Pelvic reconstruction

The process of childbirth—especially if a woman has many children and they are more than 8 lbs at birth—causes weakness in the pelvic area. Many women won’t notice any difference immediately, but, over the years, and under the influence of gravity and aging, problems develop.

The most commonly occurring problem is called uterine prolapse. In this condition, the uterus actually slips from its supports and begins to move down in the vagina, until it actually protrudes out through the vulva. The protrusion will be worse after women sufferers from this condition are on their feet for long periods of time. Some women can relieve the symptoms temporarily by literally pushing the uterus back up. (Most women will notice the prolapse before the uterus actually protrudes. They typically experience pressure and heaviness in the pelvic area and they often describe the experience of “feeling something” when they insert a finger in their vagina.)

The second most commonly occurring problem is vaginal cystocele or rectocele. During childbirth, as the baby moves through the vagina, the strong tissue surrounding the vagina is stretched and even split. The most common areas damaged are the wall between the vagina and the bladder, and the wall between the vagina and the rectum. The “splits” in the strong tissue—or fascia—are actually hernias, and can begin to bulge just like a typical hernia might.

A woman with a cystocele (a defect in the wall between the bladder and the vagina) will experience a bulging sensation in the top of her vagina when she inserts a finger in her vagina. Again, if the problem is not addressed, the bulge can actually begin to protrude through the vulva. Along with the discomfort of a cystocele, women frequently lose urine when they cough or sneeze.

A rectocele is best described as a hernia that occurs between the rectum and the vagina. Again, a woman will feel a bulge, this time in the back of the vagina. Sometimes the bulge actually protrudes to the outside.

Another common symptom associated with a rectocele is obstipation (similar to constipation). The symptoms of obstipation are an inability to move stool out of the rectum unless a finger is inserted into the vagina and the stool is actually pushed out. (The stool is being caught in the pocket formed by the hernia.)

Along with the above issues, women who have had vaginal deliveries often feel “loose” or “open” in the vaginal area, and complain that intercourse is not as satisfying to either partner.

Even women who have had hysterectomies can develop prolapse, known as vaginal vault prolapse, years after their hysterectomies. Again, these women experience pelvic pressure and heaviness and often feel something extruding from the vulva. Women who have had vaginal hysterectomies are especially susceptible to vaginal vault prolapse.

Thankfully, all of these problems can be remedied. If a woman with pelvic prolapse wants to avoid surgery, we can fit her with a “pessary,” which is a device that remains in the vagina and provides support to the organs. Although pessaries needs to be removed and cleaned regularly, some women are able to use them for years. For most, however, they’re only used temporarily.

Surgery is available for any of the above problems. For example, moderate uterine prolapse is treated by removing the uterus laparoscopically, and then using the uterosacral ligaments to support the vaginal cuff. This is a very successful procedure and recovery is swift.

If the prolapse is severe, small incisions are made in the abdomen and a mesh strip is sutured to the vaginal apex. The other end of the mesh strip is sutured to the bone of the sacrum. This procedure is very successful in permanently supporting the vagina and preventing any further prolapse.

Rectocele repair is a vaginal procedure in which an incision is made in the posterior vagina, the vaginal mucosa are separated from the underlying tissue, and a piece of cadaveric dermis is sutured in place. This corrects the hernia, and enables the body to grow fibroblasts through the dermis, ultimately replacing the dermis and forming a strong wall between the rectum and the vagina. The dermis graft is a relatively new technique, and we have been impressed by how well women heal following this procedure. Post-operative pain is minimal, and the problem seems to be permanently corrected.

At the conclusion of a rectocele repair, we will “tighten” the vaginal opening if so desired. This reduces the feeling of looseness and openness in the vulvar area and usually increases sexual satisfaction.

Cystocele repair is generally handled by a urologist, and is similar to a rectocele repair. Surgery to correct stress urinary incontinence is also performed by a urologist. Currently, there are a few different procedures available, and the surgery will be tailored to a patient’s particular problem. We will refer patients to an excellent urologist if it is determined that these procedures are necessary. If a urologic procedure is necessary in addition to a gynecologic procedure, we will arrange to have both procedures accomplished under the same anesthetic.

Again, as with other women’s health problems, many women have been suffering for years with symptoms related to prolapse, cystocele and/or rectocele. They are often embarrassed to talk about it, and thus the problem goes untreated. We urge you to feel free and comfortable to discuss any of these symptoms with us.