Jan Chaseley

Good evening, everybody, and welcome to our webinar on vaginal prolapse treatments. My name is Jan Chaseley, and I'm the Clinical Nurse Specialist here at Benenden Hospital. Our expert presenter today is Consultant Urogynecologist, Mr Abhishek Gupta.

This presentation will be followed by a question-and-answer session; if you'd like to ask any questions during or after the presentation, please do so by using the Q&A icon, which is at the bottom of your screen. This can be done with or without leaving your name, and please note that this session is being recorded if you provide your name.

If you would like to book a consultation, we'll provide contact details at the end of this session. I'll now hand it over to Mr Gupta, and you'll hear from me again shortly.

Mr Abhishek Gupta

Thank you, Jan. That's a summary of who I am. My name is Mr Abhishek Gupta. I'm a consultant gynaecologist, and I'm a urogynaecologist who has a special interest in continence and prolapse, and I do a fair amount of keyhole surgery operations as well. I'm based at Darent Valley NHS Hospital, and I'm the lead Urogynecologist there. I did my advanced training in urogynaecology and laparoscopic surgery in Southeast London rotation training, and I've been providing care for the patient and services in urogynaecology at Benenden Hospital for almost 11 years now. I'm a member of the British Society of Urogynaecology as well as the theology of OBS Gynaecology, so that's a brief background on who I am.

This session mainly aims at prolapse, so we have done a previous session for incontinence. We might do it again in the future. Still, this session is more for pelvic prolapse, so what you want to cover in this session is what the symptoms of pelvic prolapse are and what the treatment is.

What do you mean by pelvic exercises? Jan will take you through what pelvic floor exercises are. We'll touch base on a bit of oestrogen treatment vaginally. I'll explain how it helps, the side effects, and which cases to avoid and which not to avoid.

Then, we'll touch base on surgical treatment, and at the end of the session, we'll have a question and answer. You're more than welcome to put your questions in the chat, and we'll try to answer as many as possible towards the end of the session.

So, what is pelvic organ prolapse? This is a two-dimensional picture, so if you look at the woman from front to back, the first thing you notice is the bladder, which is the first thing you see behind your bone and the bladder. Then, the tube that drains water out is called the urethra.

Just behind that, you will find the womb, then the vagina, and then behind that will be the back passage, so that's the human anatomy. So, prolapse is basically a hernia because of the weakness of the tissues when they come into contact with the front wall. If it's the bladder starting to prolapse in the front wall, which is called cystocele, if the top is coming down, which is the neck of the womb, and if you have a hysterectomy for some reason or another that would be the top of the vagina, when it starts to descend to come down in the vagina, that's called either a womb prolapse or that's called a wall prolapse if you had a hysterectomy. If the prolapse is coming from the back of the vagina, then it is mainly the bowel that is trying to push into the vagina, which is called rectocele.

So, the front wall cystocele, middle compartment, is either womb prolapse, which is uterine prolapse, or the top of the vagina, which is called wall prolapse; the back wall is the rectocele, or the bowel prolapse to the back wall.

So, this is what the prolapse is. What are the causes of prolapse? It's mainly the weakness of the tissues which is the weakness in the muscles that supports the vagina and pelvic organ which causes a prolapse and the main risk factor for prolapse obviously are child birth or if you have previous instrumental deliveries I think that's that causes quite a bit of trauma to pelvic flow then repetitive straining like if you suffer from chronic constipation or you lift heavy weights or you have chronic cough then menopause also causes a lot of effect on your supporting structure and it does make it weaker and it can cause weakness in the supporting tissues or ligaments and this can increase your chance of prolapse and then unfortunately all of us are going to get older we're not going to get younger and when we get older our tissues do get weak and that causes prolapse.

A previous history of hysterectomy for benign reasons does increase your chance of prolapse in the future, and if you are obese, weight does affect a lot of pelvic organs because, if you can imagine the obesity, the whole weight you are carrying is going through your pelvis, and that makes things weak. Things like smoking don't help; smoking does have a lot of effect on the collagen, making it weaker, and you do have an increased risk factor for a prolapse.

What are the symptoms of pelvic organ prolapse? So, the main symptoms you feel are heaviness or a bulge in the vaginal area. Prolapse usually doesn't cause pain, so pain is usually not caused by prolapse; it causes discomfort and a dragging feeling. You may notice that something is coming out of your vagina, like a ball, so you might feel a lump. Usually, if you are on your feet for a long time, gravity acts and can make your symptoms worse, so the prolapse can feel worse or a lump feeling can get worse towards the end of the day, which is because of the gravity. Usually, when you lie down, your prolapse symptoms should get better because gravity is not acting, so that is important. Some of the patients do get a lot of pain in the vaginal area or pelvic area, and they get it at night, which usually doesn't happen because of prolapse. Prolapse is usually uncomfortable during the daytime, but at night things do get better.

Sometimes it can cause discomfort during sexual intercourse the bladder if you if you if you remember my previous slides if the bladder is bulging into the vagina it creates a little pouch and sometime you feel you find it difficult to empty your bladder completely so it might happen that you go for waterworks you empty your bladder then you get up and then you feel that I've not emptied my bladder completely because there's still a bit of water left in your bladder which is created a little pouch in the vagina because of prolapse you get up you feel I'm not completed and then you go back and empty the bladder again sometime it can happen because of the prolapse in the back of the vagina when your bowel get full rather than coming out to the back passage it forms a little bulge or a lump in the vagina and then it makes you uncomfortable and occasionally people have to digitate or have to assist themselves if I may explain if assist themselves through the vagina with which is splinting to empty those so that reduces the bulge and then it empties the bowel better so prolapse can cause difficulty in emptying the bladder and if the prolapse is from the back of the vagina sometimes it also causes difficulty in emptying the bowel.

And urine incontinence can happen, but it's usually more of a support structure failure at the neck of the bladder level than the bladder itself, and it's slightly difficult to quantify whether you have a prolapse only for the bladder or if you also have a prolapse or weakness at the neck of the bladder level that is causing the leak.

So treatment of pelvic organ prolapse, so it's very important for us to understand this is all about quality of life so just because anybody has a prolapse doesn't means that this this needs treatment so it really depends on your quality of life so you may go to your practice nurse who we might do a smear on you and then say you I can see a bit of prolapse so any woman who have given worth vaginally or had instrumental delivery will have some kind of weakness of pelvic floor but that doesn't need a treatment until unless it starts to affect your quality of life and your quality of life will be different than your friend's quality of life or someone else's quality of life so what is bothering you are what is this stopping you doing or how much discomfort you it's causing you that's when it needs treatment. 

So obviously if you have a problem your GP might refer you for further test we usually look for infections in the urine if you have symptoms occasionally we have to have a look inside the bladder if you it's causing you a lot of urgency but if you have a mild prolapse which is there are four stages of prolapse the stage one is when it's a starting of prolapse but the prolapse has only reached up to 50% of the vagina opening vagina but not below second stage is 50% vagina to the opening of the vaginal orifice but not coming off to your body stage three when the prolapse has started coming off to the body and stage four which is the which is what is called procidentia the when the prolapse has started come out of completely out of your body that's called stage for prolapse.

So, if you have a mild prolapse and no symptoms, you don't need any medical treatment. Lifestyle changes may be all you need—losing weight if you're overweight, avoiding lifting heavy weights, constipation—but that's really not good for you because if you strain, you'll make that worse, and then pelvic exercises.

I think pelvic exercises is so important for patients who have either mild or moderate prolapse or even if patients have got a large prolapse and need any surgical treatment or any pesty treatment future pelvic exercises will prevent the recurrence of this happening in future so I think pelvic exercises especially if you give birth and you're young woman you should start pelvic floor exercises sooner than later so that you can build up the muscles future and then if you are menopausal some hormone treatment will help and obviously if the prolapse then becomes symptomatic then we consider vaginal pessaries or doing surgeries later on so I'll leave you to Jan now to talk bit more about herself as well as pelvic floor exercises which is main first stage first main stage treatment for pelvic floor for prolapse and then if it doesn't work then we obviously have surgical treatment but I'll hand over to Jan.

Jan Chaseley

Lovely! Thank you, Abhishek. My name is Jan, and I've been managing the specialist nurse team here at Benenden Hospital for the last 15 years. We run nurse-led clinics here at Benenden Hospital to see patients with incontinence or prolapse.

So, what would happen at your appointment? So if your GP does a referral here and he's mentioning in his letter that he will do that you've got symptoms of prolapse, you will most probably come to the specialist nurses as your first appointment here at Benenden Hospital, and the idea of that is that we can undertake all the tests, we can assess you, we can get you going with the pelvic floor exercises that Mr Gupta has talked about, and hopefully everything that we do is going to be enough to manage your symptoms. If, when we review you after that, you're still symptomatic at that point, you will then be referred on to see the consultant.

So, after taking some sort of history, we want to know what symptoms you've got. You know how bothersome those are affecting your bladder, so we will test your urine. Sometimes symptoms of a urine infection can be your first indicator that you've got some sort of asymptomatic prolapse. If you are having problems with your bladder, we'll get you. We'll do a flow rate; we'll just get you to pass urine on a special sort of measuring commode, and we'll scan your bladder afterwards to check how that bladder is emptying out. We'll probably get you to complete a three-day bladder diary, and that's really important; it shows what you're drinking, but more importantly, how often you're emptying your bladder and how much you're passing, so it could be that you've got a good fluid intake but you're emptying the bladder very frequently with small volumes, and if you continue with that over time, then obviously it's going to affect how your bladder is emptying.

If constipation is an issue, we'll give you some dietary advice as well. We'll work on bladder retraining. So again, looking at what's going on in your bladder diary, ideally you should be drinking around two litres of fluid a day, and on top of that, probably emptying your bladder about every three hours as a rough guide. So if you're listening to this and thinking, Oh, actually, I'm in that toilet every hour or, my god, I probably only go three or four times a day, you know, then actually, even if you haven't got prolapse, just get yourself into good habits with your bladder so you're not storing up any problems for later life.

We'll assess your pelvic floor, and we'll get you going with structured individual pelvic floor muscle exercises. It's very easy to sometimes do those exercises incorrectly, and if you're doing that with prolapse, you could potentially make your symptoms worse, so it's always better to have a proper assessment with the specialist nurses.

Again, as I said earlier, we'll help you manage any constipation, adding in speaking to your GP, adding in any laxatives if we need to, and obviously looking at weight loss. As Mr Gupta has said, you know, if you're carrying excess weight, that's more pressure on that pelvic floor, and we'll give you advice about exercises. Obviously, if you get to be a menopausal woman, it's really important to still be doing things like weightbearing exercise, but if you've got prolapse, you want to avoid doing anything that's going to give you too much in the way of squatting and heavy weight, so we'll help you manage all of that.

So pelvic floor exercises, so your pelvic floor muscle is made up of what they call strong muscle fibres and fast muscle fibres so it's really important when you exercise your pelvic floor that you're working both of those muscles if you've got prolapse we want to focus probably slightly more on the strong contractions because you want to build that strength and support of your muscle, but it's really important you know to do both of these so when you're contracting your pelvic floor it's all about just squeezing the muscles underneath as if you almost feel you're squeezing to stop passing wind and also squeezing to feel you stop you're trying to squeeze to stop emptying your bladder it's not about pulling in your tummy it's definitely not about holding your breath because then you've got energy up here and you want all of that work to be going on underneath if you stand in front of a full length mirror and you squeeze your pelvic floor muscle you should still look exactly the same because all of the work is going on internally and that's the sort of thing that as specialist nurses we can help you with.

So if you're looking at doing what we call the fast contractions, it's about squeezing that muscle up while you count to one, and then you just relax it for a count of one, so it's literally just squeeze it up, relax it down, squeeze up, relax it down, and we're normally advised to do 10 of those at a time a couple of times a day. So, then we're looking at the strong contractions to build that strength and support to try and help support that prolapse and stop things from getting worse. Initially, you may only be able to squeeze and hold for two or three seconds, but we'll work with you, and we'll try and come up with an individual programme and very slowly start to strengthen those muscles up for you.

If we are following national guidelines which we do the National Institute for Health and Care Excellence they advise good structured pelvic floor muscle exercises as a first line treatment for prolapse for at least 3 to 4 months, so we will see you and assess you send you away with your exercises and then we will either see you back face to face in the clinic or give you a telephone call and around about sort of three and a half months to just see how things are going hopefully things are better and we can discharge you but if they're not then obviously we can move you on to the Consultants, but the important message of that I think is if you're doing your pelvic floor and you don't think they're helping don't give up keep going it's really important.

Mr Abhishek Gupta

And for the future as well, even if you have an operation and none of the operations are foolproof, the prolapse can come back in the future, so if you build up a good pelvic floor and the habit, I think postoperatively as well, you'll get the maximum benefit and less likelihood of things coming down again, so I think this part is really important.

Jan Chaseley

Yes, it is really important.

Mr Abhishek Gupta

So, hormones so we're talking about only oestrogen in the vaginal hormones at this point of time because the prolapse especially when you have gone into menopause and you've got any symptoms of prolapse or vaginal discomfort which may not be because of prolapse if your vaginal discomfort or if you have going you're going through menopause and you got prolapse which needs surgery or even if you prolapse you need a pesty treatment or if you do pelvic floor exercises and you menopausal the hormone cream in vaginal areas of vaginal pessaries are so important so what that does is it builds up the skin and sometimes because of the lack of hormones the vaginal tissues go very thin and they can itself give you a lot of dragging feeling lot of discomfort and also it can give you pain it can predispose you.

Lack of hormones can predispose you to an increased risk of water infection, and therefore, I think there's a condition called vulva vaginal atrophy, which is a lack of hormones in the vaginal area after menopause and can cause all sorts of symptoms.

So vaginal hormones come with either a pessary, which is like just a small tablet with an applicator that comes in a bottle that you can put in the vagina, and usually the treatment is that you use it every night for two weeks, then twice weekly as maintenance. It also keeps with a cream, so similarly with an applicator, you put in the vagina every night for two weeks, then twice weekly, and sometimes there is also an oestrogen, which is the pessary that goes in the vagina, and then it secretes the hormones on a regular basis.

A lot of patient have a bit of myth and obviously if you read through the patient the literature comes with it tells you that this is all about HRT yes having an oestrogen is always a part of HRT but this is a local cream or local pessary so the amount of hormone which comes in your bloodstream is minimal and hence it doesn't have that kind of side effects so only patients I say to avoid oestrogen in the vagina are either having a vaginal bleeding when you have a uterus and it has a vaginal bleeding which has not been investigated hence we need to investigate the lining of the womb if you don't have any vaginal bleeding then you can have this oestrogen only a very small patients who have breast cancer then which are obviously breast cancer has been treated already and you've been discharged even those patients can have a short course of oestrogen if you have a discussion with your oncologist or surgeons otherwise apart from this two there is no other contradiction of having a vaginal oestrogen so I think this is very safe and amount which come as I said comes in your bloodstream is so little and it's got a lot of good effect on which patient vaginal health and your symptom treatment so I usually recommend patients to have vaginal oestrogen if they have symptomatic of prolapse or even other things like recurrent urinary tract infection or discomfort in the area after they go into menopause.

Then, so you've done the pelvic floor exercises, you've done a bit of hormones, and if things are not getting better or your symptoms are affecting your quality of life, then the options are at that stage either to have an operation or try vaginal pessaries. They come in various sizes, and they are two kinds of pessaries: one is made up of PVC, which needs to be changed every four to six months, and one is made of silicon, which again has to be examined by a GP or your healthcare professional in four to six months but doesn't necessarily need a change. They may be brought out after checking, maybe washed, and reinserted, and they come in various sizes. the ring piece, and depending on whether you have the womb or what kind of prolapse you have, one pessary may be more suitable than others, and as healthcare professionals, we have to decide which is better for you.

Usually, if you're sexually active, we used to use the ring pessary, which is on the top left, but we'll have to teach you how to bring it out yourself and then insert it after you have the sexual activity; otherwise, the other pessaries are the donut, which is on the top right, and then the ring pessary with the support, which is on the bottom left, and also the general pessary, which is on the right side at the bottom.

This pessary is usually very difficult for patients to maintain themselves, and if you're sexually active, we don't usually use those. It works on one and on 50% of the patients, so that's 50% of patients. The pessaries don't work, and there's a common cause of discontinuation: either they come out or, if your muscles are not strong enough to hold them in place, they can come up. That's one reason for the discontinuation of pessaries; it can be uncomfortable. That can be the second reason; sometimes it gives you a lot of vaginal discharge on patients, and it can be unpleasant.

Occasionally it can cause infection and then sometimes it can cause pressure effect which cause bleeding so and then it can put pressure on your bladder and sometimes times the pessary itself can cause urgency of Waterworks and they are the common reasons for it not to work but if this does work on you it's 50% of the patients are happy with the pessary then we are thinking about surgical options so when do you consider surgery again as I said the prolapse needs surgical option if it does affect your quality of life and what are the goal of the operation the goal of the operation is to ensure we can support the prolapsing organ and that's the goal your bulge or small amount of bulge may still remain the place because remain in place because it's difficult to correct a prolapse to where you had to original condition when you had no children there was no prolapse your support structures were completely intact those expectations are difficult to achieve but as long as the quality of life gets better the prolapse sometime when prolapse is coming out of your body it goes in and your quality of life is better that's the main aim for doing the reconstruction procedure is to give you better quality of life and the function should get better so if you're not able to empty your bladder because of cystocele which is bladder prolapsing you're not able to empty the bowel because the back passage prolapsing once we correct that hopefully it will give you more symptomatic correction and your functions get better so that's the aim for doing the operation.

So we usually try to avoid meshes and we do more of a repair from your own tissues so for the prolapse of your bladder we do what is called colporrhaphy which is a anti colporrhaphy where we open the front wall push the bladder back where it's supposed to be and bring your tissue supporting tissues together and suture this up and with time the scar will form and that will give you a platform so that the bladder doesn't prolapse back in similarly if your bowel is prolapsing we do the same thing on the back we open that area push the bowel back in bring the supporting muscle together and suture it up and that support happens if the womb is coming down then the most common operation I do is vaginal hysterectomy which is taking the womb and the neck of the womb out if the womb is prolapsing there are alternatives to hysterectomy which is either doing mesh which is called Sacrocolpopexy or sacrohystopexy which is go through the tummy and put a mesh in now meshes are under high vigilance restriction nationally we don't do mesh surgeries here. 

It's fairly okay to do mesh operations, but if there are complications, now with the new rules, we are not allowed to do the mesh complications, and they're supposed to be referred to the mesh centres. Hence, we try to avoid doing any mesh operations because if there are any issues, we are not allowed to trim the meshes, repair them, or take them out, and they all have to go to UCL, which is our mesh centre. Hence, we try to avoid mesh operations just because if there's a problem, we find ourselves in a position where we can't deal with the mesh complications, so we try to avoid mesh operations. alternatively, if you still want to have more children and the womb is coming down or some people like to keep their womb, we can refix the womb with the fixation or suspension, which is called secosan fixation, where we can reattach either the neck of the womb if you still have the womb, or we can reattach the top of the vagina if you have already had a hysterectomy. The top of the vagina is coming down to a strong element, which is called sacrospinous fixation, which is through the vagina. It's a quite invasive surgery. The hospital stays usually one to two nights; a complete recovery will take six to eight weeks.

Risk involved: small risk of infection, bleeding, and because you operate so near organs like the bowel and bladder, there's a very small risk of injury to the organs, but I say small is less than 1%, and the plan is to do all the operation through the vagina, but only in case of complication, we either have to do a keyhole surgery or cut in the tummy to repair it up.

After we have done the treatment for prolapse we always advise our patients not to lift heavy weights, do not get constipated because prolapse can come back again so very important and that's why I was saying once we done the operation usually my once I've done the operation my follow-up is done by Jan and her team so you will be assessed that the operation has gone well healing has gone better if there's obviously it's ongoing concern then I'll see you back in the clinic but majority of patients are absolutely fine after the operation Jan and the team does the follow-up then they will go through the pelvic floor exercises with you, bladder retraining with you so that in long term we give you kind of a holistic care for preop, operation and the postop care so that it reduce your chance of having rare occurrence in future because one in three women may need this surgery done in the future because of reoccurrence of prolapse which is kind of what is noted in literature so it's quite a high risk if you look into it of one to three in 10 women one in one to three in 10 women might need this surgery repeated in future hence the postop care and postop pelvic floor exercises and optimising weight as well as non-smoking in future then not lifting heavy weights avoiding constipation are equally very important.

So, this is what I've thought about: mainly, if the womb is coming down, then hysterectomy is an option. Mesh is an option; we just had a discussion about it, and in some cases, when everything has failed or you're completely unfit for surgery, some patients are medically very unfit for surgery and pessaries haven't worked and they have a quite big prolapse, then we resort to our last option, which is called obliterative surgery, which is basically closing the vagina. In that case, you can't have sexual intercourse, but there's still a channel to empty the bladder, but we close the vagina, and that's really a last resort if operations have failed or you're unfit to have any surgery and you have a big prolapse; that's called operative surgery.

So, obviously, surgery is not risk-free. I've briefly explained what surgical risk involves, so you will either have the surgery with a spinal anaesthetic or a general anaesthetic. Very rarely, if you have a major surgery, especially a hysterectomy or sacrospinous fixation, there is a risk of blood transfusion. how often does it happen? one in three in 100 patients, approximately. We talk about damage to the surrounding organs, which are the bowel and the bladder, which again happen in around one in 100 patients. infection is the main risk we do give a shot of antibiotic while you're in theatre, however, because if you imagine that area is very close to your back passage, which is where germs are, therefore it's more susceptible to having an infection after vaginal operation, and hence we ask you to keep it clean. As you can imagine, any operation heals with scaring, and sometimes scars can cause pain during intercourse, which is called vulvar vestibulitis. Occasionally, we may have to take a patient back to the theatre to divide the scar tissue.

Some discharge or bleeding is expected after the operation. Still, when the stitches are dissolving, all the stitches we put in are dissolving stitches, so when they dissolve, it can cause a bit of discharge. Usually, things do settle in six to eight weeks, and as I said, the prolapse can come back in the future. We give you blood thinner after the operation to prevent what is called DVT, or clot, in the risk because that can happen with any surgery. You usually stay in the hospital for one to two nights.

They give you some fluid and you will have a catheter draining your waters which usually comes out next day you we put a little pack which is a course to stop the small bleeders which is usually overnight which again comes out next day you may have as we said may have some vaginal discharge and a bit of bleeding for next three to four weeks when the stitches are then starting to come up and dissolve in six weeks’ time usually things do settle down we ask you we try to mobilise you sooner than later so we want you to not to be on in bed dress for a long time we start mobilising the patient pretty much on the same day or the next day because more and we exercise mobilisation which we want to really promote patients to mobilise rather than on the bed.

We try to ask you to avoid taking a bath to soak those tissues and those stitches for a long time, but you can have a normal shower. Avoid swimming for four to six weeks if you can because you don't want the stitches to dissolve very soon, but a quick shower is absolutely acceptable, and sexual intercourse is obviously something we ask you to avoid for six to eight weeks because you will be uncomfortable, and obviously the stitches have not healed up properly and scar tissue has not formed.

Depending on what kind of work you do, we usually anticipate that after a prolapse surgery in four to six weeks, you should be able to go back to work. But if your work is quite strenuous and involves lifting heavy weights, you might have to go on a phased return to your work, but if your work is more of a work from home or it's a less physically strenuous job, then you may be able to return to work sooner. That concludes in brief what causes prolapse, what symptoms are, what investigation we do, and how we treat, and I will hand it over to Jan. If you have any further questions, please feel free to put them in the chat.

Jan Chaseley

Lovely, thank you very much, uh, Mr Gupta. That was a very informative presentation, and at the moment we only have one question, so it looks like you've answered everybody's question as we went along.

So, the first question we've got is: Are there any exercises you can do to prevent prolapse? So obviously, we've talked quite extensively about the importance of doing those pelvic floor exercises. Also, I often recommend Pilates. Pilates is very good; it's very good at engaging your core muscles, and anything that is engaging your core muscles is also engaging your pelvic floor, but I would also suggest that you find yourself sort of a qualified Pilates teacher and don't just sort of do something off the internet just in case you then find you're doing the wrong thing and potentially making prolapse symptoms worse.

 So, a question for Mr Gupta: how long after surgery can you drive?

Mr Abhishek Gupta

Usually we ask you not to drive for three to four weeks, and after that, if you feel that you are able to do an emergency stop, then usually four weeks is the time frame when we say you can start driving if you can do an emergency stop, but usually people should be okay to drive after four weeks.

Or if you're still having a bit of soreness after six weeks, I usually ask you to check with your insurance company to see if they don't have any limits on when they allow you to start driving, but usually we say around four weeks.

Jan Chaseley

Thank you. Is there a time limit for using vaginal oestrogens?

Mr Abhishek Gupta

So if you have a history of breast cancer then you and then if it's okay by your oncologist they usually ask you to give a short term of six to eight weeks otherwise once you start the vaginal oestrogen I recommend that you if you're treating daily for two weeks then the maintenance is twice weekly and of ask GPs to put twice weekly on your repeat prescription because once you stop oestrogen then you go back to where you started from and twice weekly is even small dose but it does the work of keeping the vaginal tissues healthy and it reduces your chance of developing the vulva vagina atrophy so it keeps maintaining your vaginal health and that I think you can keep it on repeat prescription.

Jan Chaseley

Thank you. What is the percentage of chronic pain after sacrospinous fixation surgery?

Mr Abhishek Gupta

So the pain usually settles down mainly it's the but pain which happens after sacrospinous fixation which usually settles down with time especially when the stitches have dissolved occasionally we may have to per put a permanent stitch in case your prolapse has come back again or your tissues are not really good and if you're in an advanced age then sometimes you put a permanent stich as well however the chronic pain is usually I would say roughly around 1% of the patients but we don't often see chronic pain after sacrospinous fixation nowadays it used to be more before because we had we used to use a device called maya hook to do this operation which was quite a big device beforehand but nowadays we use what is called a capio device and capio are much smaller devices and they much more gentler to the tissues which could use reduce chronic pain so I would say if the chronic pain happens is usually in around 1% but majority of pain usually subside in six to eight weeks’ time or three months while the time PDS stitches do dissolve because we use even if you use the dissolving stitches we use a PDS Stitch which takes around three months to dissolve and usually in three months’ time the pain does subside so chronic pain is around 1% approximately.

Jan Chaseley

And what are the complications of repeating prolapse surgery?

Mr Abhishek Gupta

The complications are the same, but the results of repeating a prolapse surgery are less than the first round. Complications are the same as with any prolapse surgery; however, the complication can increase if you are having a repeat operation because obviously scarring makes operations more difficult, and more operations you have are less effective. The slightly increased chance of complications is essentially the same, but the risk increases with more operations you have on the same site.

Jan Chaseley

Thank you, and how would you decide if it's a spinal or general anaesthetic?

Mr Abhishek Gupta

I usually leave this discussion with the anaesthetist to have with you, whether it's a spinal or general anaesthetic, so it's usually not my decision; this is between the patient and the anaesthetist. For the repair surgery, I think general anaesthesia is absolutely fine. If you're having a hysterectomy again, I mean, this is a hysterectomy done for prolapse, but there is enough literature out there that even if you're having a hysterectomy for other reasons than prolapse, there is a choice between a laparoscopic hysterectomy, an open hysterectomy, and a vaginal hysterectomy.

Vaginal hysterectomy has the quickest recovery, least pain, and shortest hospital stay with the least complication. Even vaginal hysterectomy is fine with general anaesthesia, but that's borderline when some of the anaesthetists feel that spinal anaesthesia might be better for long-term pain relief. But if you're having a sacrospinous fixation, which is slightly more invasive, and somebody rightly asks about what the reason is for the pain, then I would say the spinal anaesthetic will work better than having a general anaesthetic, or you can have a combination of the spinal anaesthetic and general anaesthetic in those cases.

Jan Chaseley

Thank you, and there's a couple of questions about yoga: is it all right to do yoga with a stage three prolapse, and is yoga as good as Pilates to strengthen core muscles?

So, my advice on that would be, yes, if you're doing yoga again, yoga is very good. If you have a stage three prolapse, you want to be cautious that you're not doing too much in the way of bending or squatting, something you probably know lying down with your legs up the wall would be a good relaxation thing to do as well. If your prolapse was slightly bothersome, have you got any advice around sort of yoga or any exercises to avoid?

Mr Abhishek Gupta

No, yoga and Pilates are all good, but be mindful that yoga and Pilates are not pelvic floor exercises; they're good for core muscles, but they may not necessarily be directed towards the pelvic floor. They're low-impact exercises, and they're good to do even if you have prolapsed or if you have prolapsed surgery, so I think yoga and Pilates won't go wrong.

Jan Chaseley

Yeah, I'd agree with that as well. Mr Gupta, would you advise women who are in the menopause who have prolapse to have oestrogens?

Mr Abhishek Gupta

I would, and I think vaginal I strongly believe, and maybe because I've been in this profession for a long time and see patients, I may have a slightly biassed view on this because I see the problems. I think women's vaginal health is underreported after menopause, and I think it needs more care than what is out there in the community and offered, so I strongly believe that if a patient has gone through menopause and they're symptomatic, vaginal oestrogen has a role to play.

Jan Chaseley

Yes, definitely, and I think sort of sometimes in GP practices, you know, there's some grey area; they don't seem to think that women should have it or should have it long-term, and it's completely safe; it's marketed to be used for long-term; it's such a low dose now.

Mr Abhishek Gupta

And now there's more awareness, and it's been licenced to be used for a long time now.

Jan Chaseley

Yes, thank you, and a question from a lady: she says she's 65 years old, she's got a grade one to two prolapse, and what would you consider normal? And I think, as Mr Gupta said in the beginning of his presentation, quite often people may have a bit of grade one prolapse, be completely asymptomatic, and might only be picked up on smear tests. Obviously, maybe not so much as you get obviously older, and they're not carried out, but I would just sort of say, You know, actually, if you're not aware you've got a prolapse or you feel you've got mild symptoms, do your pelvic floor exercises, speak to your GP about some vaginal oestrogens, and it's difficult to say what would be normal because every patient is different.

So, another question: if a ring pessary will support the prolapse at a certain time, will it prevent it from prolapsing further?

Mr Abhishek Gupta

So, the ring pessaries are not for stopping the prolapse from getting worse, so the important thing is that ring pessaries, or any pessaries, are not to stop the prolapse from getting worse; ring pessaries are only symptomatic. Correction of the prolapse to keep the prolapse in place or inside the vagina They're not used to prevent prolapse from getting worse in the future, or their treatment of prolapse is just a symptomatic correction of the prolapse you've already got.

Jan Chaseley

And can a prolapse operation be done laparoscopically?

Mr Abhishek Gupta

Yes, it depends on what kind of prolapse you have. If you have a womb prolapse, the laparoscopic way of doing a womb prolapse operation is by using mesh, which I was talking about, so that's called sacrohystopexy. If you have a prolapse of the top of the vagina that's coming out, then it's called a spectroscope hysterectomy. Usually, when you do the laparoscopy treatment of a prolapse, it is usually what is called a mesh operation, and that can be done laparoscopically, but otherwise most of the prolapse operation is done through the vagina. Some have done laparoscopy to what is called paravaginal repair. it hasn't shown to have any major benefit than the vaginal root and that is not a standard technique to be done laparoscopically for prolapse of the bladder or the back wall, so vaginal roots are the standard roots but if you're using a mesh for prolapse of the womb or the top of the vagina then absolutely yes laparoscopy can be used and that they're probably the gold standard to put the mesh in but as I said we don't do any mesh surgeries here at Benenden Hospital and if you are considering having a mesh surgery it is worth going for a person who's or a Consultant or a unit which does regular meshes and also they have a system in place where if there is a mesh issue they can be sorted out at that place otherwise worth knowing that meshes cannot be dealt at all the centre.

Jan Chaseley

Thank you, and is a prolapse bladder repair risky if I already have poor flow? Is it likely that I might need to have a catheter?

Mr Abhishek Gupta

No, it may be the other way around. To be honest, if you have a big prolapse of the bladder, that may be causing you poor flow, and once we correct the bladder, your flow might get better, so for correction of the flow, we don't have a problem, but if you're having, I mean, the stock is not for incontinence, but if you're having any incontinence surgery for incontinence surgery, then a poor flow can increase your chance of having a catheter, but if you're having a prolapse fixed, it might increase your flow a bit.

And sometimes if you have quite a big prolapse and we correct it, it can sometimes unmask a bit of leak of water work as well, so just something to keep in mind: it doesn't cause leak of water work; it can unmask a bit of leak of water work because prolapse can mask the leak, but yeah, your flow might be better to be honest.

Jan Chaseley

Definitely yes, and slightly linking into that, this lady says that she's read before that uroincontinence after an anterior prolapse or bladder prolapse can occur in one in four cases, and if it does, is it permanent or temporary?

Mr Abhishek Gupta

Usually, it's temporary, and it gets better, but I think we do more than hundreds of cases of prolapse per year. In my personal practice, I do more than around 200 cases of prolapse in a year, both in the NHS and the private sector, and I think after the prolapse operation, roughly around one or two of those, I may have to do an incontinence procedure in a year. Obviously, if you have the incontinence symptoms beforehand, that's different, but developing incontinence and needing surgery is around one in every 200 cases I operate on.

Jan Chaseley

Yes, and can you use vaginal oestrogens if you're already taking HRT?

Mr Abhishek Gupta

Yes, you can, because it is shown that sometimes you need vaginal oestrogen as well after HRT, but it really depends on your symptoms, to be honest, and it's not automatically that you should have vaginal oestrogen. If you're still symptomatic and you're examined by a healthcare professional and think there is a lack of ooestrogen in the vaginal area, you can have ooestrogen with the combination, but it's better to get checked first.

Jan Chaseley

And if you have stage two prolapses, can pelvic floor exercise make it better, or is it just time until it develops into stage three?

Mr Abhishek Gupta

Not necessarily so stage two are the prolapses if pelvic prolapse there's other prolapses which it can help and it's kind of we often get this question asked that if I leave the prolapse what happens is it going to get worse it's like how long is the piece of string so your grade two prolapse may never get worse in your life or you in in a year time you might have to see us because it progressed so the answer is not necessarily it will go to stage three it may stage still stay stage two and if the exercises are done correctly it might get supported a bit more and you will be less symptomatic of it so no, not necessarily it will get worse if we take care of this it might be chance that it may stay the same. 

Jan Chaseley

Definitely, yes, and if you have three areas of prolapse, so I'm presuming somebody is sort of saying bladder, maybe uterus vault, or back wall, is it a riskier operation to fix all three?

Mr Abhishek Gupta

So, this is not very uncommon to have all three compartments prolapse, so sometimes you have one compartment, but usually when there is a prolapse, it either is a two-compartment prolapse or, not unusually, we have all three-compartment prolapse.

Whether it's more risky obviously if you have prolapse of the bladder you're fixing the bladder there is no risk of injury to the bowel because bowel is away so we can send the patient for risk of injury to the bladder if you're operating to the bowel then there's a risk of injury to the bowel because of the back passage we are operating there is no risk of injury to the bladder but if you're doing both obviously there is a risk of injury to bladder and risk of injury to bowel but whether it increases hugely, I don't think that it increases your prolapsed complications hugely it so if you have only one or two compartment prolapse you may recover in four weeks if you had hysterectomy combine you may need six weeks to recover so yeah slightly increased risk but the risk of DVT which is clot in the risk of infection those risks remain the same with the operation you have so yeah slightly increased risk more you do more you have a risk but I wouldn't necessarily say that you massively increase your chance of any complication then a background risk of hand operation.

Jan Chaseley

Thank you, and should I continue my vaginal oestrogen up until the morning of surgery?

Mr Abhishek Gupta

Yes, you can absolutely have no problem at all.

Jan Chaseley

Lovely, thank you. So, there's a question now: is it possible to see a nurse to teach pelvic floor exercises? The answer to that is absolutely If you're watching this, I assume you're a Benenden Health member. You can use your Benenden Health membership to come directly to the specialist nurses, who will open you up to a three-month pathway that you can then spend with us. We can teach you to do your pelvic floor exercises, follow you up, or if you feel that you have maybe some slight incontinence or some prolapse symptoms, speak to your GP to get a referral here, and then obviously you'll be triaged to the specialist nurses as a first line, and then we can refer you on to the consultants if we need to in the future.

So definitely use your membership to come and see us. And there's just a last couple of questions about patients who have symptoms of prolapse and incontinence, and I would say on the back of that, you know, if you're worried about your symptoms again, get a GP, get a referral to Benenden Hospital, and a member of the team would be more than happy to see you. Sometimes you just need to assess patients on an individual basis, so it's difficult to answer those, but definitely use your membership and come along to see us.

Thank you very much if you could just move to the last slide for me. Mr Gupta, lovely, thank you so much for attending this webinar, and I hope that we've answered all of your questions. If you provide your name and you've got any other questions, we will answer them via email. As a thank you for joining the session, we're today offering you 50% off the value of your consultation and a call back from a dedicated Private Patient Advisor.

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