PREPARING FOR SURGERY
You have been scheduled to undergo pelvic reconstructive and/or urinary incontinence surgery. Below are some general guidelines to assist you in your surgery and recovery.
The goals of pelvic reconstructive surgery are to restore normal anatomy, to maintain and/or restore normal bowel and bladder function and to maintain vaginal capacity for sexual intercourse. If your own tissues appear too weak or insufficient, other materials (grafts/meshes) may be used to aid in the repair. These materials include biologic and synthetic products, some of which are permanent.
PRIOR TO SURGERY
Please make sure that you get copies of all preoperative tests done by your family physician and bring them with you to your preoperative appointment at the hospital. The hospital will call your home the night before surgery regarding what time you are to arrive on the day of surgery. Our office does not determine this time and cannot provide this information.
Warning: Do not take aspirin or any other blood thinning over-the-counter medications two (2) weeks prior to surgery.
This includes medications such as Motrin, Advil, Ibuprofen, and Aleve. If necessary, you can take Tylenol for headaches or pain. In addition, stop all herbal medications or supplements, such as vitamins E and C, as they sometimes may cause problems with bleeding during and after surgery. Other medications such as antibiotics, high blood pressure medication, and heart medication should be continued unless otherwise specified.
All blood thinners, e.g., Coumadin (Warfarin), Pradaxa, Plavix, Eliquis, Xarelto, Savaysa, Heparin, will need to be stopped for surgery; however, each situation is unique; so, you, the patient, will need to check with doctor who is prescribing your blood thinner to determine when and if it can be stopped before surgery. To be clear, surgery is elective and will not occur if patients are not medically stable enough to stop their blood thinner prior to surgery.
If you are on Coumadin (Warfarin), Pradaxa, or Plavix, these medications are usually stopped 5 days before surgery.
Cigarette smoking is one of the greatest causes of preventable mortality in the United States, and patients who currently smoke or have smoked in the past are at higher risk for complications both during and after surgery.
Tobacco smoke has a damaging effect on the heart, lungs and immune system which means that smokers and previous smokers are more likely to suffer from problems with the heart or lungs, and/or with wounds not healing properly after surgery. If you need assistance with quitting, please ask us so that we can help.
Even just one cigarette can reduce the blood flow to a wound which can affect the way it heals. Therefore it is strongly recommended that all patients stop smoking as early as possible prior to surgery.
You are scheduled to undergo an operation that includes the risk of possible bowel injury. To keep the bowel clean at the time of surgery and reduce the risk of contamination you will need to complete a “bowel prep” the day before surgery. You will need to purchase 1 bottle (10 oz) of Magnesium Citrate. This is a non-prescription item sold over the counter in the laxative section of your pharmacy.
This bowel prep must be started no later than noon the day before your surgery. Failure to do so may result in complications with your surgery.
INSTRUCTIONS FOR MAGESIUM CITRATE:
NOON: Pour the entire 10 ounce bottle of Magnesium Citrate into a glass of ice and drink the entire glass over several minutes. Follow this with at least three more 8 ounce glasses of plain tap water or any clear liquids over the next hour. It is best to drink each glass quickly rather than slowly sipping it. Do not be concerned if nothing happens in the first 2 hours.
STARTING THE MORNING THE DAY BEFORE YOUR SURGERY you are to follow a strict clear liquid diet – no solid foods. Clear liquids include fruit juices that don’t have any pulp (apple, grape, cranberry, etc.), broth soups (nothing with pieces of vegetables, meat, potatoes, pasta, etc.), Jell-O, and sherbets. Hard candies like LifeSavers and Popsicles without fruit are also okay.
Surgeries are usually performed on a “23-hour” basis in which you will stay overnight and go home the following morning after breakfast. The majority of surgeries are done through the vagina or through very small “band-aid” incisions on the abdomen. You will have absorbable suture in the vagina that will dissolve in several weeks and some deeper permanent sutures which help maintain your repair in the long term.
RISKS AND COMPLICATIONS
Although complications are infrequent, they do occur. They may include infection, bleeding, scarring, bleeding requiring transfusion, damage to nearby structures including bowel, bladder and ureter (tube that carries urine from the kidney to the bladder), inability to urinate (retention of urine), new onset or persistence/worsening of urinary incontinence, new onset or persistence/worsening of urinary urgency, new onset or persistence/worsening of pelvic organ prolapse, need for additional surgery, narrowing of the vagina, pelvic pain, and pain with sexual relations. We do not require blood donation before surgery.
MESHES AND GRAFTS
In the majority of prolapse and incontinence cases a graft or mesh is used to provide reinforcement and long-term surgical success. The use of surgical mesh to strengthen tissue is not new and mesh has been extensively used in the body, especially in hernia repairs. Grafts/Meshes can be synthetic (man-made : polyester, plastic) or biologic (animal based : human skin, cow skin, pig skin, pig intestine). While there are many types of meshes available, the synthetic mesh mainly used in vaginal prolapse and urinary incontinence surgery is a loose weave, plastic mesh. This mesh is strong, yet extremely thin; as well the mesh is soft and flexible to allow for the body’s normal movements and positions.
With any graft or mesh there is the possibility of rejection or exposure of the graft/mesh, such that the vaginal incisions partially separate. The more common exposures may be able to be treated with observation, vaginal estrogen, or a minor procedure in the office. Occasionally, patients may have another surgery to remove the graft/mesh partially or in its entirety. In rarer instances, the graft/mesh may invade into the surrounding organs such as the bladder, bowel, or rectum, which would require more extensive surgery.
Most patient undergoing major pelvic reconstructive surgery will have a tampon-like gauze pack placed in the vagina while asleep and this pack will remain in place for two to three days after surgery. The purpose of this pack is to decrease bleeding after surgery and to help facilitate success of your surgery. Premature removal of this pack may directly compromise the immediate and long-term success of your repair and is strongly discouraged. When you are to remove this pack will be noted on your hospital discharge instructions.
You will also have a Foley catheter allowing urine to drain from the bladder into a bag. The catheter has a balloon on it to prevent if from falling out. As there is often swelling, pelvic floor spasm, and discomfort after surgery, some patients may be unable to effectively empty their bladder in the days to weeks after surgery; as such, the majority of patients will go home with the catheter and follow-up in the office 3-7 days later for a “voiding trial”.
When the Foley catheter is removed in the office, you will be given the opportunity to empty your bladder on your own (voiding trial). If you are unable to effectively empty your bladder, there are a couple of options: #1 Replace the Foley and leave it in for another week; #2 Perform clean, intermittent self-catheterization as detailed on the video you watched at your preoperative appointment. The inability to empty your bladder effectively is not a reason to remain in the hospital.
After the swelling subsides, normal urination gradually returns. It is very important not to strain to urinate, but instead relax. It may take anywhere from a few days to a few weeks before normal urination resumes and the duration of this period is no cause for alarm.
If you go home with a Foley catheter:
You may cleanse the catheter area daily with mild soap just where the catheter enters the urethral meatus (where the catheter enters your body). In most cases, the catheter will be connected to a drainage bag that allows urine to empty from your bladder continuously. The drainage bag should be emptied every few hours as it fills up. Always keep the bag lower than the bladder area, so that it drains properly with gravity. In other cases, the catheter is not connected to a drainage bag, but instead has a plug in it. By removing the plug, urine will be allowed to empty from the bladder. How often the bladder needs to be emptied will depend on your fluid intake, but in general, it will be around every 4-6 hours.
If you go home performing clean, intermittent
How often you will need to catheterize yourself will depend on your fluid intake, but in general, it will be around every 4-6 hours. You always want to try to urinate normally before each catheterization, and it is very important that you do not strain to try to urinate, but instead relax. Once your postvoid residual (PVR) is consistently less than 100 ml you may stop catheterizing. For detailed instructions on intermittent self-catheterization, please refer to the pamphlet provided in your pre-op packet.
Guidelines After Foley Catheter Has Been Removed:
Once your Foley catheter is out you should be able to urinate on your own. You may notice that your urine stream is different that it was before surgery, but you still should be able to empty your bladder effectively with each void. Over the next few days, it is very important that you closely monitor your urination to make sure you are emptying your bladder effectively. Your urination should be a stream rather than just drips, and typically you should void about every 3-4 hours. It is very important not to strain to urinate, but instead relax.
MAKE SURE YOU URINATE WITHIN 4 HOURS AFTER HAVING FOLEY CATHETER REMOVED.
If at any time you have any concerns that are not emptying your bladder effectively, please call our office immediately and/or return for evaluation.
When you go home you will be walking around, probably without assistance. For the first week or so after surgery, it is usually a good idea to stay around the house, but you are NOT on strict bed rest. It is important that you be fairly active in order to avoid infections, blood clots, and slow intestinal recovery. After the first week, depending how you feel, you may walk outside, go to Services, go shopping, etc.
You may begin showering once the vaginal pack is out; typically this is 2-3 days after surgery. Please make sure someone is there to assist you getting in and out of the shower. Some patients find that placing a chair in the shower is helpful. You may resume tub baths 10-14 days after your surgery, if you desire.
Please eat and drink what you like. It is not uncommon to have a poor appetite after surgery. It is not a cause for alarm as long as you keep up some food intake. It is important to have a healthy fluid intake, 6-8 glasses per day. Although all liquids are OK, water is the best as some patients find juices and caffeinated fluids irritating to the bladder. There is no advantage in drinking excessive amounts of fluid as it will cause urinary frequency.
Post-operative pain varies widely from person to person. In any case, we expect you to have good pain control. At discharge from the hospital you will be given a prescription for a mild narcotic. It is also OK to use anti-inflammatory medications like Motrin, Naprosyn, Ibuprofen, Aleve, etc., along with your mild narcotic.
Most patients undergoing pelvic reconstructive surgery will benefit from stool softeners in the immediate post-operative period. The change in activity and diet following surgery can lead to constipation. Pain medication can be another problem in this area. If you do not have a normal bowel movement within the first few days of surgery, please take a gentle laxative such as Milk of Magnesia or Pericolace. Anything that you have used in the past with success is OK.
It is extremely important to avoid straining with bowel movements and to try to keep stools soft and formed. If you experience loose, diarrhea–like stools while on stool softeners and/or laxatives you may need to decrease the dose. Please call our office with any questions or concerns.
It is common to have some vaginal bleeding for 2-3 weeks after surgery. Over time, this bleeding should decrease and usually after the first week or so, it is only spotting on a pad. You may notice some increased bleeding or spotting as your activity increases, but usually this subsides with rest. If the bleeding persists despite decreasing your activity, call our office.
There are stitches inside the vagina from the surgery. Some of these will dissolve, but it may take several weeks. During this time, your usual vaginal secretions can collect on the stitches. This can cause bacteria to grow leading to discharge, odor, and itching. The best prevention is to soak in a tub a few times per week starting about two weeks after your surgery to help keep this area clean. Avoid using strong soaps or perfumes which may contain chemicals that will irritate the tissues. You may notice some sutures passing vaginally; as these are absorbable the passage of them is normal.
It is important to be active, walk, and breathe deeply to prevent blood clots and pneumonia. It is OK to go up and down stairs carefully. Remember that your body is using much of its energy in the healing process, so it is normal to feel tired. Plan to take naps and get extra sleep. You will not be able to do all of your usual tasks, so it is wise to plan for assistance from friends and family, particularly in the first week after surgery.
During the early postoperative period it is strongly recommended that you refrain from heavy lifting (no lifting more than ten pounds, and in general, anything which requires two hands to lift is too heavy), exercising (no treadmill, golf, aerobics, etc.), and vaginal intercourse. There is no exact time frame for resuming full activity. For simple incontinence surgery, it is probably OK to resume activities after about 2 weeks. For more complex reconstructive surgery, it is best to wait for at least 6 weeks. Complete wound healing does not occur for up to 12 months after surgery, so make sure you are careful about lifting and doing strenuous activities the first several months after your surgery.
It is fine to ride in a car, but you should not drive until you have adequately recovered. Your reflexes may be slowed by post-operative pain or pain medication. Therefore you must abstain from driving or operating machinery while you are on pain medications and for at least the first 2 weeks after surgery. A good rule of thumb is that if you have not needed any pain medication for 3-5 days then you are probably safe to drive. When resuming driving, make sure another driver is with you in case you get into a situation in which you need help.
Returning to Work
In general, pelvic organ prolapse surgery and incontinence surgery are major surgeries, and as such, they require adequate time for proper healing and long-term success. Returning to work will depend on what type of surgery you have and how quickly you recover. Most patients may return to work 1-2 weeks after incontinence surgery and 4-6 weeks after prolapse surgery. Some patients, however, feel that they do not need this 4-6 week convalescence.
Resuming normal activity prematurely and/or returning to work too soon can directly affect the success of your repair and is strongly discouraged.
Refrain from sexual activity for 6 weeks after surgery. In addition you should not put anything in the vagina including tampons and douches for 6 weeks after surgery. When resuming intercourse, most patients experience some soreness and discomfort initially, but, in the majority of cases, this will improve with time. To help alleviate some of this discomfort, it is a good idea to use water-soluble lubricants such as Astroglide or KY, both of which are available over the counter without a prescription.
Some patients will be prescribed vaginal estrogen prior to surgery. Vaginal estrogen supports vaginal health by keeping the tissues supple, well vascularized, decrease urinary tract infections, improve urinary urgency/frequency, avoid vaginal narrowing/shortening and promote healing postoperatively. Thus, for most patients who have been prescribed vaginal estrogen before surgery, it is recommended that they continue vaginal estrogen indefinitely, i.e., forever.
If you were on vaginal estrogen prior to surgery, please resume 2-3 weeks after surgery.
WHEN TO CALL:
• Bright red vaginal bleeding larger in quantity than a period.
• Temperature greater than or equal to 101.
• Persistent nausea/vomiting.
• Worsening pain not relieved by prescription pain medication.
• Redness in incision areas or severe tenderness or drainage from incisions.
• Constipation that does not respond to the above described over-the-counter remedies.
• Urinary retention (unable to urinate).
• Any questions or concerns that you may have regarding your surgery or recovery.
Prior to your surgery please make sure that all your questions and concerns have been addressed to your satisfaction. It is our privilege to have you as a patient, and we hope that your surgical experience will be as pleasant as possible.