Pelvic floor repair (anterior and posterior) without the use of mesh

Read our guide below to help you understand pelvic floor repair.

You can also download a PDF version of this patient information by following the link on the right.

This page is for women who’ve been advised to have a pelvic floor repair. It outlines common reasons for the operation, benefits, risks, recovering from the operation and what to expect when you go home.

Ask your gynaecologist about any concerns that you may have.

The information below describes procedures for the repair of the front and back walls of your vagina (anterior and posterior) using your own tissues (native tissue repairs), without the use of synthetic mesh.

What is prolapse?

Your pelvic floor muscles form a hammock across the opening of your pelvis. These muscles, together with their surrounding tissue, keep your pelvic organs (bladder, uterus, and rectum) in place.

Prolapse happens when the pelvic floor muscles, their attachments or the vaginal tissue become weak. This usually happens because of damage at the time of childbirth but is most noticeable after the menopause when the quality of supporting tissue deteriorates.

It can also be caused by chronic strain due to heavy lifting, repeated coughing or constipation.

What is an anterior vaginal wall prolapse?

An anterior vaginal wall prolapse (also called a cystocele) is when the front wall of the vagina slips down letting the bladder bulge into the vagina (Figures 1 and 2). In some large cases this can result in the vaginal wall bulging out of the vagina especially on straining, for example, exercise or passing a motion.

A large cystocele may cause or be associated with urinary symptoms such as:

• urinary leakage
• urinary urgency (strong and sudden desire to pass urine)
• having to go frequently
• difficulty passing urine
• a sensation of incomplete emptying.

Some women have to push the bulge back into the vagina or lean forward in order to completely empty the bladder. Incomplete bladder emptying may make you prone to bladder infections (urinary tract infection).

Some women find that the bulge causes a dragging or aching sensation or is uncomfortable when having sexual intercourse.

What is a posterior vaginal wall prolapse?

A posterior vaginal wall prolapse (also called a rectocele or a rectoenterocele) is a prolapse of the back wall of the vagina. The rectum (bowel) bulges through the vagina.

The perineum is the area between the vagina and the back passage. It provides some support for the vagina and may be damaged during childbirth.  With straining, for example on passing a motion, the weakness described above allows the rectum (back passage) to bulge into the vagina and sometimes bulge out of the vagina (rectocele).

A large rectocele may make it very hard to have a bowel movement especially if you have constipation.  Some women have to push the bulge back into the vagina with their fingers, support the perineum or insert a finger in the back passage in order to complete a bowel movement. Some women find that the bulge causes a dragging or aching sensation.

What is an anterior repair?

An anterior vaginal repair (colporrhaphy) is an operation performed within the vagina to treat an anterior (front) vaginal wall prolapse also called a cystocele.

What is a posterior vaginal repair?

A posterior vaginal repair (colporrhaphy) is an operation performed within the vagina to treat a posterior (back) vaginal wall prolapse also called a rectocele.

Posterior repair is often combined with a repair of the area between the vagina and the back passage, the perineum (perineorrhaphy).

How is the anterior or posterior vaginal wall repair done?

The operation is usually done under a general anaesthetic. A general anaesthetic will mean you will be asleep during the entire procedure. A spinal anaesthetic can also be used which involves an injection in your back to numb you from the waist down.

The operation is all performed within your vagina and involves repairing the supportive tissues using dissolvable stitches. These stitches usually take 4-6 weeks to dissolve although some surgeons use sutures that take about 3-6 months to dissolve completely. This should not affect your recovery time.

If your perineum is repaired, you might notice a few stitches on the outside but these will dissolve and fall away fairly quickly.

A catheter and a vaginal pack (gauze tampon) may be inserted in your vagina after the operation but this is not essential and depends on the surgeon’s preference and method of operating. These are usually removed the following day.

Other operations we may do at the same time

This includes surgery for:

• other types of prolapse, for example, a vaginal hysterectomy, a sacrospinous fixation or sacrohysteropexy to treat a prolapse of the uterus (womb) or the top of the vagina
• urinary incontinence.

You should also refer to an information leaflet about any planned additional procedure.

What are the benefits of the procedure?

The primary aim of the operation is to reduce the bulge in your vagina. You’re likely to feel more comfortable. Intercourse may be more satisfactory. Your bladder
and/or bowels may empty more effectively. Urinary frequency and urgency may be reduced.

Altered sensation during intercourse

Sometimes your sensation during intercourse may be less and occasionally orgasm may be less intense. On the other hand, repair of your prolapse may improve it.

What are the risks associated with surgery?

Anaesthetic risk

This is very small unless you have specific medical conditions, such as a problem with your heart, or breathing. Smoking and being overweight also increase any risks. A posterior repair can be performed with you asleep (a general anaesthetic) or awake but numb from the waist down (a spinal anaesthetic). We’ll discuss this with you.

Make the anaesthetist aware of medical conditions such as problems with your heart or breathing.

Bring a list of your medications. Try to stop smoking before your operation. Lose weight if you are overweight and increase your activity.

Bleeding

There is a risk of bleeding with any operation. It is rare that we have to transfuse patients after their operation.

Tell your doctor know if you are taking a blood-thinning tablet such as warfarin, aspirin, clopidogrel or rivaroxaban as you may be asked to stop them before your operation.

Infection

There’s a small risk of infection with any operation (about 5 to 13 cases in 100 operations). If it happens, an infection can be a wound infection, vaginal infection or a urinary infection, and is usually treated with antibiotics. The risk of infection is reduced by routinely giving you a dose of antibiotic during your operation. Chest infection may also  happen because of the anaesthetic.

Treat any infections you’re aware of before surgery. After surgery, regular deep breathing exercises can help prevent chest infections; the nurses will guide you how to do this.

Deep vein thrombosis (DVT)

This is a clot in the deep veins of the leg. Occasionally this clot can travel to the lungs (pulmonary embolism) which can be very serious and in rare circumstances it can be fatal ( less than 1% in patients who already have DVT).

The risk increases with obesity, severe varicose veins, infection, immobility and other medical problems. The risk is significantly reduced by using special stockings and injections to thin the blood.

Stop taking hormone replacement therapy (HRT) if using oral oestrogen (you don’t need to stop transdermal oestrogen). These can usually be restarted 4 weeks after surgery when the risk of blood clots has reduced.

Do not arrange surgery the day after a long car journey or flight. As soon as you are awake start moving your legs around. Keep mobile once you are at home and
continue to wear your compression stockings during times when you are less mobile.

Wound complications

The wound within the vagina can become infected. Occasionally stitches can become loose allowing the wound to open up or on the other hand, tighten up causing discomfort.

Keep the surrounding area clean, and dry carefully after washing using a clean towel or a hairdryer on a cool setting. Do not douche the vagina or use tampons.

General risks of prolapse surgery

Getting another prolapse

There’s little published evidence of exactly how often prolapse recurs. Recurrence of the same prolapse probably happens in about 1 in 10 cases but it is generally believed that about 3 in 10 women who have an operation for prolapse will eventually require treatment for another prolapse. This is because the vaginal tissue is weak.

Sometimes even though another prolapse develops it is not problematic enough to need further treatment.

Keeping your weight normal for your height (normal BMI), avoiding unnecessary heavy lifting, and not straining on the toilet, may help prevent a further prolapse, although even if you are very careful it does not always prevent it.

Failure to cure symptoms

Even if the operation cures your prolapse it may fail to improve your symptoms, for example, change in the way your bowel works. Some patients experience worsening constipation following surgery. This may resolve with time. Try to avoid being constipated following surgery to reduce prolapse recurrence.

If you’re struggling with constipation after simple changes in diet and fluid intake, your doctor/GP may prescribe some laxatives.

Specific risks of an anterior vaginal wall repair

Damage to your bladder is a rare complication but requires that the damage is repaired, and this can result in a delay in recovery. It’s sometimes not detected at the time of surgery and therefore may occasionally require a return to theatre following surgery.

A bladder injury will need a catheter to drain the bladder for 7 to 14 days following surgery but usually there are no long-term problems.

Overactive bladder symptoms

Urinary urgency and frequency (with or without incontinence) usually improve after the operation, but occasionally can start or worsen after the operation.

If you experience this, tell your doctor so that treatment can be arranged.

Stress incontinence

Having a prolapse of the anterior vaginal wall sometimes causes some kinking of the tube through which you pass urine (urethra). This can be enough to stop urine leaks on coughing, laughing or sneezing. By correcting the prolapse this kink gets straightened out and the leaks are no longer stopped. It’s difficult to define an exact risk but it is reported to be in the order of 10% (1 in10).

Doing pelvic floor exercises regularly can help to prevent stress incontinence.

Damage to your bowel

This is a rare complication but requires that the damaged organ is repaired and this can result in a delay in recovery. It is sometimes not detected at the time of surgery and may occasionally need a return to theatre. If the rectum (back passage) is damaged at the time of surgery, you may need a temporary colostomy (bag) but this is exceptionally rare.

Painful sexual intercourse

The healing usually takes about 6 weeks and after this time it is safe to have intercourse. Some women find sex is uncomfortable at first, but it gets better with time. You’ll need to be gentle and may wish to use lubrication initially. Occasionally pain on intercourse can be long-term or permanent.

Before the operation (pre-op assessment)

Usually, you’re seen in a preoperative clinic some weeks before your planned operation. At that visit a nurse and possibly also a doctor will see you. You will be asked about your general health and any medications you take. Your blood pressure will be checked and you may have tests to assess your heart and breathing. Blood tests will be taken to check you for anaemia and other things according to your medical condition.

Swabs may be taken from your nose and groin to make sure that you do not carry MRSA (bacteria that are very resistant to antibiotics and may cause problems
after your operation). You may be asked to sign a consent form if this has not been done already.

After the operation – in hospital

Pain relief

An anterior repair is not a particularly painful operation and often includes injection of local anaesthetic into the vaginal tissues during the operation .Sometimes you may need tablets or injections for pain relief.

Some women describe the pain as similar to a period. It’s often best to take the pain killers supplied to you on a regular basis aiming to take a pain killer before the pain becomes a problem.

Drip

You may have a drip after the operation; this is to keep you hydrated until you are drinking normally. The drip is usually removed within 24 hours.

Catheter

You may have a tube (catheter) draining the bladder. The catheter may give you the sensation as though you need to pass urine but this isn’t the case. It’s usually removed the morning after surgery or sometimes later the same day.

Pack

Some gynaecologists insert a length of gauze into the vagina at the end of the operation. It acts as a
pressure bandage and is usually removed the following day.

Vaginal bleeding

There may be slight vaginal bleeding like the end of a period after the operation.

Eating and drinking

You should be able to drink and eat within a few hours of returning to the ward.

Preventing deep vein thrombosis (DVT)

You’ll be encouraged to get out of bed soon after your operation and take short walks around the ward. This improves general wellbeing and reduces the risk of clots in the legs. You may have a daily injection to keep your blood thin and reduce the risk of blood clots until you go home or for longer in some cases.

Going home

You’re not usually in hospital for more than one or two days and may go home the same day. If you need a sick note or certificate, please ask.

After the operation – at home

Moving around is very important. Using your leg muscles will reduce the risk of clots in the back of the legs (DVT).

You should:

• bath or shower as normal
• not use tampons for 6 weeks and avoid douching the vagina
• avoid constipation
• drink plenty of water / juice
• eat fruit and green vegetables, especially broccoli
• eat plenty of roughage for example, bran/oats
• treat a constant cough promptly. See your GP as soon as possible.

When can I return to my usual level of activity?

At 6 weeks gradually build up your level of activity. After 3 months, you should be able to return completely to your usual level of activity.

You should be able to return to a light job after about 6 weeks, a busy job in 12 weeks. Avoiding unnecessary heavy lifting will possibly reduce the risk of the prolapse recurring.

You’re likely to feel tired and may need to rest in the daytime from time to time for a month or more, this will gradually improve.

What will happen to my stiches?

Any of the stitches under the skin will melt away by themselves. The surface knots of the stitches may appear on your underwear or pads after about two weeks, this is quite normal. There may be a little bleeding again after about two weeks when the surface knots fall off, this is nothing to worry about.

It’s important to avoid stretching the repair particularly in the first weeks after surgery. Therefore, avoid constipation and heavy lifting. The deep stitches dissolve during the first 3 months and the body will gradually lay down strong scar tissue over a few months.

When can I drive?

You can drive as soon as you can operate the pedals and look over your shoulder without discomfort, generally after three weeks, but you must check this with your insurance company, as some of them insist that you should wait for 6 weeks.

When can I have sex?

The healing usually takes about 6 weeks and after this time it’s safe to have intercourse. Some women find sex is uncomfortable at first, but it gets better with time. Sometimes the internal knots could cause your partner discomfort until they dissolve away. You will need to be gentle and may wish to use lubrication initially.

Occasionally pain on intercourse can be long-term or permanent.

Will I need a follow up appointment?

You usually have a follow up appointment anything between 6 weeks and six months after the operation. This may be at the hospital (doctor or nurse), with your GP or by telephone. Sometimes follow up isn’t needed.

Find out more about recovering from a pelvic floor operation

What to report to your doctor after surgery

You need to tell your GP about:

• heavy vaginal bleeding
• smelly vaginal discharge
• severe pain
• high fever
• pain or discomfort passing urine or blood in the urine
• difficulty opening your bowels.
• warm, painful, swollen leg
• chest pain or difficulty breathing.

Non-surgical treatment alternatives

Do nothing

If the prolapse isn’t too bothersome then treatment isn’t necessarily needed. If the prolapse permanently protrudes through the opening to the vagina and is exposed to the air, it may become dried out and eventually ulcerate. Even if it’s not causing symptoms in this situation, it’s probably best to push it back with a ring pessary (see below) or have an operation to repair it.

Weight reduction in overweight women and avoiding risk factors such as smoking (leading to chronic cough), heavy weight-lifting jobs and constipation may help with symptom control. The prolapse may become worse with time but it can then be treated.

Pelvic floor exercises (PFE)

The pelvic floor muscles support the pelvic organs. Strong muscles can help to prevent a prolapse dropping further. PFEs are unlikely however, to provide significant improvement for a severe prolapse where the uterus is protruding outside the vagina.

A women’s health physiotherapist can explain how to perform these exercises with the correct technique. It’s important that you try the pelvic floor exercises to help to manage the symptoms of your prolapse and to prevent it becoming worse.

It’s also very important to continue with your pelvic floor exercises even if you have opted for other treatment options.

Pessary

A vaginal device, a pessary, may be placed in the vagina to support the vaginal walls and uterus. A pessary is usually used continuously and changed by a doctor or nurse every 4 to 6 months depending upon the type used and how well it suits you.

Alternatively, if you prefer, you may be taught to replace the pessary yourself. It’s possible to lead a normal life with continuation of activities such as bathing, cycling, swimming and, in some cases, sexual intercourse. Ongoing care is often at the GP practice, but some women will need to be kept under review in the gynaecology clinic.

Pessaries are very safe, and many women choose to use one long term rather than have an operation. On occasions their use has to be discontinued due to bleeding, discharge, sexual difficulties or change in bladder function but these all stop quickly after removal. Sometimes it will take several visits to the clinic to determine the
best size for you, but a pessary is not suitable for all women.

More information

If you’d like to know more about uterine prolapse and the treatments available, ask your GP or ask the doctor or nurse at the hospital.