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’.