Vaginal hysterectomy for uterine prolapse

Read our guide below to help you understand why you’ve been advised to have a vaginal hysterectomy. It outlines common reasons for the operation, benefits, risks, recovering, and what to expect when you go home.

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

What is a vaginal hysterectomy?

It’s an operation to remove the uterus (womb), including the cervix, through the vagina.

What conditions does a vaginal hysterectomy treat?

This includes uterine prolapse (dropped womb) and heavy periods.

What is prolapse?

The pelvic floor muscles form a sling or hammock across your pelvic floor. These muscles together with surrounding connective tissue keep all your pelvic organs (bladder, uterus, vagina and rectum) in place and functioning correctly. (Fig 1)

Pelvic organ prolapse happens when your pelvic floor muscles, their attachments and/or the surrounding connective tissue become weak or damaged allowing your uterus (womb) or the walls of your vagina to drop. (Fig 2)

This normally happens as a result of childbirth but is most noticeable after the menopause. The descent of the pelvic organs tends to be worse when you’re tired or straining to empty your bowels. The amount of prolapse varies from person to person.

Individual women may have prolapse affecting:

• the uterus only
• the front wall of the vagina only (Cystocele: Fig 3)
• the back wall of the vagina only (Rectocele: Fig 4)
• any combination of these.

There may be bladder and bowel symptoms as well.

 

 

How is a vaginal hysterectomy done?

A vaginal hysterectomy can be done with you asleep (a general anaesthetic) or awake (a spinal anaesthetic) but numb from the waist down. The womb is removed through the vagina, so there are no cuts in your tummy, unless there are complications.

Other operations which may be performed at the same time

Your doctor may suggest that a vaginal hysterectomy is all that’s needed to help your prolapse. Sometimes, we do additional operations at the same time as a vaginal hysterectomy. Your doctor should advise you before your operation.

Vaginal repairs

Sometimes there’s also a prolapse of the front wall (anterior – cystocele) or back wall (posterior – rectocele) of the vagina. Your doctor may suggest repairing them at the same time as your hysterectomy which is quite common.

This may alter the risks of the operation, for example, painful intercourse (sex) is more likely if a repair is done, although it’s still uncommon. You should,
discuss this with your doctor who may have extra information for you about vaginal wall repairs.

Continence surgery

Sometimes an operation to treat any urinary leakage can be done at the same time as your vaginal hysterectomy. Some gynaecologists prefer to do this as a separate procedure at a later date.

You should also refer to a patient information leaflet about the planned additional procedure.

What are the benefits of prolapse surgery?

These include:

• relief from prolapse symptoms
• no more periods
• no need for cervical smears in the future
• removes risk of problems with the womb and cervix in the future, for example, cancer
• improvement in difficulty passing urine for some women after a vaginal hysterectomy, especially if they have a large prolapse
• improvement in overactive bladder symptoms, for example, less urgency passing urine less frequently.

What are the risks involved?

General risks of surgery include:

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.

What you can do

• tell the anaesthetist about medical conditions such as problems with your heart or breathing
• bring a list of your medications with you
• try to stop smoking before your operation
• lose weight if you’re overweight and increase your activity.

Bleeding

There’s a risk of bleeding with any operation. It’s rare that we have to give patients a blood transfusion after their operation. Excessive bleeding is unusual during a vaginal hysterectomy. If this happens, you may need a cut in your tummy to stop the bleeding.

What you can do

Tell your doctor if you’re taking a blood-thinning tablet such as Warfarin, Aspirin, Clopidogrel or rivaroxaban. We may ask you to stop them before your operation.

Infection

There’s a small risk of infection with any operation (approx. 5 to 13 cases in 100 operations). If it happens, it can be a wound infection, vaginal infection or a urinary infection which 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.

What can you do?

Treat any infections you are 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 100 of those who get a clot). 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.

What can you do?

Stop taking Hormone Replacement Therapy (HRT) if you’re using oral Oestrogel. 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.

Don’t arrange surgery the day after a long car journey or flight. As soon as you’re awake, start moving your legs around. Keep mobile once you’re at home.
Continue to wear your compression stockings during times when you’re less mobile.

Wound complications

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

What can you do?

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

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

What can you do?

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’re very careful it doesn’t always prevent it.

Failure to cure symptoms

Even if the operation cures your prolapse it may fail to improve your symptoms.

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.

What can you do?

Tell your doctor know so that treatment can be arranged.

Stress incontinence

Having a prolapse 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’s reported to be in the order of 10% (1 in 10).

What can you do?

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

Bladder emptying or voiding problems

Generally, these improve after surgery for prolapse but there may be problems emptying the bladder in the first few days. Your doctor may wish to do bladder tests (urodynamics) prior to surgery to predict post-operative voiding difficulties. There can be persistence of voiding problems in 1 in 10 women.

What can you do?

If you experience difficulty passing urine, lean forwards or even stand slightly to allow better emptying of your bladder. Make sure that you have  your legs apart rather than having your knees together when sitting on the toilet. Waiting for two minutes after the initial void and trying again may help. This is known as the double void technique.

A change in the way your bowel works

Some patients experience worsening constipation following surgery. This may resolve with time. It’s important to try to avoid being constipated following surgery to reduce prolapse recurrence.

What can you do?

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

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.

Altered sensation during intercourse

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

Specific risks of vaginal hysterectomy

Damage to the bladder or bowel

Overall 5 to 6 injuries in 1,000 operations) can happen because these organs are immediately next to the vagina. The risk is greater if you’ve had pelvic surgery or pelvic infection in the past or if there’s inflammation of the tissues.

It’s usually possible to repair the damage straight away, but it may slow down your recovery. Occasionally the damage isn’t recognised at the time of surgery and has to be repaired later. Risk of making a hole in the bladder is about 5 in 1,000 operations. Risk of a fistula (abnormal communication) between the bladder and vagina
is about 2 in 10,000 operations.

Risk of bowel injury is about 1 to 5 in 1000.

Damage to the ureter(s)

The ureter is a narrow tube which transports urine from each kidney to the bladder. It can be damaged during a hysterectomy. The risk of damage is about 2 to 4 for every 10,000 operations.

Before the operation – pre-op assessment

Usually we see you in a preoperative clinic a few weeks before your planned operation. At that visit a nurse and possibly a doctor will see you, ask about your general health and any medications you take. They’ll check your blood pressure and you may have tests to assess your heart and breathing.

You’ll also have blood tests to check you for anaemia and other things according to your medical condition. You may have swabs taken from your nose and groin to make sure that you do not carry MRSA. This is bacteria that are very resistant to antibiotics and may cause problems after your operation.

After the operation – in hospital

Pain relief

Pain can be controlled in a number of ways depending on the preference of your anaesthetist and/or gynaecologist. Options include:

• an epidural
• injection of local anaesthetic into the tissues during the operation
• self-administration of pain relief (patient-controlled analgesia – PCA)
• drugs in a drip
• tablets or suppositories.

A vaginal hysterectomy isn’t a particularly painful operation but 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

This is to keep you hydrated until you’re 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’ usually removed the morning after surgery or sometimes later the same day.

A vaginal pack

Some gynaecologists insert a length of gauze into the vagina at the end of the operation. It acts as pressure bandage and it’ 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 can drink fluids soon after the operation and will be encouraged to start eating as soon as you can tolerate.

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.