Tuesday, 19 July 2011

Lump at Introitus-Is it Preventable?


Pelvic Organ Prolapse is the herniation of the bladder, rectum, uterus or vagina presenting as a lump at the introitus. Uterovaginal prolapse is traditionally treated with vaginal hysterectomy and pelvic floor repair. Corrective surgery of the vaginal prolapse must aim at objectives to relief symptoms; restore normal vaginal anatomy and restore potential coital function.

However surgeons sometimes face patients who returned shortly after surgery with recurrence of the lump at introitus. This is embarrassing for the surgeon and disappointing for the patient.

The pelvis can be thought of as a three-tiered system of support, consisting of the bony pelvis, the pelvic floor muscles and the endopelvic fascia (1).

In the standing position, the vertebral orientation places the pelvic inlet in almost vertical plane, turning the pelvic cavity almost at right angles to the abdominal cavity, allowing the abdominal organs to push against the pubic symphysis. The bony orientation directs transmission of weight from the upper body to the lower extremities via the hip joint and the head of the femur. The pelvic bones also provide points of insertion for the major muscles of pelvic support.

The pelvic floor consists of a bilateral set of U-shaped muscular sheets known as the levator ani and coccygeus muscles. The levator ani consists of puborectalis, pubococcygeus and iliococcygeus components. Pubococcygeus and iliococcygeus, tonically contracted, form the levator plate, which is the horizontal floor on which the bladder, the proximal two-thirds of the vagina and the rectum rest.

In 1992, J O L Delancey (2) reported an elegant study on 69 cadavers to look at the support of the pelvic viscera. He reported that the bladder, uterus, vagina and rectum were all attached to the pelvic sidewalls by a network of connective tissue strands that are collectively called the endopelvic fascia. The structures that support the vagina can be divided into 3 levels that correspond to differing areas of support (See diagram). The 3 levels of vaginal support are interdependent and continuous with one another. Defects in level I support would result in uterine or vault prolapse. Defects in level II support will result in cystocele and/or rectocele. As the vagina is intimately attached to the adjacent structures at level III, displacements of the urethra, levator ani or perineal body carries the vagina with it.


Pessaries are the mainstays of non-surgical therapy. They come in all shapes and sizes that may allow tailoring of the pessary to a specific support defect and individual anatomy. However it may be impossible to retain a pessary in patients with weak pelvic diaphragm, large genital hiatus and complete procidentia.   Sulak (3) described three types of patients that benefit from pessary use:
1.     The patient unfit for surgery
2.     One awaiting surgery
3.     One who declines surgery

It is crucial to identify the site/level of defect before we start the repair procedure.

Other important factors to consider include damage to the levator ani muscles with resultant increased inclination of the levator plate and the alteration of the vaginal axis after surgery.

(I)     Repair of Level I Defects

If surgery is preferred in cases of severe prolapse, additional support of the apical compartment of the vaginal is necessary to reduce the risk of vault prolapse where the uterosacral ligaments are found to be deficient or the vaginal vault is sitting near or outside the introitus after hysterectomy.

Many procedures have been described to increase support to the vaginal vault. These tend to be cul-de-sac obliteration, vault suspensions or a combination of both.

Cul-de-sac obliteration could be done transabdominally as described by Moschowitz (4) or Halban (5) or transvaginally by McCall (6 ).

Many procedures for Vault suspension had been described:
1.          vaginally, by hitching the vault to the sacrospinous ligament (sacrospinous 
            colpopexy ( 7) or iliococcygeus muscle(8 ).
2.         or abdominally by hitching the vault to the presacral ligament
            (sacrocolpopexy (9))
         3.         abdominal vaginal approach e.g. Zacharins procedure(10).
         4.         laparoscopic approach

Vaginal procedures are generally associated with less morbidity but higher recurrence of prolapse(11). Abdominal procedures are associated with fewer recurrences but there is rare association with severe bleeding from the presacral plexus and 3.3% chance of mesh erosion (12). Abdomino-vaginal approach ahas increased morbidity and high recurrence rate and is not advocated. Lapaproscopic repair of pelvic organ prolapse follow the same principles as above methods but adequate laparoscopic suturing skills are essential and there may be increase in operative time. More prospective clinical trials and long term studies are required.

(II)    Repair of Level II Defects


Anterior vaginal wall defects could be due to Central defects, paravaginal defects or both.
Central defects could be repaired vaginally by anterior colporrhaphy but paravaginal defects need to be repaired specifically either by attachment to the cooper’s ligament(13) (abdominally) or the White line and ischial periosteum (vaginally)(14).


Repair of the posterior vaginal is similar to the anterior vaginal wall . Discrete fascial tears is identified & repaired after vaginal epithelium is incised and separated from the underlying endopelvic fascia.

Synthetic meshes had been reported in the repair of cystoceles / rectoceles with good success. The only worry is that of mesh erosion which occur in 2% of patients in one series (15).

(III)   Repair of level III Defects

The normal vagina is a collapsed organ. Closure of a gaping introitus by perineal reconstruction is important. However one must not be too overzealous or the patient may complain of dyspareunia.


Repair of pelvic organ prolapse is complex and the surgeon need to understand the anatomy and support of the pelvic organs before planning a site specific repair procedure for the patient.  Use of synthetic and non-absorbable sutures decrease the risk of prolapse recurrences but the advantages had to be balanced with the risks of infection, erosion and rejection of foreign bodies by the body.

However despite all precautions taken, recurrence of prolapse can occur.  We can do our best to reduce it.


Thursday, 14 July 2011

Suburethral Sling Patients information

The suburethral sling is a new minimally invasive operation performed to correct stress urinary incontinence (SUI). It utilises the concept of providing support for the urethra, as seen with the popular tension-free vaginal tape (TVT) operation, which has been shown to cure SUI in 80 to 90% cases at 7 years follow up. However, in contrast to the TVT operation, the transobturator sling (TOT) is performed with a different approach that is thought to reduce the risk of bladder injury during surgery. The sling used in this operation is made up of polypropylene, the same material used in TVT operations, which have been shown to be very, well tolerated by the body.

What is involved?
The procedure is mainly performed under a short general anaesthetic, and takes about 15-30 minutes. Local or Spinal anaesthesia may be used if required. During the procedure, 2 small incisions will be made at the suprapubic region (TVT) or vulval area (TOT) and another small incision will be made inside the vagina just under the urethra. The sling will be tunnelled between these incisions inside the body. The incisions are then either closed with dissolvable sutures or surgical glue.

There can be a small risk of bleeding (which is rarely severe enough to require blood transfusion), wound infection and injury to surrounding organs (eg. Bladder, bowels). There is also a very small risk of sling rejection or infection, which may require sling removal. A small number of women (3% risk with the TVT operation) may develop difficulty-passing urine following surgery, and this may require the use of a catheter. Some women (7% risk with the TVT operation) can develop bladder overactivity, but this can be treated with pelvic muscle exercises and medication. Anaesthesia is not, without risks; these are outlined in the Ministry of Health consent forms.

Studies have shown it to cure SUI in 86-95% of cases in short term (follow up of up to 12 months) and up to 81.3% (Nilsson et al) at 7 years (TVT). Weight loss if overweight, reducing or quitting smoking, improving pelvic muscle tone by doing pelvic muscle exercises and continuing to do them after surgery will ensure that the operation is a success.

When you go home you must not lift heavy objects (more than 9lbs or 4kgs) or do strenuous work for about 6 weeks. Avoid intercourse for the same period. You can return to work usually in ten to fourteen days (10-14 days).

You will be seen in either the clinic or at urodynamics 6 to 8 weeks after the operation. If everything is well the success of your operation should be permanent.

Post Operative Instructions:
You will have some vaginal discharge for 4 to 6 weeks. This should be light bleeding or spotting only, and this may vary during that period of time as healing occurs and your stitches dissolve.
Pain should be relieved with Panadol, Tramal or Ponstan, Constipation should be avoided, so ensure you have an adequate intake of fibre and fluids in your diet).

Do not use tampons, pads are better.
Do not drive an automatic car for: 1 week
Do not drive a manual car for: 2 weeks
Do not make a bed for: 2 weeks
Do not hang out washing for: 4 weeks
Do not use your Vaginal Oestrogen for 4 weeks
Do not stretch upward for: 6 weeks
Do not lift anything over 4kg for: 6 weeks
Do not have sexual intercourse for: 6 weeks
The first week is the most important, where one must rest.

Discharge instructions:
You may experience for up to 72 hours:
• Urinary frequency
• Dysuria (burning and stinging sensation when you pass urine)
• Haematuria (blood stained urine)

Remember when emptying your bladder, sit on the toilet, feet flat and lean forwards. Drink 6 – 8 glasses of fluid per day; limit your caffeinated drinks to 3 per day, and take Ural (for the frequency and dysuria) if required.

You will be sent a follow up appointment 6 to 8 weeks after surgery; if you have any queries during this time please contact Dr Aruku or the Urogynae Nurse or his registrar at the telephone number provided on the front page.
Contact your G.P or your local hospital if you experience any of the following: You can see the Registrar in ward IC (Gynae ward) if in real emergency.
• You cannot pass urine
• You have severe pain or bleeding
• You develop a fever
• You have unusual vaginal discharge or odour
• You have heavy vaginal bleeding or clotting

Your doctor will be happy to discuss any concerns that you may have regarding this operation.
I have read this information leaflet and understand its content.


Name: ________________________________
Date: _________________________________


Patient Information Leaflet