Making your own individual treatment decision on how to treat your pelvic floor dysfunction will depend on your symptoms, what you have already tried, and what you have researched.  There is no doubt that there are success stories out there for all the treatment options available, including exercise-based rehabilitation of the pelvic floor, medication for symptom management, pessary use, and various surgical procedures.  It is not my job to speak out against any decision that you may choose, but it is my job to help make you more informed so that you can make a decision that is well thought out. 

Of all the treatment options listed, there is only one option that can cause permanent damage and that treatment is surgery.  The “quick fix” may sound perfect to just take care of your symptoms, but there is no going back after you attempt surgery.  I have included a study below that highlights many of the concerns associated with surgery.   My recommendation is that you thoroughly research all of your options (read through my previous blog, “Finding your options and knowing your risks,” before making a decision so that you are confident you gave yourself every opportunity to heal naturally and without risk.

From Reuters Health Information
Mesh Support for Vaginal Prolapse Repair Prone to Erosion

NEW YORK (Reuters Health) Jul 28 – Polypropylene mesh placement during vaginal reconstructive surgery for pelvic organ prolapse appears to do more harm than good, according to a small randomized trial in the August issue of Obstetrics and Gynecology.

The investigators stopped study recruitment early when five of 32 women experienced mesh erosion.

According to the American Urogynecologic Society, about half of all women between the ages of 50 and 79 have some form of prolapse, and about 11% in the U.S. will have it surgically treated. Approximately 200,000 procedures for correction of pelvic organ prolapse are performed each year in the United States.

Physicians at three academic centers in the U.S., led by Dr. Cheryl B. Iglesia at Washington Hospital Center, Washington, DC, treated 65 women (mean age 65) with uterovaginal or vaginal prolapse. They randomly assigned 32 women to colpopexy with Prolift mesh (Ethicon Women’s Health & Urology) and 33 to vaginal colpopexy without mesh. Women with a uterus also underwent vaginal hysterectomy.

Patients were blinded as to group assignment, as were evaluators at months 3 and 12.

The women in both groups reported very high subjective satisfaction with their procedures, with no significant differences in scores on quality-of-life questionnaires at 3 months.

During median follow-up of 9.7 months, 59% of women in the mesh group and 73% in the no-mesh group had recurrence of their prolapse, a nonsignificant difference.

Erosion of mesh support developed in 15.6% of patients within 2.1 months of surgery. Three erosions required surgical removal.

“This study questions the value of additive synthetic polypropylene mesh for prolapse repairs considering that there are no statistically significant differences in subjective or objective cure rates,” the investigators conclude.

The authors note that in 2008, the US Food and Drug Administration reported on complications from mesh use, such as erosions, infection, pain, incontinence and rare but serious visceral injury. In response, manufacturers have developed lighter weight and mixed composite meshes, including the next generation Prolift +M, but they have no long-term data for the new products.

SOURCE: Abstract

Obstet Gynecol 2010;116:293-303.

Published by Tasha

10 Comments

  1. Amen!

    My sister (younger by 2 years) had prolapse surgery in her mid 30s when her 2nd child was only a toddler (no mesh was used, I think). The “repair” came undone within a short time, about a year. Her 2nd surgeon did the best he could, given the lack of tissue to work with (due to the first surgery) but that surgery came undone, too. Her children were very young during these ordeals and it was very difficult She lives with it the bet she can, but it isn’t easy.

    About 4 years ago (my early 40s), I realized I also was experiencing pelvic prolapse (in hindsight, I probably had been prolapsed with mild rectocele for a number of years, but I made a mistake being “efficient” by having my PCP internist take care of my annual gyn exams for a number of years and she never recognized it). By that time I had a cystocele and rectocele. I asked for a referral to a gynecologist – he said I needed an A & P (anterior & posterior) repair for cystocele and rectocele, and since I didn’t need my uterus anymore it might as well come out, too (reminds of that saying about the man with the hammer seeing everything as a nail). He was one of these very skilled surgeons on the cutting edge of developing surgical techniques and new materials (which could be great, but then again, new and improved may not work out so well as tried and true – then again there is no “tried and true” with surgical prolapse repair, which is why they keep trying to improve on it ). He warned me that about 30% of women who didn’t have incontinence before the surgery go on to develop the condition post-operatively. Oh great.

    No, he didn’t think a pessary would be satisfactory for me – said pessaries were hard to select and fit properly, weren’t effective enough, were bothersome to many women, caused infections, and so on. I said I’d give his recommendation some thought (what I really meant was I’m going home to research this). I have enough experience with modern medicine now that I don’t do *anything* anymore without trying to fully understand and explore *everything* first, whether it’s pharmaceutical, surgical, or whatever. Heaven help me if I end up in an ER with something serious and acute. I’d better be unconscious 😉

    Surgery is a h-u-g-e step through a door than one can never go back through, regardless of the technique used, the skill of the surgeon, or the reputation of the hospital. Surgeons cut & snip and, stitch and staple best they can, but they don’t put our bodies back into the form they were designed to be. So far I’m holding my own with non-surgical management of my prolapse condition; I hope to never pursue surgery.

    Hmmm. Given my younger sister’s experience, I wasn’t keen on surgery at all. I sought out a consultation with a recommended gynecology nurse-practitioner in my HMO and she fitted me with a pessary that has worked beautifully for the nearly three years. She isn’t anti-surgery, but she was willing to work with me to find a pessary design that would work for me – first trying the simplest and easiest design that worked well and I could insert/remove myself (a ring design). That design has been great so I stuck with it, but she said we could keep trying until we found a design that worked best for me if the first one didn’t work out.

    I know some women have successful surgeries and never look back. But too many don’t have such great experiences and many times the surgeries need “refreshing” 5-10-15 years later. I’d rather start that revolving door as late as possible, hopefully never.

    Reply
  2. I was wondering if you could help me with a query about using e-stim? I have a kegel 8 device which I have started using (following 6+mths of physio without any e-stim) in the hope that this will help strengthen/waken up muscles damaged during childbirth and hence help me avoid surgery at this stage.

    I have read conflicting advice as to which type of e-stim programme is best to use to help with prolapse (in my case grade 2 cystocele and rectocele). What would you recommend – one designed for urge incont or stress incont, or something else? Also how often should I use it in terms of number of times per week and for a period of roughly how many weeks/months? Sorry, probably not easy to say but any guidance would be much appreciated – I am feeling confused! Is there any downside to using e-stim – can it cause any bladder damage etc being in such close proximity?
    Many thanks

    Reply
  3. Great questions! This is the challenge in having a home e-stim unit. In the clinic, we would get a feel for what type of program your muscles are responding to…so I would encourage you to do the same. Try one program for a week and then try the other. I would lean toward the setting for stress incontinence, but you may find that you respond better to the “urge incontinence” setting. You can use e-stim every day, but remember to keep your reps down. I recommend 8-10 two step kegels every day. Use the e-stim while doing these kegel sequences and you should be good. My thoughts would be to use the e-stim every day for 2 weeks, then reduce to every other day, and then every 3rd day and then phase off of the e-stim unit. Remember, to voluntarily contract along with the estim.

    Also, on the question of possible damage to the bladder. I recently heard of a fellow PT that had significant pain with internal estim and it did affect her bladder. Her advice was to be aware that sharp pain with use of the e-stim is not normal. Stop using the e-stim if you are experiencing sharp pain.

    -Tasha (sorry about my delay in getting back to you – the back to school chaos has got me working over-time)

    Reply
  4. Hi Tasha,

    I just received your DVD yesterday and I have gotten through the intro section and the first workout. Maybe I missed it or haven’t gotten to this info yet, but do you recommend doing all 3 workouts in one session 3 times per week? Also, is it beneficial to do the workouts more often then you recommend? Is more better or is it overkill? I am just so eager to get rid of my prolapse symptoms because I fee like I am not being as active as I want to be and it is driving me nuts.

    Thanks,
    Leslie

    Reply
  5. Many thanks for your reply – your advice is always really helpful. I know what you mean about the back to school chaos – I’m glad it’s the weekend again!

    Could I just check my understanding of a couple of things? The Kegel-8 programme I am doing is 20mins long. When you say initially use this daily while doing the 2step kegels do you mean have it switched on for the full 20mins but just co-contract 8 times during this and the rest of the time just have it doing the programme unassisted?
    I have been using e-stim daily now for 2 months! I feel like it has helped me turn the corner in my rehab & that now I have some hope that I might be able to manage without surgery (?) I am therefore nervous about stopping using it so soon – not sure if this is a genuine physical thing or a security blanket….Would it be harmful to continue for another few weeks before starting the phasing out of it? What are the downsides to using it for a longer period?

    Reply
  6. Sorry,
    I thought there might be a manual program option where you could use it with your voluntary contractions. If not, certainly decrease your use as you are comfortable. There is no down side to using it longer, as long as you are working your voluntary contractions along with it. Sounds as though it is helping you and so I would encourage you to roll with it as long as you feel it is helping in your recovery of your muscle control.

    Tasha

    Reply
  7. Exercise frequency

    At a minimum, doing one of the workouts 3 days a week is what you will need to do to see improvement. You certainly can do a workout every day if you like – you can even do more than one in a day AS LONG AS you do only 8-10 two step kegel sequences per day. The other muscle groups that we work in the workouts are bigger and can handle a bigger workload, but your pelvic floor can get over fatigued if you over do the kegels.

    I am excited for you. Enjoy the workouts, let them become part of your routine and just as important, let the neutral spine posture that I teach, become part of your daily thoughts as well!

    tasha

    Reply
  8. I am impressed. I have been doing the workouts for 4 weeks now and with the physical demands I have experienced in the last two days (sick two year old who I have been picking up frequently and carrying around a lot along with carrying my newborn in her heavy car seat and chasing my dog for about 2 miles who ran away)I have to report that I have not felt any bothersome symptoms of my cystocele. I am so excited!! I am so motivated now to be more active and I plan to start running again soon. I just had to share the good news and say thank you!!!!

    Reply
  9. Fantastic Leslie! Keep up the good work. Your body awareness will continue to improve for some time to come, so your progress will only continue!

    tasha

    Reply
  10. I’m 62 just diagnosed with stage 4 uteren and bladder prolapse, dr. Sending me to urogyn to explore robotic lapriscopic surgery,can you help with this method.

    Reply

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