What is cystocele and rectocele repair? General information on anterior and posterior colporrhaphy, grafts, recovery, sexual function and recurrence.
Cystocele and rectocele repair is an operation that supports, through the vagina, the wall where the bladder or the rectum bulges towards the vagina. The term anterior colporrhaphy is used for the front wall and posterior colporrhaphy for the back wall; both can also be done together in the same operation. The method, whether a graft will be used and the recovery process are planned according to you. The information below offers a general framework; it does not replace the individual assessment made for you.
When is cystocele and rectocele repair considered?
Surgery is considered if you have complaints that disturb your daily life and have not benefited enough from non-surgical methods, or if you do not want these methods. The method is determined according to the area of the prolapse and your situation. Surgery is not necessary for prolapse that causes no symptoms or only mild ones. The types of prolapse, its symptoms and the non-surgical options are a separate subject; repair is considered when surgery is recommended after this assessment.
How is anterior colporrhaphy (front wall repair) performed?
It is used when the bladder bulges towards the front wall of the vagina. The front wall of the vagina is opened lengthwise, the connective tissue surrounding the bladder is separated and pushed back into place, and the strengthened tissue is rejoined with stitches; the excess vaginal tissue is then removed and the wall is closed. The aim is to rebuild the supporting layer that prevents the bladder from descending towards the vagina.
How is posterior colporrhaphy (back wall repair) performed?
It is used when the rectum bulges towards the back wall of the vagina. The back wall is opened, the connective tissue between the rectum and the vagina is strengthened with stitches, and the wall is closed. If there is also weak support in the lower part of the vaginal entrance, an additional procedure that strengthens this area (perineorrhaphy) can be added.
Is a graft or mesh used in the repair?
In native tissue repair only your own tissue is used. A graft is material added to strengthen the repair; there are biological grafts of human or animal origin and synthetic meshes. This choice is determined by the wall on which the repair is made and the balance of benefit and risk of the additional material.
In front wall repair, polypropylene mesh can improve some anatomical and subjective outcomes, but it also increases problems such as mesh exposure, longer operating time and more blood loss. Guidelines on this subject consider permanent mesh applicable for the front and back walls only within research; the data show that this mesh is associated with bladder and urinary problems. In back wall repair, it has also not been shown that synthetic mesh or a biological graft improves outcomes. Data for absorbable mesh are very limited; no clear difference from native tissue repair has been shown for absorbable mesh and biological grafts. For this reason, the decision on a graft is one that is assessed separately for each wall and made after you have been given detailed information.
Is another procedure done with the operation?
If the support of the uterus or of the upper end of the vagina is also weak, providing this support can be added to the same operation, because it can affect how durable the front wall repair is. If you have urinary incontinence, a procedure for this can also be planned at the same time. Your doctor decides which procedures will be done together according to the examination findings and your complaints.
How do you prepare for the operation?
At the examination it is determined whether the bulge is on the bladder side, the rectum side or both. If your doctor wishes, you may be asked to note your urinary and bowel pattern for a few days; these notes help to understand which wall your complaints are related to. The necessary tests and the anaesthetic assessment are part of the standard pre-operative process. If your vaginal tissue is thin after menopause, the use of local oestrogen depends on your doctor's decision. The relevant teams will tell you specifically the instructions on food, medicines and bowel routine before the operation, and the type of anaesthetic.
What happens on the day of the operation and in the first days?
Because the operation is performed through the vagina, no incision is made in the abdominal wall. After the operation a pack aimed at reducing bleeding or a urinary catheter may be placed in the vagina; when they are removed depends on the doctor's instructions. In the first days, monitoring your passing of urine and bowel function, pain control and moving early are part of the plan. Your length of hospital stay varies with the procedure and with your situation. The operation is performed by Assoc. Prof. Dr. Nurettin Türktekin at Memorial Şişli Hospital.
What can be expected during recovery?
Because the stitch lines are in the vagina and around the anus, in the first days there may be tenderness or a feeling of heaviness in this area, mild cramp, a little brown or bloody discharge, a feeling that the bladder is not emptying fully and discomfort with the first bowel movement.
Arrangements that prevent constipation (a high-fibre diet, enough fluid and, if needed, stool softeners recommended by your doctor) are part of the recovery process. Your doctor will tell you the duration and your follow-up schedule.
How is sexual life affected after the operation?
After the operation, sexual function may improve, stay unchanged or, in some people, get worse, depending on the person; no definite generalisation can be made. Pain during intercourse has been reported particularly after back wall repairs; this may depend on the technique used. Your doctor will tell you when to start sexual intercourse by looking at the state of the stitch lines in the vagina. Because your expectations can shape the choice of technique, it will be useful to share them with your doctor before the operation.
What are the risks of the operation, and does prolapse come back?
The main problems specific to colporrhaphy are as follows (anaesthetic risks excluded):
- Bleeding and a collection of blood in the vagina (haematoma)
- Infection
- Injury to neighbouring organs, that is, the bladder or rectum
- Temporary straining of the urinary stream, or new leakage
- Constipation or difficulty with bowel movements
- Pain during sexual intercourse
- A feeling of narrowing or shortening of the vagina
- Clot formation in the leg veins
- If a graft or mesh is used, exposure, pain and the need for an additional procedure
- The bulge recurring on the same wall or appearing on another wall
The operation does not mean the prolapse will never happen again; the likelihood of recurrence varies with the person, the state of the prolapse and the chosen method. Urinary complaints may improve after the repair, stay the same or start anew; it has been reported that stress-type urinary incontinence can be seen particularly after front wall repair. You may wish to ask at the pre-operative consultation what risks are specific to you.
Frequently Asked Questions
Is the operation performed through the abdomen?
No. The operation is performed through the vagina; no incision is made in the abdominal wall.
Are a pack or catheter placed after the operation?
Yes, they may be needed. A pack or a urinary catheter may be placed in the vagina to reduce bleeding; your doctor decides when they will be removed.
Is a graft or mesh used in every repair?
No. In native tissue repair only your own tissue is used; a graft or mesh is added in situations where it is considered necessary to strengthen the repair. Permanent mesh is accepted as usable in front and back wall repair only within research; this mesh has been reported to be associated with bladder and urinary problems.
Can a procedure for urinary incontinence be done in the same operation?
Yes. If you have urinary incontinence, a procedure for this can be added to the same operation according to the examination findings. If the support of the uterus or of the upper end of the vagina is weak, this support can also be included in the same session.
Does the operation mean the prolapse will never happen again?
No. The likelihood of recurrence varies with the person, the state of the prolapse and the chosen method. The bulge may reappear on the same wall, or appear on another wall.
Can a new urinary incontinence problem develop after the operation?
Yes, it can. Urinary complaints may improve after the repair, stay the same or start anew; it has been reported that stress-type urinary incontinence can be seen particularly after front wall repair.
Will there be pain during sexual intercourse after the operation?
There may be. Pain during intercourse has been reported particularly after back wall repairs, and this may depend on the technique used. Sexual function may improve, stay unchanged or get worse depending on the person; no definite generalisation can be made.
When can sexual intercourse be started?
No definite time can be given. Your doctor will tell you the suitable time by looking at the state of healing of the stitch lines in the vagina.
Does thin vaginal tissue after menopause affect the operation?
It may. If your vaginal tissue is thin after menopause, the use of local oestrogen before the operation can be considered, depending on your doctor's decision.
What is the difference between standard colporrhaphy and site-specific repair?
In the standard method the tissues are gathered in the midline and strengthened. In site-specific repair, on the other hand, each tear or defect in the tissue is identified individually and only those points are repaired. Data directly comparing these two approaches are limited. Your doctor decides which method will be chosen according to the examination findings.
On which technique does the risk of pain during intercourse depend in back wall repair?
In posterior colporrhaphy, stitching the muscles called the levators and drawing them together (plication) has been associated with a risk of pain during intercourse after the operation. If you expect your sexual life to continue, telling your doctor this before the operation ensures that this expectation is taken into account in the choice of technique.
Why are heavy lifting and straining avoided?
Straining and heavy lifting, which raise the pressure inside the abdomen, can strain the stitch lines that are healing. Your doctor will tell you, according to your recovery, how long you should avoid them; if bowel movements become difficult or your pain increases, you should consult your doctor.
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