Jan Chaseley

Good evening, everybody. Welcome to our webinar tonight on pelvic organ prolapse presenting this evening is Mr Abhishek Gupta, our Consultant Urogynaecologist, and myself, Jan Chaseley, the clinical Nurse Specialist for continence care. This presentation will be followed by a question-and-answer session.

If you'd like to ask a question during or after the presentation, please do so by using the question-and-answer icon which is at the bottom of your screen. This can be done with or without leaving your name. Please note that this session is being recorded if you do provide your name. If you'd like to book a consultation, we'll provide details at the end of this session. I'll now hand over to Mr Gupta and you'll hear from me again shortly.

Mr Abhishek Gupta

Hello, good evening, everyone. So, my name is Abhishek Gupta. I'm a Consultant Gynaecologist and Urogynaecologist which is a doctor who has a special interest in treating prolapse and incontinence.

So, I got into the southeast London rotation and did my training in the southeast London rotation.

I'm a Consultant Gynaecologist and Urogynaecologist at Dartford and Gravesham NHS trust and I also do, of course, also special interest in keyhole or laparoscopy surgery.

After that I completed the Advanced Training in vaginal surgery as well as laparoscopy and urogynaecology and I'm a member of the British Society of Urogynaecology and also in their governance committee. So that's my brief background.

So, what's included in this session? So, it's very important, I think, that when we put this webinar on, we wanted to take into consideration what actually pelvic organ prolapse means for the patients.

It's more of an awareness, more of a understanding what it means for you, it's more of what symptoms does it cause and how to recognise where you need treatment and what you can do to help yourself. And also if you do to have to go down the route of any surgical intervention, what it means and what are the aims and objectives for that. So this is a kind of a brief overview which we included in this session and I hope that it is it will be informative for you as well as you'll have a greater understanding of what prolapse means, what symptoms it does produce and what treatment options you have and when to seek treatment as well. And we will also give a bit more background, so if you do have an operation - what to expect post-operatively and how the recovery process does work and what to expect and not to expect.

So, what is pelvic organ prolapse? So, if you look into human anatomy - this is two-dimensional picture - so if we can say that we're looking at the womb from the side the first thing you notice this is a pubic bone here which my cursor is showing. Just behind the pubic bone you will find this little balloon-like thing which is called the bladder, and which drains water out which is called urethra here, Now just behind that there is the womb. That's the neck of the womb, this is the vagina and that is the back passage.

So what is prolapse? So, prolapse is basically a hernia of any of this organ. So can you see the support structure here between bladder and the vagina? The support structure here between vagina and the back passage, and the womb has got support structure here (which is not seen in this diagram) but they are called ligaments. So, when they get weakened for one reason or other, they start to come down - which is a herniation too. So, if the womb comes down, it's called womb prolapse or uterine prolapse. If the bladder starts to descend here, that's called cystocele, or it’s called bladder prolapse and if the bowel starts to come here that's called rectocele or bowel prolapse.

Now in this particular picture, you can see the womb is primarily prolapsing down. This is a prolapsed womb.

Now what causes this weakness, which leads to a prolapse? So the basic trigger - and this is the your collagen, which is your support structure which gets weakened and hence you get the prolapse. What causes the weakness? Childbirth, which is a vaginal birth; especially if you have an instrumental delivery with the forceps or ventouse - or with a prolonged childbirth - then that causes trauma to the pelvic floor or weakness to this area. Repeated straining, for example, if you're chronically constipated and you have to strain to empty the bowel then constant straining will have an impact on the pelvic floor. If you suffer from chronic, really bad, chest and you have to cough all the time - it's not good for pelvic floor.

Lifting heavy weights; so, if you're in a profession or somewhere where you have to constantly lift heavy weights, the access to the heavy weight pressure goes through the pelvis and then repeated strain will make this weaker and more make you more susceptible to prolapse.

Similarly if you had a previous surgery in this area, or even if you have hysterectomy sometimes for a non-prolapse reason, for example if you have a hysterectomy for fibroids or heavy periods or cancer or some other reason, then the structure which holds the womb is cut and hence it makes you more susceptible for prolapse of the top of the vagina or the bladder or the back of the vagina. And the last, but not the least, unfortunately all of us are going to get older (we're not going to get real younger) and hence with age, the support structures do get weak.

The other big thing which happens to a females bodies going through the menopause. And menopause is a quite a big trauma to a female body and it does increase your chances of prolapse and it becomes more when you go get into menopausal age group then because the tissues become weaker.

So, what are the symptoms? So, symptoms of pelvic organ prolapse are that you may feel heaviness around your lower tummy and in the vaginal area. You can get a dragging sensation because, when the prolapse pulls and it's coming down, it can give you a dragging sensation. Some people do have a backache.

Patients describe it in various ways, different symptoms; they can feel like something is coming down into the vagina. It may feel like sitting on a small ball. You can feel a lump in the vagina, it can feel uncomfortable during sexual intercourse and sometimes - if it's quite full – and, if you notice in my previous slide, if the bladder is coming down here it can kink this tube which drains water out, which is called the urethra. And if it does kink it, then you might feel that you're not able to empty the bladder well and hence sometimes you go for water works then you come back and then you feel that you have not emptied your bladder well and have to go back and empty it more.

And similarly, it can happen when your bowels are full; it may feel like a little pouch which is going into the vagina and some people may have to push it from the vagina to empty your bowel.

Sometimes stress incontinence can happen. That's more of a weakness at the level of the bladder neck - but these are the common symptoms of prolapse.

Patients do sometimes feel a lot of pain and then they go to their practice nurse or general practitioner and they say “You've got a prolapse” and hence you got pain. The prolapse usually causes discomfort. Unless you've got a very big prolapse, it usually doesn't cause a lot of pain. It can cause discomfort but not pain. Pain may be a sign that you have a lack of oestrogen or hormone in the vagina which sometimes makes the skin very, very thin and that can cause pain. But prolapse per se doesn't cause pain that much; it may cause dragging and discomfort.

So, what are the treatments for pelvic organ prolapse? So, if you have a problem with your bladder your GP may refer you to us. We sometimes check the urine to make sure that you don't have an infection and that's causing you the problems. Occasionally we may have to look inside the bladder, depending on what symptoms you have. If you have mild symptoms or mild prolapse and it's not affecting your quality of life that much, just simple lifestyle changes like avoiding constipation, if you're on the overweight side then you need to lose weight, that will help both with the symptoms of prolapse and obviously - if you ever have to have surgery in future - it will help you recover quicker and reduce your chance of failure of the surgery. Or sometimes avoiding lifting heavy weight or preventing constipation. These are kind of  things which you can do it yourself if you have a mild symptom or mild prolapse or are in the early stages of prolapse - and that can help it not get worse in the future.

The main objective of any treatment of pelvic organ prolapse is to manage your quality of life. So that can be the functional aspect, which is affecting doing things like you're not able to empty the bladder well, you are not having able to have intercourse very well, or you're not emptying the bowel well, or it's giving a lot of dragging sensation. So it is the symptoms we're correcting, the function we are correcting, and that's the main objective of any treatment of pelvic organ prolapse – it's the function which we need to correct.

If your quality of life is not disturbed - I get referrals from some of the primary care when a patient has gone to have a normal smear done and they’re not aware of any prolapse and the nurse has picked up a prolapse - and send the patient to us.

If you are not symptomatic with that, it doesn't need treatment. You can try pelvic floor exercises or manage it yourself. It doesn't need any surgical or any other treatment. Prolapse which causes you symptoms (and you're the best person to know whether it's affecting your quality of life) then it needs treatment.

So what are the treatments for prolapse? The first step is to do pelvic floor exercises then we'll come to hormonal treatment and then vaginal pessary and surgery. So I'll hand over the mic to Jan who's our specialist nurse here who takes patients for continuous care and pelvic floor exercises. Over to you Jan now.

Jan Chaseley

Thank you, Mr Gupta. So, I'm the clinical nurse specialist here at Benenden Hospital, I've been in this role now for 12 years and prior to that I probably had 10 years’ experience just in general Gynaecology. I manage the specialist nurse team here as well. We have four specialist nurses and we run nurse-led clinics so you can just come and have a referral just to continence care you don't always need to have to see a Consultant.

So what happens when you come to our appointment? Well the first thing we're going to do is we're going to ask lots of questions; we want to assess how your prolapse is affecting you and - as Mr Gupta - said a lot of it is around how is it impacting on your quality of life. Is it affecting your bladder?

So, if it is we're going to test your urine to rule out a urine infection. We can then scan your bladder to check how much urine is left behind. When you empty your bladder you never empty your bladder completely, there's always going to be maybe up to 100 mmls left behind. But if there's in excess of that, it may go with some of your symptoms of urine infections, of getting urgency a feeling that you need to empty your bladder frequently and we'll help you manage that with things like bladder retraining. We'll look at your fluid intake; are you having too much caffeine, are you drinking enough, or are you sort of restricting your intake to manage some symptoms? And if bowels are a bit of an issue we will give you some dietary advice there as well.

The bladder retraining is all about not always sort of emptying your bladder every time you see a toilet it's doing things like double voiding if you feel you're not emptying the bladder then emptying the bladder go back after 10 minutes and empty again particularly at night.

S structure pelvic floor muscle exercises they’re key and the guidelines say structure pelvic floor for at least four months you know potentially before you look at any other interventions, If you're having issues with constipation or if you're having issues as Mr Gupta said actually physically emptying the bowel out because the prolapse is bulging in and making that difficult will give you advice to manage that.

Weight loss is obviously going to help if you're if you're overweight and we'll give you advice about exercise particularly if you're on a weight loss program and you're trying to exercise if you've got prolapse you probably don't want to be doing too much in the way of squatting, lunges, kettle balling certain weights so we'll help know manage the symptoms and help you exercise safely.

So if you're doing pelvic floor exercises and remember a pelvic floor contraction is a very subtle movement it's not about pulling your tummy in tight squeezing your buttocks holding your breath because then all of your energy is going into other places it's purely just focusing on that area between your legs and particularly if your prolapse is around you can feel a vaginal lump or you can see a vagina or lump imagine with your pelvic floor that you're literally trying to suck that prolapse back into the vagina with just a very gentle movement.

So when you're doing exercises you do fast contractions and strong contractions to work the muscle effectively with a fast contraction you'll just squeeze that muscle up while you count to one and relax it for a count of one and generally sort of look at doing 10 of those at a time and because they're sort of relatively quick and easy you can do those little and often throughout the day if you've got prolapse you definitely want to work on the strong contractions and build that strength and support up so start by sort of maybe just squeezing it while you count to four, repeating it a few times gradually trying to build that up as you feel that strength is increasing and aim to do that potentially three times during the day.

If you're doing the strong contractions give yourself a little bit of time to really concentrate on them so you can get a good strong contraction and you can do these exercises whether you're sitting down lying in bed sitting in the chair you know so you can fit them in when the dinner's cooking, if you sat in the car at traffic lights you've not got to get a mat out and give sort of structured time for it it's little and often through the day, and as I say it's at least three to four months to start to strengthen up that muscle and so the general advice around that is don't give up stick with them.

Mr Abhishek Gupta

Thank you Jan, so we'll go for the treatment option and I'll quickly talk about some of the hormone pessaries which are a hormone treatment we recommend through the vagina which is quite local which either comes in a tube it comes with an applicator which you can put in the vagina before you go to bed or it can come with a little tablet form which again comes with an applicator which you can put in the vagina or sometimes it comes with a ring which is excretes a controlled amount of oestrogen uh every day so either a cream or a little suppository or it comes with a like a ring so that's a vaginal oestrogen.

Now in this oestrogen treatment locally especially with patients who are menopausal age group when they have symptom prolapse or they have discomfort dragging and pain during intercourse there's a condition called vulvovaginal atrophy where the skin down below becomes very, very thin and when it happens it can cause a lot of discomfort and this hormone will make to make the skin more supple, it will help for you to feel much more comfortable and even if you go down the route of any pessary for treatment of prolapse or any operation this helps to heal up better.

Now apart if you look at the fine print of any, if you've ever been prescribed as medication if you look into the fine print of what the product says it will tell you all this all the concentration for a hormone replacement therapy however it is a very small dose and it's local so amount which comes in your bloodstream is so little that the side effects are generally not there with this treatment it's very, very safe and with the little tablet form which is called Vagifem which we used to put in the vagina they can be used for long term on twice weekly basis which will really help patients and apart from a contributing a complication if you have breast cancer not your family no anywhere else if you have breast cancer then we'll try to avoid it until illness it's been cleared by your breast surgeon otherwise there's not much contraindication having local hormones, because as I said it's a local It's very effective it's very small dose and the amount which comes in your bloodstream is very little it's very well tolerated and fairly safe and that helps with the mild prolapse and vaginal atrophy this really works very well.

Then the next steps or next options you have is pessaries so as you can see in this little slide here they come in various different shapes they also comes in various different sizes and this first specially scholar ring pessary, this is a donut pessary this is a ring pessary with support and this is called gel horn so there are various pessaries and depends on whether you have the uterus or you had a previous hysterectomy and which and how big the prolapse is this very different pessaries are suitable for different kind of prolapse and also different patient age different patient subgroup so we have to individualise patients to which pessaries to use.

Now pessaries coming with your size of this site depending on the sites of the prolapse the mind or the vaginal capacity we resize the prolapse and put the pessary you opt for they're successful roughly in 50% of the patients so this continuation rate is roughly one in two and the patients who are sexually active until unless they can change the pessaries themselves they don't usually prefer if patients do want to have pessary because they want to avoid surgery or they're not suitable for surgery then this needs to be to be looked at every four to six months so that we need to know that this capacity is still the same size for you we have to make sure that it's not causing any ulcers from the pressure we also have to make sure that we either wash it and reinsert if it's made of silicon or if it's made of latex we have to change to new one, so this needs to be done every four to six months.

What are the common side effects? Sometimes it doesn't work in the sense that the pastries are if it's not stitched anywhere your muscles have to still hold it in place if you've got a really weak pelvic floor it didn't come out and it's not about which size you put in if it's a pelvic floor is weak it can come out, it sometimes gives you very unpleasant smell and a discharge because of irritation of the skin, hormones do help to reduce the discharge as well as reduce any risk of infections and also makes the changes easier for the patient and more comfortable.

It can occasionally cause infection and soreness and irritation, sometimes it does cause pressure on your bladder and sometimes patients do complain that they may have to go for water works a bit more often and also it can cause some bleeding however if you have the pessary in and you are in a menopausal age group and you still have the uterus if you have any bleeding you should contact a healthcare professional to ensure that this bleeding is not coming from any other source but only from the pastry itself.

Now coming to surgical options so if you're if your prolapse is really symptomatic to you and you want to have the surgical option. So if you have the bladder which is coming down in the vagina then this is the area from the vagina we open this area up push the bladder back in and we bring your native tissues and close it you know we bring together your native tissues with the use of stitches and suture this up.

Similarly we do the same thing if you if your back passage is prolapsing in your vagina which is called rectocele the front is called cystocele, the back is called rectocele but that's happening then we do the same thing we open the vagina from the back we open the vagina here and then we bring the muscles together and close it up so that's a front wall repair that's the back wall repair.

I mean this picture is the patient who previously had a hysterectomy, and this is just about a top of the vagina if the top of the vagina has started to come down then that can be stitched with a very strong ligament called a sacrospinous ligament and that's the stitching approach and this can all be done through the vagina.

Now for vaginal mesh so the mesh which is done through the vagina or prolapse surgery has now completely been stopped in a UK since 2018. So, we don't do any vaginal mesh operations anymore since 2018. And if the top of the vagina is coming down on a high vigilance restriction, very selected patient where everything has a fail or the size of the vaginas restricted you may be offered a mesh operation through the tummy to put the mesh through and stitch it to a bone here the mesh operations are only done in a very selected centres Benenden Hospital, we certainly don't do any mesh operations and it's only done on a very small cohort of patients who are not suitable for any other form of surgeries but we try to do the surgery fits using your native tissues uh or your own tissues and do through the vagina.

So now if the womb is coming down then what are our other options? We have touched base on that if the bladder is coming down we open from here and then we bring your tissues together here which are weakened and similarly for the bowel here but if the womb is coming down what are our options so the complex operation we do for the womb prolapse is a hysterectomy which is taking the form and the neck of the womb out through the vagina and then there is there is a ligament called uterosacral ligament which is here somewhere which we stitch on the top of the vagina and that works well and this one of the most common operations I do for the womb prolapse and gives me good results.

If the womb can also be stitched with a strong ligament which is called sacrospinous cervicopexy this is a conservative option of the womb prolapse so one is a hysterectomy if you don't want to do hysterectomy the alternative are to do a secure sacrospinous cervicopexy which is with a stitch.

We stitch the neck of the womb with the strong ligament called sacrospinous ligament it's as invasive as hysterectomy and the recovery period is almost the same it's a good procedure it gives a good success rate to resuspend the boom however if you have a big bladder prolapse alongside with your womb prolapse then technically it once I give more support to the womb it prevents me giving good support here at the bladder level.

So I found with my surgical experience if you are having associated bladder prolapse which is quite big then doing a hysterectomy repair works better than resuspending the womb and doing the repair if you don't have a big bladder prolapse and all these only mainly the womb prolapse, then hysterectomy or doing the suspension operation are equally good in terms of the outcomes sacrohysteropexy so this surgery is to show the laparoscopic which is the keyhole which has gone in sacrohysteropexy is an operation which is use of a mesh so we go through the tummy put the mesh around the neck of the womb and suspend it here to the bone so it lifts the womb as it as almost like a tent now this surgery again as I said is done only in a specialist centre mesh operation it does have a role to play in patients who have a prolapse and not completed their family and they're quite symptomatic so then the meshes do work in those cohort operations but they're selected and only done in few surgeries.

Then something called obliterative surgery so we get patients who have huge prolapses and also sometimes we do the operation and this the prolapse comes back and it's difficult to re-put the prolapse back in place so patients who are not sexually active that's the most important patients who are not sexually active or they're very unfit for surgery sometimes we do obliterative surgery if it doesn't happen too often but occasionally when we basically in a in a simple language close to vagina so that the womb or the top of the vagina doesn't have space to come down but this is only an only reserve for patient who are not sexually active or patients who have failed previous surgeries multiple occasions but if you're sexually active this operation is not for you.

So what are the possible complications with surgery obviously there is a risk of anaesthesia, especially when any major like hysterectomy or sacrospinous fixation, there is risk of bleeding and require blood transfusion how often this happen is uh around one to two in 100 patients or will need blood transfusion so around two percent as you can appreciate we operate very close to bladder and the bowel and a tube draining from kidney to bladder called ureter that the surrounding organ damage can happen now how often this happens again the risk of uh happening of any injury to surrounding organs less than a percent so less than one in 100.

Infection is common because the operative site is very close to the back passage which has got full of germs so sometimes infections are common and hence after the operation we ask you to just keep it clean.

Anything cut heals with scarring so if you're going to a surgical route you have to keep in mind that if whatever operation you have this can cause scarring and that can cause pain in the Intercourse, usually settles out with time and as the scar stretches however sometimes you have to take you back to theatre and divide the scar tissue.

Some bleeding and discharge is common and we always cover this with cover this operation with an injection to thin your blood to prevent what is called DVT or clot in the leg, and on the day of the operation you also get compression stockings which helps to reduce the risk of clot in the legs.

Now two more things to consider or take into account after any prolapse operation, one is prolapse can come back because at the end of the day we are trying to bring the tissues together and make it stronger, but unfortunately that in as the time goes the tissues can get weak again and hence the prolapse can come back.

How often it happens if you look into this the various literature one in three out of ten women we have to go undergo a repeat surgery in future and it's more common with the bladder less common from the back of the vagina where the bowel prolapses. That's because there's more muscles on the back which we can bring together than the front and it's more common for the bladder prolapse to come back so collapse can come back what can you do to reduce your chance of having of reoccurrence or prolapse is again avoiding lifting weight avoiding constipation i.e. you're not straining too much.

Optimising your weight and keeping the weight as normal as possible and if you are a smoker please avoid or reduce or preferably stop smoking because smokers don't heal very well, and with smoking or a bad chest you will have more chance of prolapse coming back in the future so those are the few things which you can do to reduce your chances of prolapse coming back after the surgery.

So, recovering from surgery so most of this is surgical surgeries you can go home the next day so after the surgery if it goes straight forward then you can go home next day.

It's thought that you have to be in hospital for a long time and it's just a repair on the back of the vagina with no bladder prolapse needed or a hysterectomy or repair of the top of the vagina needed just the prolapse of rectal that you may be able to go home the same day as well.

You usually give for the catheter draining your bladder which usually stays for 24 hours and comes out, majority of your patients will be able to pass you in very well and go home on the next day after the catheter has taken out, very occasionally once we fix the prolapse it takes a bit of time for bladder to recover and the and the swelling around the operation site can prevent you passing urine well in that occasion you may go home with the catheter for a period of seven to ten days.

But majority patients will pass you the next day and we take the catheter out we put a pack in the vagina after the operation especially if you have hysterectomy of any major pelvic floor operation that is just to put a pressure in that area to reduce the chance of bleeding and it can be slightly uncomfortable but comes out first thing in the morning after the operation day. You may find a bit of bleeding with the stitches dissolved it gives a bit of discharge and cleaning but you shouldn't get anything heavier.

We want the patients to start moving pretty much next day we don't want patients to be on Hospital in the couch or not mobilising, we want them to mobilise and then slightly build it up, and that also reduces chances of clotting the leg you can have the shower pretty much from the next day.

If you look into literature they said you could have the bath but I personally this is my personal practice to ask patient not to take bath but take shower for at least four to six weeks when the stitches are still holding together and are not dissolving.

Avoid swimming for obvious reason for six weeks and for at least six to eight weeks avoid sexual intercourse because the stitches are still in in situ and you don't want them to be them to be disturbed.

Depending on what kind of jobs you do if your job is not very strenuous then most of the patients should most of the patients should return back to their normal activity in four to six weeks and should be able to resume your job, some people do have prolonged standing in their jobs or their jobs can be quite physically taxing then sometimes it gives them a phased return after six weeks but usually patients should be going back to normality within six to eight weeks of that procedure.

That's a brief overview on prolapse and what options you have and understanding of where to seek help from prolapse and how to go forward and I will now stop and Jan can start taking the questions.

Jan Chaseley

Thank you, Mr Gupta, for that very interesting presentation. We've got several questions let's start from the top so I could probably answer the first one which is can you do any damage doing your pelvic floor exercises?

And I think the answer to that is possibly if you're not doing them correctly some patients when they think they're contracting a pelvic floor particularly if they're using some of the accessory muscles and you can almost be bearing down, doing what's called the Valsalva maneuvre and not actually contracting in that case that would make your prolapse worse and I think that's an advantage of having a good continence or a good specialist nurse assessment or Women's Health physiotherapist to ensure that you are doing those properly.

Mr Abhishek Gupta

And Jan if my if I may add with on this point some patients do ask this question if they have a prolapse they feel that if they are continuing to be sexually active they may harm themselves sexual activity in presence of prolapse should be absolutely fine there shouldn't be a problem doing it and you won't harm yourself or your partner.

Jan Chaseley

Thank you Mr Gupta, and also slightly on the same line would you recommend the use of a TENS device to aid with pelvic floor exercises? So you can buy a lot of gadgets now that you put into the vagina that will give basically a little bit of electrical stimulation to your muscles they can be an advantage if you're having difficulty isolating your muscle and it's difficult to do a good effective contraction.

For me, if you've got significant prolapse I probably wouldn't advise them particularly if the vaginal tissues are a little bit dry and thin because putting sort of a device in and out of the vagina can cause irritation and can cause more discomfort, so it's just yes they may help but I'd use them with caution.

Mr Gupta is there anything I can do to prevent a prolapse before any signs or symptoms?

Mr Abhishek Gupta

Yeah, I think the script which I said about the prevention of reactions of prolapse after the surgery the same script courses with not having your prolapse in the first place, so if you can start your pelvic floor exercises sooner than later then if you can if you're overweight optimise your weight, avoid lifting heavy weight, avoid constipation, and if you're a smoker please, please try to stop preferably because these are the small things but goes in a great way to prevent your risk of having a prolapse in future.

Jan Chaseley

Thank you, I have a rectocele and I'm awaiting surgery I'm on HRT and have gone through the menopause would hormone estrogen via the vagina in addition be beneficial for me before the surgery to help healing?

Mr Abhishek Gupta

It only depends on during examination whether you still have residual lack of hormones in the vagina. So if sometimes even if you're not on an HRT but if you still have lack of estrogen and you have what is called vulvovaginal atrophy then we supplement with local estrogen, but not in every case, so it really depends on the examination finding of this of your surgeon if your surgeon finds vaginal atrophy and your hormone HRT which you are on is more than enough then you don't necessarily need more estrogen through vagina but if it's if that atrophy is still present then you may benefit from having it. So it really depends on the examination finding at the time examination finding from your surgeon.

Jan Chaseley

Thank you, do the risks of the treatment increase if you have adhesions from multiple previous surgeries?

Mr Abhishek Gupta

It depends on which surgeries we're talking about, if you have vaginal surgeries in past then the risk does increase and the success does reduce. So if you had a prolife surgery already in past and you have a repeat surgery especially on the same site with your bladder surgery and you have a repeat bladder surgery of your bowel prolapse and you have a repeat bowel prolapse surgery then obviously the scarring makes, slightly more tricky slightly more difficult increases your complication rate and reduces the success rate so therefore.

We tend to avoid operating on a smaller prolapse because success rates are not that good because you can't make things flatter but if if you have to operate ever in future then the success rates are not great.

So first operation is always the best operation however if you had surgery somewhere else in the tummy or somewhere else and we're not doing any and we're doing only pelvic floor operation then that shouldn't change any success chances of success or cause any problem for us.

If you're having hysterectomy but you have a caesarean section or some people had an operation to remove the fibroid then it can be a bit tricky to do the operation but otherwise it shouldn't have any impact if you have any surgery anywhere else apart from the vagina.

Jan Chaseley

Thank you I've got a couple of questions now relating to pessaries, my nurse went straight to inviting me to have a pessary she didn't really talk about pelvic floor exercises but she didn't explain how the pessary works or how it stays in?

Mr Abhishek Gupta

That's quite individualised kind of, it's different to give an opinion on somebody else's treatment but the pessary is basically goes in the vagina and behind your pubic bone which is a bone, and on the on the back of the vagina which is called sacrum which is a bone which curves, so the pessary sits up there and it's not stitched anywhere and your muscles have to hold it in place so that it doesn't keep coming down that's how it works.

So, the pessary sits across there so we press the pessary, compress it, put it back open it so it sits in that little curvature of your pelvis and the bone in front to hold things in place. That's how it works.

But I think pelvic floor exercises should be done in parallel with the pessary, not just in place of pessary or if pessary is done then you have to constantly make sure the muscles are strong enough so even if you have pessary you should continue with pelvic floor.

Jan Chaseley

Thank you Mr Gupta, do bioidentical hormone replacement creams work instead of the HRT creams that you're talking about?

Mr Abhishek Gupta

I do not have much experience with alternatives to the hormones estrogen so bioidentical estrogens I don't have much experience with I only have experience with vaginal moisturisers which are used in patients who have for example breast cancer or get side effects or have allergic reactions to hormones they work by making your symptoms bit better when you're dragging and pain a bit better but they usually don't build up the tissues very well.

Jan Chaseley

Thank you, I can feel a lump coming out of my vagina and it feels like something is coming out when I sit down could this be a womb prolapse? It happened since I started coughing a lot due to covid.

Mr Abhishek Gupta

It really depends on your age and what's happening it can be your womb prolapse but as I said in the front where the bladder is coming down it can be a bladder prolapse as well which is which does feel like a bulge ball or some people describe in a various ways it can be the back of the vagina coming into which is a bowel prolapse it can be either of the womb or neck of the womb or bladder or the back of the vagina however as I said it depends on different ages as well we have seen fibroids coming down like this presenting like a bulge in the vagina we have also seen vaginal cyst which looks like this bulge which is coming down so it's worth getting it checked but it can be either of it more commonly a prolapse but it can be other things as well so it's worth getting checked.

Jan Chaseley

Thank you. Why would it, why might it be difficult to have prolapse operation if I've had a hysterectomy due to fibroids or would it be difficult?

Mr Abhishek Gupta

If you had a hysterectomy because of fibroid doing a prolapse operation from the vagina should not be difficult or anything out of the ordinary this is quite a quite a routine operation we do for a prolapse if you had a previous hysterectomy through the tummy by the keyhole or opening so it shouldn't be more difficult than any normal um operation for a prolapse.

Jan Chaseley

Thank you. I can probably answer this question. Is there benefits in starting pelvic floor exercises if I already have a rectocele?

And the answer is absolutely, as I said earlier first line treatment should always be good structured pelvic floor exercises and I think as Mr Gupta said just because you have a prolapse doesn't mean that you need to have surgery it's working through the treatment options, you know just because we think your prolapse is small or moderate you may feel that you know your symptoms, it's more bothersome than that it's very difficult to get a successful operation on something that's generally relatively small because it's harder to do the surgery so pelvic floor would absolutely be your first line treatment, so yeah definitely pelvic floor is your first line and if you think you're struggling with them they look at coming to Benenden Hospital and we'll help you out with those.

Mr Abhishek Gupta

The pelvic floor will never go wrong whether it will help or not it's a different question but pelvic floor you will never for exercises you can't go wrong even if you had a surgery in future then reduce your chance of coming back you would need probably pelvic floor stronger so you will never go wrong with all the pelvic floor exercises.

Jan Chaseley

Yeah absolutely. If I've had a suspension operation before can I have another?

Mr Abhishek Gupta

Suspension of your uterus?

Jan Chaseley

Yeah, it just says suspension operation so I'm not sure.

Mr Abhishek Gupta

Now is that because of that with the mesh because suspension operation we don't do anymore for the prolapse apart from a very selected mesh operation we do we don't do suspension operation if you're talking about secure sacrospinous fixation which is a stitch to reattach the neck of the womb to a stronger sacrospinous ligament, if you had already had it once I wouldn't repeat it again because if it's not formed scarring once properly it's a bit difficult to do on the same side and it doesn't give a good effect, and other suspension operation we usually don't off do this nowadays I know it's in many years ago the people used to do suspensions but they've long been not very commonly done nowadays.

Jan Chaseley

Thank you. And how successful is the closing of the vagina?

Mr Abhishek Gupta

It is fairly a successful operation closing of the vagina is fairly a successful operation if in first six to eight weeks while the healing is taking place if you don't have a blood clot in the vagina or you don't have infection, either stitches get time to heal up properly then it becomes a really successful procedure.

Jan Chaseley

Thank you. And how long should you use the hormone treatments for?

Mr Abhishek Gupta

If it's helping you out and there's no side effect or contraindication I tend to once we've done the treatment of atrophy or well vaginal atrophy, I tend to recommend patients should carry on with twice weekly little pessaries which is a very different pessaries, because once you stop you go back to where you started from so if you keep maintaining those of twice a week which is again even smaller dose then it does have a good effect but if you really don't want to take hormones if you want to stop then you can give it three to four months then stop and then restart when you get the symptoms backup.

Jan Chaseley

Thank you, and is the surgery safe? and is it all right to go up and down the stairs straight afterwards?

Mr Abhishek Gupta

I would like to think surgery is safe there otherwise I wouldn't be in the job so I'm sure such as I say it comes with this complication doesn't happen too often well and the results are quite rewarding so when as a surgeon when you see patients quality of life getting better you feel very rewarded.

If you go home after surgery and you have to have a flight of stairs because your bedroom is upstairs or a toilet upstairs then going one or two flight of stairs is not a problem keep going up and down it's more often listening to your body so if you feel that you are you are able to go up and down the stairs more frequently then yeah build it up, obviously you're not going to run up and down but you're going to be gentle to yourself but going up and down is not a problem.

Jan Chaseley

Thank you very much. Does joint hypermobility syndrome make prolapse more likely or worse?

Mr Abhishek Gupta

It does make prolapse more likely and it does increase your chance of prolapse getting worse so hypermobility more than likely is because of what is called collagen problem which is a connective tissue problem for your body and that does increases your chance of weakness of the collagen tissue which basically holds the organ in place and when it does get weaker it tend to drop.

Jan Chaseley

Thank you is it possible to get discomfort on one side of the pelvis if you have prolapse?

Mr Abhishek Gupta

It can happen but it can happen but uh usually it's more bilateral or both sides it can happen that it's more pronounced on one side than other and it's not common but it's it can happen but it usually is a dragging sensation in both the site and the descending.

Jan Chaseley

Can you use the pessary lifelong or do you end up having to have surgery because the prolapse worsens?

Mr Abhishek Gupta

No if it works well for you can use the best way as long as you want and sometimes I've seen if it's a moderate prolapse and you have used specially for five six years sometimes your vaginal shape changes and therefore you have to keep getting it checked every six months that is the right size for you.

I've seen that we have to change the size of the capacities and occasionally after a few years of use some patients then stop using it because of various changes in their skin and the size of the pessary as well so some people may need it forever some people may go for surgery but in in long and short you can carry on Pastry as long as you want.

Jan Chaseley

Thank you somebody here said is it okay to leave a prolapse unattended if it's not giving any discomfort? I'd like to try the pelvic floor exercises before seeing my GP um on I'm 63 years old.

And I would definitely say yes, if it's not overly bothersome and it's maybe just been picked up on a smear test or on another examination. Absolutely do your pelvic floor exercises you know for up to six months also make sure you're not constipated keep your weight in check and all of other things that Mr Gupta has talked about as well.

Mr Abhishek Gupta

So Jan, if I add at this point I purposely didn't mention in my this lecture this webinar but maybe for next one I'll be more prescriptive for the patients as well there are four stages of prolapse.

Stage one, is starting a prolapse. Stage two when it's coming into the fifty percent into the vagina but just not starting to come out of your body. Stage three, is when it started to come out of your body and Stage four is everything hanging out.

So if you got Stage two prolapses or bordering to stage three and it's not symptomatic you can try pelvic exercises. But if it's stage three and then if it's going through stage four and you'll be surprised how many patients don't attend when it's even stage four because it's not bothering the under too much I think you should at least see a healthcare professional because if this exposed to air for a long time and it's come out of your body then it can cause ulcers and because the blood supply also reduces the return of the blood supply reduces when it's down so much and also it can develop ulcers and the healing and everything becomes so difficult so even if you don't want anything and if it's exposed out see a healthcare professional you may be able to manage a bit of a hormone cream or something rather than going through any procedure.

But yeah rather if it's not coming out of your body and it's not exposed that as Jan said you don't need to see it or anyone else just do pelvic floor exercises.

Jan Chaseley

Lovely and if you do the pelvic floor exercises will the cervix go back up?

Mr Abhishek Gupta

I wouldn't say that it cervix will, I mean it marginally may go up obviously the tissues will get strengthened and that will pull things up it won't go back to where it was and depending again on where your cervix was if it is stage two prolapse which is still inside your body then if you do the pelvic floor exercises it will make things stronger it may move up a bit and more importantly your symptoms might get better but just tiny movement of the cervix up when the muscles are more stronger. But once it starts to come out of your body it doesn't significantly go up.

Jan Chaseley

Thank you, and interestingly there's two questions from different people just asking about caruncles and using hormones for that is that sort of relating to prolapse at all?

Mr Abhishek Gupta

So caruncle has got nothing to do with prolapse caruncle is from you urethra which is a tube which drains water out caruncle doesn't need treatment.

If it causes you bleeding or something and which is bothering you up then you can have oestrogen which also helps with caruncle, however if it's causing you constant bleeding all the time then we can take the caruncle out but it's not cost because of prolapse.

Jan Chaseley

Thank you, and what is the recovery period if you have the closing of the vagina is it the same as others?

Mr Abhishek Gupta

Yeah, then you need the stitches to heal up.

Jan Chaseley

Lovely, thank you very much Mr Gupta. I'm very sorry if we didn't answer all of your questions and if you provided your name we will do so via email.

If you would like to discuss or book your consultation please use the contact details on your screen and call between 8am and 6pm Monday to Friday and we are offering a discount for joining this session with the terms as you can see on the screen.

You will receive a short survey and I'd be grateful if you could spare a few minutes to let us have your feedback and I hope you've enjoyed the presentation, the next webinar is on Thursday the 9th of February at half past six and that is on hernia treatments and please visit the website if you wish to sign up so on behalf of myself Mr Gupta and the team at Benenden Hospital I'd like to say thank you for joining us today and we hope to hear from you very soon thank you very much goodbye.