Dr. Kathleen Connell strives to “keep it real” with her patients
Okay, I admit it. No matter how hard I focus on putting myself in my patients’ shoes, some information may not be conveyed as explicitly as I’d otherwise prefer – especially when explaining complex conditions and procedures.
Many women may have urinary incontinence or pelvic organ prolapse (POP), but not all are in need surgery. Genetic background, lifestyle, medical history and the condition of your pelvic anatomy are all significant factors when determining the right treatment, with the best long-term outcomes for an individual.
As a doctor, one of my primary goals is to engage my patients in all aspects of their medical decision making so they are empowered to choose the treatment that best fits their lifestyle. As part of the process to ensure a well-informed patient, I’ve put together a list of questions every woman should ask her urogynecologist before reconstructive pelvic surgery.
1.) What’s my condition?
This is the most obvious of questions, but there are several types of incontinence and POP. With regard to the latter, there is a “staging system” for POP: stage I (mild) to stage IV (advanced). Both the type and stage determine the choice in procedure and, sometimes, where the procedure is performed.
It is helpful for the surgeon to give you detailed information regarding your condition and seeing visuals such as pictures on a handout or website can be very helpful.
2.) What is the proposed procedure?
Again, another seemingly silly question, but it’s not uncommon for urogynecologists to see women who aren’t sure what procedures they have had in the past.
Whether it’s your first or fifth visit to a urogynecologist, it is important to know exactly what will be performed. Will the surgeon use your own tissue? Are they proposing to use a material to augment your tissue? Will it be an open or minimally invasive surgery?
3.) What is the reasoning behind the proposed procedure(s)?
As previously mentioned, different stages and combinations of POP exist, which can dictate the type of procedure that’s necessary for the best long-term outcome. The advantages and disadvantages (risks) should be weighed against the safety and benefits of the procedure.
Your surgeon should be able to clearly state why they have chosen the proposed procedure and route (vaginal or abdominal? Do the data to support that choice?).
The medical condition of the patient also guides what procedure is safest for them.
4.) What type of training has the surgeon received in performing these procedures?
This rule applies for all specialties. Knowing where your doctor received their education, how long they trained and how many procedures have they completed is important.
Additionally, if a complication occurs, will your doctor continue to follow you? If a mesh is being utilized, does your doctor perform mesh removals (if things don’t go as planned)?
5.) What is the average recovery time?
In general, most post-operative healing occurs in the first eight weeks. This time is crucial for reconstructive surgery since requires the repair of weakened tissues.
Typically patients should be aware of restrictions for lifting weight and activity. In general, it is advised to avoid heavy lifting and strenuous exercise in the first two months after surgery – it is possible, however, that it may take longer for you body to heal if you have a complex medical history.
Taking time off from work can depend not only on the procedure, but also on one’s profession and the level of physical activity required. With repair of the rectum or perineum, avoidance of prolonged sitting is advised and is not comfortable for those with “desk jobs”. Similarly, extended travel plans may need to be put on hold after surgery.
6.) What type of anesthesia will be used?
Although general anesthesia is usually required – and often preferred by patients – for reconstructive pelvic surgery, there are cases where spinal anesthesia may be used. Local anesthesia alone is used for a few minor procedures, but is routinely used in tandem with general and spinal anesthesia to help with postoperative pain and to reduce the amount of narcotics needed.
7.) Are there any alternatives to surgery?
Surgery for POP and incontinence is recommended when it interferes with daily activity and quality of life. Because it is not urgent such as surgery for cancer – and is not mandatory for patients who are not bothered by their symptoms – it is considered elective. If a woman chooses not to have surgery, she can be examined at regular intervals to monitor her prolapse.
A pessary (similar to a diaphragm), for example, can be used for mechanical support. Pelvic floor therapy and Pilates can also strengthen the pelvic floor muscles to keep the prolapsed organs from protruding outside the vagina and to help maintain continence.
8.) What are the short-term outcomes of the procedure?
Short-term success of surgery is usually predictable, except in patients with complex medical conditions or previous procedures. Reconstructive surgery will restore the anatomy and correct stress urinary incontinence. It will not correct symptoms such as going to the bathroom frequently, rushing to get to the bathroom and the inability to hold urine when there is an urge to relieve oneself.
9.) What are the anticipated long-term outcomes of the procedure?
In any type of reconstructive surgery, you are repairing weakened or damaged tissue. There is a wide range of recurrent rates of POP and incontinence following surgery as reported in medical literature.
The long-term outcomes of reconstructive pelvic surgery are difficult to study in clinical trials as most recurrences occur years following surgical repair. However, what we do know is that both POP and incontinence can recur in an individual’s lifetime. This is dependent upon genetics, lifestyle and individual medical conditions. While recurrence is unclear in pelvic medicine – diet, exercise and optimizing one’s personal health can make all the difference.
10.) What can I do to help optimize my health in preparation for surgery?
No two bodies are the same: response to surgery and the healing process are unique to each patient. Utilizing antihypertensive medications will help prevent cardiovascular complications. For instance, achieving optimal glucose control for diabetics is important for wound healing and to decrease the risk of infection. Consult with your primary care provider before taking any medication.
For any surgery, smoking has a negative effect on the surgical outcome. The carbon monoxide (CO) and nicotine from cigarette smoke increases heart rate and blood pressure thereby raising the body’s demand for oxygen. Smoking also causes vasoconstriction, reducing the blood flow to certain parts of the body inhibits immune responses, both of which affect wound healing.
11.) What can I do to prevent incontinence or prolapse from recurring after surgery?
Maintaining overall health is of utmost importance. Consider the following:
We are what we eat and eating a healthy diet is just as important for the pelvic organs to function properly as all other organs.
It’s been shown that diabetes can affect nerve function overall, including the nerves of the bladder and pelvis. This can cause overactive bladder (urinary urgency and frequency) but can also affect the bladder muscle function causing incomplete emptying.
It’s also important for the pelvic floor muscles and supportive connective tissue to maintain strength. Stay active and maintain a healthy body weight. Surgery can restore the position of the pelvic organs, but pelvic floor muscles are also important for maintaining continence. The pelvic floor muscles are like a hammock at the base of the pelvis. They are always contracting to keep the urethra and rectum closed. You do not want these muscles to become weak with age.
Regular physical activity and exercises focused on the pelvic muscles and core muscles, such as Pilates, are great ways to keep your pelvis healthy.
Quit smoking, now
Smoking is associated with increased risk of developing POP and incontinence. It has also been shown that smokers have a higher rate of recurrent incontinence after surgery and higher rates of mesh erosion.
Smoking causes the small airways in the lungs to narrow making them more prone to collapse and leading to increased susceptibility of infection, coughing, pulmonary complications and chronic bronchitis. The chronic coughing associated with bronchitis is thought to expose the pelvis to increased pressure and recurrent POP.
University of Colorado Urogynecology is a specialty women’s health practice focused on female pelvic health and surgery. Our physicians are also professors & researchers for the CU School of Medicine, one of the top-ranked medical schools in the nation.