Bladder and Uterine Prolapse Surgery in Turkey

Bladder and uterine prolapse surgery is a surgical treatment method applied in advanced stages of pelvic organ prolapse in order to re-support anatomical structures and correct functional losses. This procedure aims to reduce symptoms such as urinary incontinence and the sensation of pressure.

Surgical treatment methods for pelvic organ prolapse are planned according to the patient’s age, general health status, and the degree of prolapse. By preferring vaginal or abdominal approaches, the support tissues are strengthened and the organs are brought back to their anatomical position. Minimally invasive techniques may accelerate the recovery process.

The recovery process after bladder and uterine prolapse surgery varies depending on the patient’s response to surgery. In the first weeks, it is recommended to avoid heavy lifting and to perform exercises that support the pelvic floor muscles. Careful follow-up is required against the risk of infection.

Among the risks and complications of uterine and bladder prolapse surgery are infection, bleeding, and rarely recurrence. With appropriate surgical technique and regular follow-ups, these risks are minimized. In the long term, significant improvement in quality of life is aimed for.

How Do Bladder and Uterine Prolapse Occur Anatomically?

To understand how bladder and uterine prolapse occurs, it is necessary to know the magnificent three-layered supporting structure of the pelvic floor. In this structure, the main elements that keep the organs in place are a complex network composed of muscles, fasciae, and extremely strong ligaments.

The support levels are as follows:

• First-level suspensory ligaments
• Second-level lateral fascial attachments
• Third-level lower outlet supports

The structure referred to as the first level is the strong ligament complexes that keep the upper dome of the vagina and the uterus suspended above, at the highest level of the pelvis. They function just like the main poles at the top of a tent. Weakening or collapse of these poles results in the uterus descending directly downward. The second level consists of the structures that stretch the middle portions of the vagina to the lateral walls of the pelvis like a sheet. Loosening in the front part of this sheet causes bladder prolapse, while loosening in the back part causes bowel prolapse. The third level is the dense tissue center located right at the outlet of the vagina where the muscles merge. Any rupture in this support system creates a picture of mechanical insufficiency that, over time, places extra load on the other regions as well and causes the entire pelvic hammock to collapse in sequence.

What Are the Main Risk Factors in the Development of Bladder and Uterine Prolapse?

It is difficult to speak of a single cause in the emergence of this problem; the process is usually shaped over the years by the combination of multiple factors.

The most prominent risk factors are as follows:

• Advanced age
• Menopause
• Pregnancy process
• Difficult vaginal deliveries
• Excess weight
• Chronic cough
• Persistent constipation
• Heavy lifting

Pregnancy and especially vaginal delivery create a very serious traumatic effect on the pelvic floor. During the baby’s passage through the birth canal, the pelvic muscles are stretched far beyond their normal stretching capacity. Especially a large baby, a very prolonged labor, or the use of interventions such as vacuum may cause microscopic or macroscopic tears in these muscles. In addition, excessive stretching of the nerves in this region prevents the muscles from recovering in the following years.

In addition, menopause is a very critical turning point. Estrogen, the female hormone, plays the leading role in the production of collagen protein, which gives tissues strength and flexibility. The sudden decrease in estrogen with menopause causes the connective tissues in the pelvic region to become thinner, drier, and lose their mechanical resistance. In addition, obesity, diseases such as asthma or COPD that cause constant coughing, the constant need to strain due to chronic constipation, and occupationally lifting heavy loads all the time keep the intra-abdominal pressure constantly high. This high pressure acts like a press on the weakened pelvic hammock over the years, making the picture of bladder and uterine prolapse inevitable.

What Symptoms Do Bladder and Uterine Prolapse Show?

The complaints caused by the disease vary greatly depending on the severity of the prolapse and which organ has descended more. In some cases, the process progresses very insidiously, while in others it can completely bring daily life to a standstill.

The most frequently encountered symptoms are as follows:

• A sensation of fullness in the vagina
• Pressure and heaviness in the lower abdomen
• A palpable mass
• Frequent urination
• A feeling of incomplete bladder emptying
• Difficulty urinating
• Pain during sexual intercourse
• Constant ache in the lower back

Patients usually feel better in the early hours of the day, while toward the evening, with the effect of gravity, that feeling of heaviness in the vaginal region and the sense that something is coming out become much more pronounced. As the prolapsed tissue approaches the vaginal opening, patients notice a mass in their hand while cleaning in the toilet or taking a shower.

Urinary tract complaints are one of the most annoying parts of this condition. Since the prolapsed bladder disrupts the anatomical structure where urine accumulates, urine cannot be emptied properly. Patients feel the need to go again immediately after getting up from the toilet. In advanced prolapse, due to folding of the urinary canal, the need may arise to push the prolapsed mass upward with a finger in order to urinate. In addition, this anatomical deterioration may cause serious pain during sexual intercourse, a feeling of discomfort, and as a result, the patient may completely withdraw from sexual life.

What Are the Stages and Grading of Bladder and Uterine Prolapse?

In medical evaluation, in order to draw up a correct treatment plan, it is essential to clearly measure the amount of prolapse and stage it according to international standards. During this staging, the anatomical distance of the prolapsed organ to the vaginal opening (hymenal ring) is taken as the reference.

The stages in which prolapse is classified are as follows:

• Stage one
• Stage two
• Stage three
• Stage four

Stage one is the phase in which the prolapse has anatomically begun, but the farthest point remains at least one centimeter or more above the vaginal opening. At this stage, patients generally do not experience any physical complaints. The condition is mostly noticed during routine examinations performed for another complaint.

Stage two is the condition in which the prolapsed organ has descended to the exact level of the vaginal opening, that is, to the area between one centimeter above and one centimeter below it. Patients now begin to gradually experience that increasing sensation of pressure and fullness at the end of the day.

In stage three, the condition is now easily noticeable from the outside. The prolapsed bladder or uterus has protruded outward more than one centimeter beyond the vaginal opening. Difficulty urinating, urinary tract infections, and the feeling of a palpable mass are the most prominent features of this stage.

Stage four is the most severe form, called “procidentia” in medical language, in which the organ has completely come out and the vagina has, so to speak, turned inside out. Bleeding wounds form on the tissues that remain outside and constantly rub against the underwear. The patient experiences great difficulty even in urinating and walking and reaches the point of completely withdrawing from social life.

Which Examination Methods Are Applied in the Diagnosis of Bladder and Uterine Prolapse?

For the detection of the problem and the mapping of its extent, an extremely detailed urological and gynecological evaluation process must be followed. An examination performed only while lying on the table may be insufficient to show the true extent of the prolapse.

The examination methods and tests used are as follows:

• Standing physical examination
• Valsalva maneuver
• Stress test
• Q-tip test
• Pelvic muscle evaluation
• Neurological reflex control

While lying on the back on a standard examination table, the organs may slide backward under the effect of gravity, and the prolapse may appear milder than it actually is. For this reason, the examination must definitely be repeated while the patient is standing and in positions in which she coughs and strains strongly (Valsalva maneuver). In this way, it is clearly determined how far the organs descend when intra-abdominal pressure reaches its highest level.

The stress test is the process of having the patient cough while the bladder is full of urine. Any urinary leakage observed at that time shows how weakened the support at the bladder neck is. In a simple procedure called the Q-tip test, the angular movement during straining of a sterile cotton swab placed at the tip of the urinary canal (urethra) is measured. An excessive increase in this angle proves that the connective tissue around the urinary canal has ruptured. In addition, with vaginal palpation, the patient is asked to tighten the pelvic muscles, the voluntary contraction strength of the muscles is scored, and basic reflex tests are performed to understand whether the nerves in that region are functioning properly.

What Are the Advanced Urodynamic Tests for Bladder and Uterine Prolapse?

The visible size of the prolapse and the patient’s urination complaints may not always be consistent with each other. Sometimes a very mild prolapse causes severe urinary incontinence, while at other times a very large prolapse may completely and silently disrupt the bladder’s working system. In order to resolve this complex situation and map the inner world of the bladder before deciding on surgery, computerized tests are needed.

The advanced urodynamic evaluations are as follows:

• Cystometry
• Uroflowmetry
• Pressure and flow study
• Post-void residual measurement

The cystometry procedure is the filling of the bladder with fluid by means of a very thin catheter with millimetric sensors placed through the urinary tract into the bladder and the transfer of the pressure changes during this filling to a computer. This test objectively reveals how flexible the bladder muscle is, its storage capacity, and whether the patient experiences a sudden feeling of urgency to urinate.

Uroflowmetry is the second-by-second graphing of the urine flow rate while the patient urinates into a special toilet. When combined with the pressure and flow study, it is very clearly distinguished whether the prolapse creates a physical obstruction in the urinary tract or whether the bladder muscle has lost its contractile strength due to years of straining. Post-void residual measurement is the measurement by ultrasound of how much urine remains in the bladder immediately after the patient has urinated; since the bladder’s inability to empty completely carries a major risk for kidney health, knowing this data is of vital importance in planning the surgery.

What Is the Risk of Hidden Urinary Incontinence in Bladder and Uterine Prolapse Surgery?

One of the most critical and most often overlooked points in the management of this condition is the condition called “occult stress urinary incontinence.” Many women with advanced bladder and uterine prolapse state when they consult a doctor that they do not leak urine at all, but only feel a mass descending downward. However, this is a great illusion and the underlying mechanism is quite interesting.

The critical evaluation steps applied are as follows:

• Anatomical reduction test
• Simulated cough test
• Re-updating of the surgical plan

In major prolapse, as the bladder and uterus descend downward, they also pull the urinary canal (urethra) along with them and fold it at a sharp angle. Just as the flow of water stops when a garden hose with water flowing through it bends in the middle, this folding also creates a mechanical obstruction in the urinary tract. This obstruction masks the patient’s actually existing sphincter insufficiency. If the physician overlooks this detail and, based on the patient’s complaint, performs only a surgery to suspend the prolapse upward, the urinary canal will be freed from where it was folded and straighten out, and the bend in the hose will open. As a result, the patient will begin to leak urine severely from the moment she wakes up from the surgery and stands up.

To prevent this tragic situation, the anatomical reduction test must definitely be performed before the surgical decision. With the help of a special examination instrument, the prolapsed tissue is gently pushed back toward its former anatomical place. While the bend in the hose is temporarily opened, the patient is asked to cough forcefully with a full bladder. If urinary leakage appears during this test, it is understood that the surgery to be performed should not be limited to correcting the prolapse alone, but that a sling procedure to support the underside of the urinary canal must also be added simultaneously.

What Are the Non-Surgical Methods in the Treatment of Bladder and Uterine Prolapse?

Not every case of prolapse necessarily requires going under the knife. For patients who are caught at an early stage, whose complaints have not yet made daily life unbearable, or whose general health condition and advanced age make anesthesia high risk, non-surgical treatment options are extremely valuable and effective.

The non-surgical treatment options are as follows:

• Pelvic floor muscle exercises
• Biofeedback applications
• Electrical stimulation
• Posterior tibial nerve stimulation
• Vaginal weighted cones

Pelvic floor muscle exercises (Kegel exercises) are based on consciously tightening and relaxing the muscles in this region. However, most women have difficulty finding the right muscle and accidentally tighten the abdominal or gluteal muscles. This is where biofeedback applications come into play. Thanks to a small sensor placed inside the vagina, when the patient contracts her muscles, she receives a graphical change or an auditory warning on the computer screen. This feedback allows the patient to learn to activate the correct muscle group through brain-muscle coordination.

If the pelvic muscles are too weak for the patient to contract by her own will, the electrical stimulation method is used. By giving low-voltage, completely painless microcurrents, these muscles are made to work passively and become stronger. Posterior tibial nerve stimulation is the process of recalibrating the functioning order in that region by applying mild stimuli to a nerve passing around the ankle, with these stimuli reaching the bladder and pelvic floor nerves through the spinal cord. Vaginal cones are a method of strengthening the muscles against physical resistance, like weight training, by trying to hold small devices of different weights inside the vagina.

What Are Pessary Applications for Bladder and Uterine Prolapse?

For women who refuse surgical treatment, are not suitable for surgery, or want to postpone their surgery because they are planning pregnancy, the medical devices called “pessaries” are excellent lifesavers. Pessaries are support devices, generally made of flexible and tissue-friendly medical silicone, that keep the prolapsed tissue inside and upward by creating a mechanical barrier.

The main types of pessaries used are as follows:

• Ring pessary
• Gellhorn pessary
• Cube pessary
• Donut pessary

Ring pessaries are the easiest to insert and remove and are generally preferred in milder prolapse such as stage one or stage two. In terms of shape, they resemble a thin bracelet and can also be comfortably used in daily life by sexually active women.

Gellhorn pessaries are preferred in more advanced stages of prolapse. Thanks to their umbrella-like structure, they create a strong vacuum effect in the vaginal vault and provide broad support. However, since this model occupies space, it does not allow sexual intercourse. Cube and donut pessaries, on the other hand, prevent the organs from protruding outward by providing strong mechanical retention with their wide surface areas in special situations where the vaginal tissue has widened greatly and other pessaries cannot stay in place and slip out.

The success of pessary use depends entirely on compliance and hygiene. A foreign body left inside over time may lead to vaginal discharge, bad odor, and most importantly wounds (erosion) on the mucosa due to friction. Therefore, it is essential that the devices of patients using pessaries be removed and cleaned by a specialist every few months and that regional estrogen creams be used regularly to prevent thinning of the vaginal tissue.

What Are the TURC Technique and Modern Approaches in the Surgical Treatment of Bladder and Uterine Prolapse?

If prolapse complaints have brought the patient’s social life to the point of ending, cause constant urinary tract infections and deterioration in kidney functions, and non-surgical methods have remained insufficient, surgical treatment is inevitable for permanent anatomical repair. Surgical methods are generally divided into those performed through the abdomen and those performed through the vaginal route.

The surgical approaches applied and developed from past to present are as follows:

• Vaginal colporrhaphy repairs
• Traditional open abdominal surgeries
• Laparoscopic and robotic suspension procedures
• TURC technique operation

Vaginal repairs are surgeries performed entirely from below and do not leave a scar outside. However, since tension is created by suturing together the patient’s own already weakened tissues, the risk that these tissues will stretch again over the years and the prolapse will recur is quite high. For this reason, especially in young, physically active women and in women with a high risk of recurrence, intra-abdominal surgeries in which the upper part of the vagina is suspended to the firm points of the pelvis using an external supportive synthetic patch (mesh) are accepted as the gold standard.

One of the most revolutionary innovations in this field in modern medicine is the TURC (Trans-Umbilical Retroperitoneal Colpopexy) technique, introduced into the literature by Prof. Dr. Yavuz Önol and resonating all over the world. The biggest difference of this special method is that, unlike traditional open or robotic surgeries, the peritoneal cavity is never entered. The surgery is performed through very small incisions opened only from the navel and the lower part, advancing through tunnels behind the peritoneum without ever touching that sensitive abdominal cavity where the intestines are located. Since the abdominal cavity is not entered, the risks of postoperative bowel obstruction, adhesions, and organ injury fall to zero.

In addition, in this technique, instead of the gigantic synthetic patches used in older methods, very thin and narrow strips of special macroporous mesh are used. The reduction of the amount of mesh to this extent almost completely eliminates feared complications such as the body’s reaction to the foreign body, the mesh protruding out of the vagina (erosion), or shrinking within the tissue and shortening the vagina (contracture). Thanks to this operation, which is completed in a short time such as an average of one to one and a half hours, while anatomical success reaches the highest level, patients can usually stay in the hospital for only one night and return home walking the next day.

What Should Be Considered After Bladder and Uterine Prolapse Surgery?

No matter how superior and successful the surgical technique applied may be, the care that the patient shows to her own tissues during the critical recovery period after surgery is the most important factor determining the long-term success of the treatment. It takes months for that newly established support system to fully fuse and become strong.

The strict rules that must be followed during the recovery period are as follows:

• Avoiding heavy lifting
• Applying sexual abstinence during the recovery period
• Following a diet that prevents constipation
• Having chronic coughing attacks treated
• Maintaining weight control
• Not remaining standing motionless for very long periods

Especially during the first three months after surgery, lifting any weight over four kilograms, pushing or pulling a heavy object on the floor is absolutely prohibited. Because such movements may suddenly raise intra-abdominal pressure to its peak and cause the sutures or mesh that have not yet fused with the tissues to detach from their place. In the long term, staying away from very heavy sports and regular heavy lifting activities throughout life minimizes the risk of recurrence.

It takes a very serious amount of time for the vaginal tissues to regain their integrity and for the mesh or sutures to integrate with the cells in that region. For this reason, although it varies according to the type of surgery, strict sexual abstinence should be applied for at least forty days to six weeks. If synthetic mesh was used in the surgery, since this integration process proceeds more slowly, the resumption of sexual life should usually be postponed for a period such as three months. In addition, if increasing severe pain at the suture sites, foul-smelling and purulent discharge outside of normal discharge, fever exceeding thirty-eight degrees, or fresh bleeding more than slight leakage from the suture areas are seen during the recovery period at home, the physician who performed the surgery should be consulted without losing time.