usually gets rid of the dragging sensation and can improve urinary and bowel symptoms.

It needs to be changed every six to nine months, or earlier if there is any bleeding or discharge, and can be very popular; we can show you an example in clinic. Other pessaries may be used if the ring pessary is not suitable.

Some couples feel that the pessary gets in the way during sexual intercourse, but many couples are not bothered by it.

Shelf pessary or gellhorn

If you are not sexually active this is a stronger pessary which can be inserted into the vagina and again needs changing every four to six months.

Operations available for uterine prolapse

There are several operations which can be performed for uterine prolapse. Often your doctor will advise you regarding one of these operations after considering your symptoms, whether you want more children, any medical problems you may have and any treatments you may have tried before in the past. It is important that you have time in clinic to talk about this with your doctor.

The most common operation for uterine prolapse is a vaginal hysterectomy. It involves taking out the womb through the vagina so there are no cuts on your abdomen.

As the womb is removed, this operation is not suitable for women who want more children. If you have not gone through the menopause (change) and might want more children you must discuss this with your doctor.

It may be better for you to do nothing or use a pessary until you have had your family. The prolapse lump may get worse during pregnancy and not improve once the baby has been born. Having a prolapse does not usually stop you from having a normal delivery. Some types of pessary can be used in pregnancy.

It is sometimes possible to do an operation for uterine prolapse but leave the womb behind. These operations use strong stitches or artificial mesh (like netting) to hold the womb up in its normal position. Your doctor can discuss these with you. They may want you to see another doctor at a different hospital where they have experience of these operations and can give you advice about them.

General risks of surgery

• Anaesthetic risk
  This is very small unless you have specific medical problems. This will be discussed with you.
• Haemorrhage
  There is a risk of bleeding with any operation. The risk from blood loss is reduced by knowing your blood group beforehand and then having blood available to give you if needed. It is rare that we have to transfuse patients after their operation.
  Please let your doctor know if you are taking an anti-clotting drug such as warfarin or aspirin.
• Infection
  There is a risk of infection at any of the wound sites. A significant infection is rare. The risk of infection is reduced by our policy of routinely giving antibiotics with major surgery.
• Deep Vein Thrombosis (DVT)
  This is a clot in the deep veins of the leg. The overall risk is at most 4% to 5% although the majority of these are without symptoms.
  Occasionally this clot can migrate to the lungs which can be very serious and in rare circumstances it can be fatal (less than 1% of those who get a clot).
  DVT can occur more often with major operations around the pelvis and the risk increases with obesity, gross varicose veins, infection, immobility and other medical problems. The risk is significantly reduced by using special stockings and injections to thin the blood (heparin).

Specific risks of a vaginal hysterectomy

Some risks are specific to operations for prolapse and some risks are special to just a vaginal hysterectomy. You should have the opportunity to discuss these with your doctor.

• Getting another prolapse
  Unfortunately having a vaginal hysterectomy does not always stop you from getting a further prolapse. Although the womb has been removed, the vaginal walls or the top of the vagina (the vault) can sag with time.
  About one in three women who have an operation for prolapse get another prolapse during their lifetime. This second prolapse may not cause them bother.
  Keeping your weight normal for your height, avoiding unnecessary heavy lifting, and not straining on the toilet, will help prevent a further prolapse although even adhering to this sometimes does not prevent a further prolapse.

• A change in the way your bladder works
  Having a prolapse sometimes causes some kinking to the exit of your bladder. This can be enough to stop urine leaks on coughing, laughing or sneezing caused by a weak bladder.
  By removing the prolapse this kink gets straightened out and the leaks are no longer stopped.
  If your doctor thinks this might happen to you, they may suggest having some bladder tests before the operation so that you know what the risks are.
  After a vaginal hysterectomy, the bladder becomes irritable or overactive in up to 15% of women. This means that for every 100 women who have a vaginal hysterectomy, 15 get an irritable or overactive bladder that they didn’t have before.
  This gives symptoms like needing to rush to the toilet or needing to pass urine more often. Sometimes an overactive bladder can make you leak because you can’t get to the toilet in time.
• A change in the way your bowel works
  Having some constipation after an operation is very common and this usually settles quickly. Women rarely find their bowels have changed after a vaginal hysterectomy.
• Needing to make a cut in your abdomen (tummy)
  Occasionally an incision is required in the abdomen to remove the womb. This may be because there is heavy bleeding making it difficult to see or because the womb is much bigger than expected or because there is scar tissue from a past operation sticking to the womb.
  If the incision is needed it is usually a bikini line cut. A hysterectomy via the abdomen (abdominal hysterectomy) is usually more painful than a vaginal hysterectomy so you may need extra painkillers and a bit longer in hospital.
  Your doctor will explain why it was needed so you know what happened in the operating theatre.
• Damage to the bladder or bowel
  During the operation, cuts and stitches are made very near the bladder, ureter (tube taking urine from kidney to the bladder), and bowel, and occasionally the surgeon may make a hole in the bladder or bowel by accident. It is usually possible to repair the hole straight away but it may affect your recovery. Your doctor will explain what happened and what, if anything, needs to be done about it.
• Painful sexual intercourse
  Once the wound at the top of the vagina has healed, there is nothing to stop you from having sex. The healing usually takes about six weeks.
  Some women find sex is uncomfortable at first but it gets better with time and sometimes improves using a bit of extra lubrication (KY Jelly). Sometimes sex continues to be painful after the healing has finished but this is rare especially if only a vaginal hysterectomy has been performed.
• Change in sensation with intercourse
  Sometimes the sensation during intercourse may be less and occasionally the orgasm may be less intense.

Other operations performed at the same time

Your doctor may suggest that a vaginal hysterectomy is all that is required to help your prolapse. However, sometimes extra operations are done at the same time as a vaginal hysterectomy and your doctor may advise you regarding these.

• Removal of the ovaries
  The ovaries are usually left behind during a vaginal hysterectomy. This is because they are quite high up in the pelvis and can be difficult to reach when taking the womb out vaginally. The ovaries are not involved in prolapse and don’t need to be taken out to treat a prolapse. If there is a special reason why you need your ovaries taking out, you should discuss this with your doctor. They may suggest leaving them behind or taking them out through your abdomen (tummy), perhaps with keyhole surgery.
• Vaginal repairs
  Often the vaginal walls sag when the womb sags. Sometimes the front (anterior) or back (posterior) walls of the vagina sag so much that your doctor may suggest repairing them at the same time as your hysterectomy. This shouldn’t make your stay in hospital any longer and the recovery at home is much the same. However, some things are different including the risks of the operation. For example, painful intercourse (sex) is more likely if a repair is done, although it is still uncommon. You should, therefore discuss this with your doctor. They may have an extra information leaflet for you about vaginal wall repairs.
• Sacrospinous fixation (SSF)
  If your doctor is worried that the top of the vagina will sag down as soon as the womb is out, they may suggest a SSF. This involves holding the top of the vagina up by stitching it to a strong ligament in the pelvis. It is done through a cut on the back wall of the vagina so it might be combined with a back wall repair.
  There is another information leaflet about the SSF operation which you should be given if you are thinking about having it done.

After the operation: in hospital

• On return from the operating theatre you will have a fine tube (drip) in one of your arm veins with fluid running through to stop you getting dehydrated.
• You may have a bandage in the vagina, called a ‘pack’ and a sanitary pad in place. This is to apply pressure to the wound to stop it oozing.
• You may have a tube (catheter) draining the bladder. The catheter may give you the sensation as though you need to pass urine but this is not the case.
• Usually the drip, pack and catheter come out the morning after surgery or sometimes later the same day. This is not generally painful.
• The day after the operation you will be encouraged to get out of bed and take short walks around the ward. This improves general wellbeing and reduces the risk of clots in the legs.
• It is important that the amount of urine is measured the first couple of times you pass urine after the removal of the catheter. An ultrasound scan for your bladder may be done on the ward to make sure that you are emptying your bladder properly. If you are leaving a significant amount of urine in your bladder, you may have to have the catheter re-inserted into your bladder for a couple of days more.
• You may be given injections to keep your blood thin and reduce the risk of blood clots normally once a day until you go home or longer in some cases.
• The wound is not normally very painful but sometimes you may require tablets or injections for pain relief.
• There will be slight vaginal bleeding like the end of a period after the operation. This may last for a few weeks.
• The nurses will advise you about sick notes, certificates etc. You are usually in hospital for up to five days.

After the operation: at home

• Moving is very important; using your leg muscles will reduce the risk of clots in the back of the legs (DVT), which can be very dangerous.
• You are likely to feel tired and may need to rest in the daytime from time to time for a month or more, this will gradually improve.
• It is important to avoid stretching the repair particularly in the first weeks after surgery. Therefore, avoid constipation and heavy lifting. The deep stitches dissolve during the first three months and the body will gradually lay down strong scar tissue over a few months..
• Do not use tampons for six weeks.
• There are stitches in the skin wound in the vagina. Any stitches under the skin will dissolve by themselves. The surface knots of the stitches may appear on your underwear or pads after about two weeks, this is quite normal. There may be little bleeding again after about two weeks when the surface knots fall off, this is nothing to worry about.
• At six weeks gradually build up your level of activity.
• After three months, you should be able to return completely to your usual level of activity.
• You should be able to return to a light job after about six weeks, a busy job in 12 weeks. Avoid all unnecessary heavy lifting.
• You can drive as soon as you can make an emergency stop without discomfort, generally after three weeks. You must check this with your insurance company, as some of them insist that you should wait for six weeks.
• You can start sexual relations whenever you feel comfortable enough after six weeks, so long as you have no blood loss. You will need to be gentle and may wish to use lubrication (KY jelly) as some of the internal knots could cause your partner discomfort. You may, otherwise, wish to defer sexual intercourse until all the stitches have dissolved, typically three to four months.
• Follow up after the operation is usually six weeks to six months. This maybe at the hospital (doctor or nurse), with your GP or by telephone. Sometimes follow up is not required.

Avoiding constipation

• Drink plenty of water or juice

• Eat fruit and green vegetables especially broccoli

• Plenty of roughage, for example; bran or oats

Information about the British society of urogynaecology surgical database (surgical register)

The British society of urogynaecology (“BSUG”) is a national group of gynaecologists with a special interest and expertise in the treatment of incontinence and prolapse.

BSUG has developed a database of clinical and surgical data for the purposes of publishing anonymous statistical information for research purposes and to enable individual NHS Trusts and consultants to audit information about operations to ensure that the procedures performed at their hospitals are as safe and effective as possible.

The patient information held in the BSUG database comprises name, hospital number and date of birth, together with clinical and surgical information (“patient identifiable data”).

Because this information is confidential to each patient and is that patient’s personal data within the meaning of the Data Protection Act 1998, we do not disclose patient identifiable data to BSUG without written consent.

The benefits the BSUG database may bring to you:

• Improving patient awareness of the outcomes of incontinence and prolapse surgery

• Finding out how long the different operative procedures last

• Helping to identify individual patients who have received an implant and where there may be a need for urgent clinical review

The BSUG database will also be used to bring additional long-term benefits by:

• Providing feedback to gynaecological surgeons and teams to help maintain high clinical standards

• Promoting open publication about the performance of implants used in operations.

• Providing feedback on implant performance to regulatory authorities

• Providing feedback to suppliers about the performance of their implants

• Monitoring and comparing the performance of hospitals

Data collection – its security and confidentiality

The BSUG database uses an electronic system for data collection. The data is sent securely to a protected database, avoiding the need to send paper records through the post, to ensure your data receives maximum protection.

Your personal information is confidential and cannot be used outside of the BSUG database. Strict procedures are in place to protect your information and keep it confidential; it will only be available to you and your surgeon. If you wish, you can obtain access to a copy of your own record in accordance with the Data Protection Act 1998.

BSUG database consent

I consent to:

1. The processing of my patient identifiable data for the research and auditing purposes described in this information sheet.
2. The disclosure by BSUGs of my patient identifiable data to its IT service provider or any future IT service provider, where such IT service provider has:
   
   (a) Agreed to adopt appropriate technical and organisation measures to protect the
   security of my patient identifiable data and only to process it in accordance with
   BSUGDL’s instructions;
   (b) Been instructed NOT to store my patient identifiable data on a server which is located
   outside of the United Kingdom; and
   (c) Been informed of the existence of my legal right to confidence in respect of my
   patient identifiable data.
   
3. The disclosure of my patient identifiable data to the consultant team (and the NHS Trust employing that consultant team) who disclosed it to BSUG.
4. The disclosure of my patient identifiable data to BSUG or any legal entity which is wholly owned by BSUG, for processing in accordance with the consents in this section.

Your participation is voluntary

The form asks for your consent for your personal information to be recorded by the BSUG database.

Your participation in the BSUG database is entirely voluntary. You can request access to view your entry on the BSUG database from your consultant team.

If you agree and then change your mind, you may revoke this permission at any time by sending a written notice to your consultant OR to the address below. If you do not agree, your data will not be entered.

BSUG Database Limited
c/o BSUG,
Royal College of Obstetricians & Gynaecologists
27 Sussex Place
Regents Park
London
NW1 4RG

Things I need to know before I have my operation

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