SACROSPINOUS FIXATION

 

If the supports of the vagina are very weak sometimes, months or years after a hysterectomy, the top of the vagina can start to bulge or flop down (see picture below). The womb, bladder or bowel can also drop to the extent that they sit outside the vagina. When these occur the supports of the vagina are really too stretched and fragile to hold things in the correct position. This may be more likely if you have a bad chest, have very stubborn bowels or have a very heavy job.

 

 

 

In mild cases all you may feel is a dragging sensation when you are on your feet or towards the end of the day. In more severe cases you may feel a soft lump appearing from the vagina from time to time, whilst if very severe a pronounced lump may be present all the time.  A lump such as this may have a very unpredictable effect on your bladder; it may make it difficult to empty the bladder, cause you to leak urine or indeed stop you leaking. The important point is that curing the bulge may unmask other problems and it is vital that this is taken into consideration. If necessary other procedures may be added to deal with the bladder.

 

A prolapse such as this is not dangerous or life threatening but can be uncomfortable and embarrassing. Unfortunately this problem will not go away by itself and physiotherapy is ineffective. Usually the lump will get bigger with time if left alone, which is always one option. The other alternatives are pessaries and surgery. If you do not want an operation, or if this would be risky, we sometimes use a shelf  pessary. These are made from hard black plastic and do look rather odd. They are however surprisingly comfortable, made in a variety of sizes, and can be very effective. Once inserted into the vagina you should hardly be able to feel the pessary;  it acts as a shelf or support for the prolapse to rest on. One drawback for some ladies is that sexual intercourse is not possible with one of these in place. They also need replacing by a doctor every 4-6 months. For some ladies however they are well worth considering.

 

If the pessaries do not appeal or are ineffective then surgery may help. Since the problem in these cases is that the vagina has become detached from its supports, any surgery has to attach it to something firm and solid that will not give way. There are various ways of doing this; these include a sacrocolpopexy which supports the vagina by hitching it up from the top (see picture below), or a colpocleisis  which completely obliterates the vagina.

 

 

 

Another alternative which may be the most appropriate for you is called a sacrospinous fixation. This is particularly the case if there is also a large prolapse of the back wall of the vagina (bowel) or the uterus is very low and prolapsed. In these cases we may combine a sacrospinous fixation with a vaginal repair or hysterectomy. This can be done under either a general anaesthetic where or a spinal anaesthetic; there may be specific reasons for recommending either one or the other.  We will also give you a suppository and possibly an enema to empty the bowel on the ward before the operation.

 

The procedure is performed through an incision in the back wall of the vagina without any abdominal incision. The right sacrospinous ligament (a tough band of tissue) is found at the top of the vagina near the back of the pelvis. Two sutures are placed through this and then either through the skin at the top of the vagina or through the cervix if the uterus is to remain in place. In the former case the stitches take about 6 months to dissolve whereas in the latter they are permanent and buried deep under the skin. The vagina or cervix is then hitched upto the ligament (see picture below). This may be combined with repairs of the front and/or back walls of the vagina or bladder operations such as a TVT or TOT.

 

 

Full-Size Figure

 

Usually we would leave a catheter in place for 24-48 hours and sometimes a pack inside the vagina overnight. We will also give you antibiotics for a few days and ask you to wear special leg compression stockings and give you injections to prevent clots forming in the veins of your legs. This is routine after any surgery. The sutures in the vagina will usually dissolve by themselves and do not need removal, and thus we would allow you home after 3-5 days. Obviously everyone is different, and a lot depends on whether you are passing urine and feeling well. It also depends on your age, health and home circumstances. Immediate but rare complications include damage to bowel or bleeding either of which would have to be dealt with at the time.

 

You may have some discomfort initially, but this should soon settle. Sometimes right buttock pain can persist for a few weeks but this almost always disappears. At this stage it is better to take things easily and be cured, rather than to rush things and then find the operation has not been as successful because you overdid it in the first few weeks. Other problems that you may notice when you get home could be discomfort, a smelly discharge or signs of a urine infection (cystitis). If any of these occur, your GP can prescribe a short course of antibiotics. If you have any concerns we can always be contacted by leaving a message on our answering machine on 0121-378-6206 ext 3208.

 

We always try from past experience to judge the repair correctly so as to improve the prolapse and the bladder. Occasionally, as outlined above, bladders can behave in unpredictable ways following surgery. If this occurs we will deal with it as necessary. Rest assured this happens rarely as we always try and think one step ahead!

 

By the time we see you after 6 weeks you should be well on the mend and hopefully feeling that the operation has been worthwhile. Past results suggest that this procedure will last, but we are dealing with very weak tissue (or else it wouldn’t have given way to start with!) and for this reason we can never give a 100% guarantee.  If you do have any other questions please ask us at the clinic or contact us on the above number; we will try to answer any questions and put your mind at rest.

 

 

Glyn Constantine FRCOG