Q I am debating whether to have a vaginal hysterectomy for prolapse, which is affecting my bladder and leading to frequent urination. There are no other medical problems.
I would like to know more about bladder prolapse and which alternative route to go down, such as pelvic exercise or homoeopathy.
I am determined not to have an operation, but the consultant gynaecologist at my local hospital tells me that my womb has dropped 50 per cent, taking my bladder with it and distorting its position, and that, therefore, a vaginal hysterectomy is the only answer. - RB, Totnes, Devon
A Bladder prolapse (cystocoele) is a surprisingly common condition that occurs when the pelvic floor muscles become weak or damaged, usually because of childbirth (and especially after a forceps delivery), or as a result of ageing, obesity, strain from heavy lifting or coughing, or fibroids.
Once the pelvic muscles are weakened, they may not be able to support the pelvic organs, thus allowing the bladder to fall towards the vagina, creating a bulge in the vaginal wall. The bladder and urethra often prolapse together (cystourethrocoele), which is the most common form of prolapse. The womb can also drop down into the vagina.
A typical symptom of cystocoele is urinary incontinence or an urgent need to urinate. Other symptoms can include a heavy sensation in the vagina, lower-back pain, pelvic pain or pain during sex.
There are a few changes you should make to your daily regime that can make your life more comfortable.
One important aspect is diet. You should be eating plenty of fibre - found in fresh fruits, vegetables and bran - which will avoid constipation, and so reduce any straining. Try to lose weight if you are very overweight or obese.
Yoga can also help relieve strain, but it's important to attend a class with a teacher who understands your problem, and so can recommend the best postures.
As far as long-term solutions go, medicine tends to offer either hormone replacement therapy or surgery. But as doctors in the UK are now being advised by government agencies not to prescribe HRT for secondary conditions such as osteoporosis, it may follow that the therapy will also be dropped for prolapse.
Surgery is the last resort, and is usually only recommended when all other (recognised) alternatives have been tried, and if the patient is willing to have the operation. This is especially true for a hysterectomy, whether or not the patient is of child-bearing years.
Hysterectomy will, of course, remove the prolapsed organ altogether, and the surgeon should take into account your health, age, sexual activity and whether you want to keep the uterus.
It's equally important for you to find out your surgeon's level of skill, and the number of such procedures he has successfully completed. The surgery is complicated, and it may not resolve the problem, especially if other prolapsed organs are involved.
Your surgeon should tell you that hysterectomy increases the risk of other types of prolapse, especially vaginal vault prolapse. You should also be aware that your sex life may well be affected, despite the denials of your surgeon. Some women also feel a sense of profound loss after surgery, and may require counselling.
The surgeon should also be proposing some alternative procedures, which usually involve lifting the prolapsed organ back into place, and strengthening the supporting muscles.
One technique, called 'anterior repair' or 'colporrhaphy', is carried out through the vagina under general anaesthesia. An incision is made into the front (anterior) wall of the vagina so that the bladder and urethra can be pushed back into position. The tissues are then stitched together to provide extra support for the organs ('sacrospinal fixation'), or a mesh can be fitted, if prolapse has occurred before, in a procedure known as 'sacrohysteropexy'.
Colporraphy comes with its own problems. It is a very complicated procedure, and so it is even more important than with hysterectomy to fully know the experience level of the surgeon. Painful sex and incontinence are common problems after surgery, which throws into question the purpose of undergoing the procedure in the first place.
Your concerns about surgery are well founded. Surgical outcomes can be very hit-or-miss, and can often make the problem worse in the long run, if not immediately. Around one in three women need additional and corrective surgery at some stage later on.
Mild prolapse is usually treated without surgery, especially if the patient is not experiencing too much discomfort or pain. Your described symptoms suggest that yours is a mild condition, or grade-1 prolapse, although the physical evidence from your surgeon suggests it is more serious. A grade-2 prolapse is when the uterus has dropped into the vagina and the cervix is visible at the vaginal opening. Grade 3 is when more of the uterus has fallen through the vaginal opening, and is also known as 'procidentia'.
A new technique is being tried in the US to help bladder control, although it does not correct the prolapsed organs. Intestim therapy, approved in the US a year ago, is an implant described as a 'bladder pacemaker'. It can be fitted to men and women who experience a sudden and pressing urge to urinate, and involves placing an electrode in the lower back that sends mild electrical pulses to the sacral nerve. This, in turn, controls the bladder and surrounding muscles that manage urinary function. Unfortunately, Intestim is too new to be assessed in terms of its safety, reliability or efficacy.
A variety of non-surgical options can control and improve the problem. Physiotherapy can help even moderate (grade-2) prolapse, and usually involves pelvic floor, or Kegel, exercises. These exercises can stop the prolapse from worsening, and can also ease backache, pelvic pain and incontinence.
It's better that a trained physiotherapist instructs you at the beginning, and checks your progress with biofeedback. The pelvic floor muscles act as a 'hammock' to support the pelvic organs, and the exercises involve tightening just the muscles around the anus and vagina - not those of the stomach, legs or buttocks.
The exercises should form part of your daily routine, but it's essential to be patient and to persevere. It may take up to six months before you start noticing any improvements.
You can 'supercharge' the exercises by using a vaginal cone - a small weight placed in the vagina. The pelvic floor muscles are then used to keep it in place for up to 20 minutes a day.
Another option is the vaginal pessary, a device, similar to a diaphragm or cervical cap, that is inserted into the vagina to keep the prolapsed organs in place. They can be a good option if you have elected not to have surgery.
A pessary needs to be fitted by your doctor, and you should be monitored to ensure that the fit is correct and that it's doing its job. A two-ring pessary is often recommended for women with severe (grade-3) prolapse. Pessaries are usually also removed by a doctor or nurse.
As with surgery, pessaries are not for everyone. They can interfere with sexual intercourse, and there can sometimes be a smelly discharge. Some women are also allergic to latex, from which the pessary is made.
Because prolapse is a physical condition, alternative and complementary therapies do not offer many options. There is a range of herbs that can help strengthen the body's tissues, such as false unicorn root (Chamaelirium luteum), white oak bark (Quercus alba), pond lily root (Nymphaea), black walnut hull (Juglans nigra), stone root (Collinsonia canadensis) and goldenseal root (Hydrastis canadensis).
Finally, try following a diet rich in raw fruits and vegetables, which can also help the strengthening of tissues.