Suburethral Sling

What Dads and Husbands Need to Know About "Suburethral Sling" Surgery.

What is a "Suburethral sling"?

A "Suburethral Sling" is a type of pelvic support that is constructed (surgically) from muscle, ligament, or synthetic material that elevates the bladder from underneath in the treatment of stress incontinence.

What happens during "Suburethral Sling" surgery?

In Suburethral Sling surgery, the surgeon inserts a supportive strap of material (called the suburethral sling) which elevates the woman's urethra and bladder neck, and then "anchors" it to each side of her pubic bone. 

Suburethral Slings are medical devices made from synthetic material, or they can be fashioned from donor tissue or the patient's own tissue, which is cut from her abdominal wall. Although it is a more invasive procedure, some patients prefer using their own tissue, because synthetic material may erode into the urinary tract and cause infection or reduce effectiveness.

Newer techniques for Suburethral Sling insertion are minimally invasive, allowing for smaller incisions and shorter hospital stays. These techniques are "variations on the suburethral sling and they conceptually work the same way to provide a little hammock for support to the urethra.

What is a "Tension Free Vaginal Sling"?

Tension Free Vaginal Sling is a minimally-invasive surgery that provides support for women with a sagging urethra.  This will help prevent or eliminate the accidental release of urine when women cough, laugh or move vigorously or suddenly.

The Tension Free Vaginal Sling procedure uses a mesh or tape that is placed under a woman's urethra like a sling or hammock to keep the urethra in its normal position. The Tension Free Vaginal Sling is inserted through small incisions in a woman's lower abdomen and vaginal wall. Sutures are not required to hold the Tension Free Vaginal Sling in place. Tension Free Vaginal Sling surgery takes about 30 minutes and may be done under local anesthesia so you can cough when asked by the doctor during the procedure to make sure  the Tension Free Vaginal Sling is providing the necessary support of your urethra.

What is a "Suburethral sling"?

A "Suburethral Sling" is a type of pelvic support that is constructed (surgically) from muscle, ligament, or synthetic material that elevates the bladder from underneath in the treatment of stress incontinence.

What happens during "Suburethral Sling" surgery?

In Suburethral Sling surgery, the surgeon inserts a supportive strap of material (called the suburethral sling) which elevates the woman's urethra and bladder neck, and then "anchors" it to each side of her pubic bone. 

Suburethral Slings are medical devices made from synthetic material, or they can be fashioned from donor tissue or the patient's own tissue, which is cut from her abdominal wall. Although it is a more invasive procedure, some patients prefer using their own tissue, because synthetic material may erode into the urinary tract and cause infection or reduce effectiveness.

Newer techniques for Suburethral Sling insertion are minimally invasive, allowing for smaller incisions and shorter hospital stays. These techniques are "variations on the suburethral sling and they conceptually work the same way to provide a little hammock for support to the urethra.

What is a "Midurethral Sling"?

The "Midurethral Sling" is a minimally-invasive surgical procedure that is performed to treat women with "Female Stress Urinary Incontinence."

What is a "Transobturator Sling"?

The Transobturator Sling is another minimally-invasive surgical procedure that is performed to help women with Female Stress Urinary Incontinence. The 
Transobturator Sling surgery is performed by the doctor placing a narrow strip of tape or mesh in a position that provides support for the woman's urethra. The Transobturator Sling procedure eliminates some of the potential complications that come about from other Sling type surgical procedures that blindly passes a large needle carrier through the retropubic space.

What is "Intrinsic Sphincter Deficiency"?

Primarily affecting women, "Intrinsic Sphincter Deficiency" is defined as a weakening of the urethra sphincter muscles. 

As a result of the weakening of the urethra sphincter muscles, the urethra does not function normally regardless of the position of the bladder neck or urethra. This condition is a common cause of Female Stress Urinary Incontinence.

What is "Urethral Hypermobility"?

Primarily affecting women, "Urethral Hypermobility" is defined as a failure of the urethra to close.

What is "Urethropexy"?

Urethropexy is a surgical procedure where the support of a woman's urethra is re-supported through sutures that surround the urethra's pelvic floor  and vaginal tissues to her pubic bone.

What Is Sacrocolpopexy?

Sacrocolpopexy is an operation performed from the abdomen to support the vagina to the ligament on the spine (after previous or present surgery to remove the uterus) by using a synthetic mesh.

Why Is Sacrocolpopexy Performed? 

Sacrocolpopexy is performed to treat severe protrusion or bulge(s) of the vagina after removal of the uterus.

A woman's vagina that has one or more of these vaginal protrusion(s) may experience one or more of the following:

• The vaginal lump/bulge or protrusion feels uncomfortable or causes pain.  
• Difficulty with urination (e.g. unable to completely empty the bladder) 
• Bowel difficulties (e.g. constipation, incomplete emptying of bowels) 
• Pain 
• Infection 
• Bleeding 

The objective of the Sacrocolpopexy operation is to relieve the woman's symptoms and to restore her vagina and her vaginal anatomy (as much as possible) and recover her sexual function.

Are there any risks associated with Sacrocolpopexy surgery? 

Sacrocolpopexy surgery is a very common and relatively safe operation with excellent prognosis and outcomes.  However, like any surgical procedure, there are complications which may occur. Possible complications from Sacrocolpopexy surgery may include:

• Bleeding 
• Infection 
• Injury to surrounding tissues (e.g. nerve or blood vessels, ureter, intestines) 
• Formation of blood clot(s) in the legs or lungs 
• Recurrence of problem
• Slow return of bowel or bladder function 
• Erosion of synthetic material through vaginal mucosa 

What Happens Before Sacrocolpopexy Surgery? 

1. Blood tests, electrocardiography (ECG) and chest X-ray may be done to ensure that you are in optimal health for Sacrocolpopexy surgery. 

2. Your doctor may prescribe oral or vaginal estrogen (hormone) if you are already menopausal. It is important to comply with this medication as it ensures that your vaginal tissues are optimal for surgery and healing. 

3. You will be admitted to the hospital one day before Sacrocolpopexy surgery. 

4. You will be given preparations to clear your bowels.

5.  Your pubic area will be shaved. 

6. You will not be allowed to eat or drink after midnight on the day before the surgery. 

7. All your medical and surgical conditions, if any, must be made known to the doctor and must be optimally controlled. 

8. If you are on aspirin, please keep your doctor informed. You must stop taking aspirin at least one week before Sacrocolpopexy surgery. 

What happens during the Sacrocolpopexy surgery? 

The surgery is done under general or regional anesthesia. The anesthesiologist will discuss with you the advantages and disadvantages of both methods.

An abdominal incision is made. The synthetic mesh is stitched to the posterior surface of the vagina and to the ligaments in front of the spine.

A tube / drain may be inserted into the abdomen to monitor the bleeding.

Another tube will be inserted into the urethra as there may be difficulty in urination after the Sacrocolpopexy procedure.

Painkillers, laxatives and antibiotics would generally be prescribed after the procedure.

What happens after Sacrocolpopexy surgery? 

1. Immediately after the operation, you may experience one or more of the following:

• Tiredness - You should rest and gradually increase your mobilization until you feel fit to return to your normal activities. 

• Discomfort - In the lower part of the abdomen, over the incision. This is to be expected and painkillers should help to relieve the discomfort. 

• Vaginal bleeding - Mild to moderate amount of reddish watery discharge after surgery is quite normal. You will need to wear a menstrual pad during the recovery period, but you will not be permitted to use tampons for obvious reasons.

2. One day after surgery, you will usually be allowed to drink and eat. You will be encouraged to move around. Blood chemistries and normal follow-up visits will be performed. 

3. The catheter that was placed in your urethra is usually removed the day after surgery. The drain is usually removed two days after the operation.

4. You may be discharged on the third or fourth day after surgery if the doctor is pleased with your progress and the outcome of the Sacrocolpopexy procedure. 

5. You should refrain from:

• Strenuous exercise for 2 months. You may return to normal activity after that, or upon clearance by your doctor. 

• Using tampons, douching, sexual intercourse and driving for 4 weeks. 

• Carrying heavy weights (> 10 pounds) for 6-8 weeks after Sacrocolpopexy surgery.

6. You should (immediately) return to the hospital or notify your doctor if you notic any of the following:

• Heavy vaginal bleeding 
• Foul smelling vaginal discharge 
• Severe abdominal distension and / or pain not relieved by painkillers 
• High fever 
• Pain associated with passing urine 
• Difficulty in passing urine 
• Constipation 

Follow-up doctor visits after Sacrocolpopexy surgery 

You will be examined by your doctor (at your doctor's office) at approximately; 2 weeks, 4 weeks, six months and and one year after Sacrocolpopexy surgery. 

It is important to keep your follow-up appointments to ensure the best possible results.

What is "Colposuspension" surgery?

Age and vaginal childbirth takes it toll on women's pelvic organs.  

"Female Urinary Incontinence" is one of the problems most (over 50%) women who have delivered babies vaginally have to contend with.  Women with Female Urinary Incontinence "leak" urine when they strain,  cough, laugh or run. This condition is also called "stress urinary incontinence" meaning the stress of physical activity, not emotional stress is causing her to "leak" urine.  

The problems associated with female urinary incontinence are corrected in the the "floor" of the woman's pelvis by several methods or types of surgeries - one of which is called Colposuspension. 

A woman's pelvic floor is a sheet of special muscles and ligaments that stretch across the inside of the female pelvis. Women can feel it "tighten" when they try to hold back the flow of urine - or when they strain,  cough, laugh or run. The uterus and bladder are located above the pelvic floor. The vagina and the opening of the bladder (the urethra) pass through the pelvic floor. If the pelvic floor weakens, the uterus and bladder "drop" down. The control of the urine is thereby weakened. 

Colposuspension surgery strengthens the pelvic floor to lift, or "suspend" the uterus and bladder back up to their correct position within the woman's pelvis

Colposuspension comes from the Greek word for vagina - "colpos."

What is "Urethropexy"?

Urethropexy is a surgical procedure where the support of a woman's urethra is re-supported through sutures that surround the urethra's pelvic floor  and vaginal tissues to her pubic bone.

What is "vulvar health"?

Vulvar health is a term that covers the many health issues of a woman's - or young girl's vulva.  This includes vulva care, gynecology, feminine hygiene, vaginal health, vaginal hygiene, menstruation, and the changes in women's vulvas from menarche to menopause. 

Husbands and fathers - as well as women and mothers need to learn more about vulva health, to provide the care and support the special women in their lives may need. Husbands and fathers have a unique role in providing the healthcare and knowledge, especially those single dad's that have young daughters.  

Vulvar health is an area that is related to the health and care of the vulva. Many men and women are afraid to use the term "vulva" due to its' technical, and medical sound, and most simply prefer to call the vulva a "vagina."  Yet that would be incorrect.  The vagina is just one part of the vulva. Nobody, with the exception of a doctor, can see a woman's vagina, and only he/she can see a woman's vagina by looking into the vagina, using a special instrument called a speculum.  

It's time to begin calling a "spade a spade."  When mother's and fathers are bathing, or toilet training their daughters, they should explain that the vulva, which is on the outside, has several parts, and that her vagina, is on the inside.   

What is/are Vulvar Diseases?

Vulvodynia-chronic vulva discomfort, vulvar vestibulitis, dysesthetic vulvodynia

Vulvar dystrophy-broad term to describe various epithelial changes.  In 1987-ISSVD International Society Studies of Vulvar disease found the following symptoms; a. nonneoplastic.  b.intraepithelial neoplasms - spuamous cell CIS c. nonsquamous intraepithelial neoplasia

LESIONS AND DISEASES

HSV

Women with HSV reports flu like symptoms, pain, itching, UTI symptoms, vaginal discharge, sores on labia, anus, perineum, buttocks, thighs, dyspareunia Vesicles, ulcers, pustules, tender adenopathy, 70% will have lesion in vagina

Syphilis

Women with syphilis report painless sores in vulvovaginal area.  Primary - red, round, firm ulcer with granular base with well-formed edges. Secondary- moist, mucus lesions which resemble herpes. Moist cutaneous lesions called condyloma lata, appear flat and gray. Adenopathy, maculopapular rash.

Condyloma Acuminata

Women with CA report new bump: itching, generalized pruritus, last pap.  Warty, flesh colored, sharp and pointed, cauliflower, + acetowhite

Candidiasis

Women with candidiasis report burning, itching, discharge, dyspareunia, vulvar edema, h/o diabetes, high carbohydrate diet, use of AB, frequent intercourse, h/o steroids, HIV.

Bartholin's Gland Infection

Women with barthloin's gland infections eportr unilateral bump. Reports active sex, recent trauma, new sexual partner leading to infections, fever, complaints of pain with intercourse, warmth, tender to touch, difficulty walking, sitting. H/O Crohn’s disease.

Contact Dermatitis

Women with contact dermatitis report vulvovaginal itching, rash, and increased incidence when wearing tight pants.  The vulva skin is red, inflamed, edematous, vesicles or bullae if severe, weeping, crusting and lichenification. 

Lichen Sclerosus

Women with LS report vulvovaginal itching, familial linkage, edema, superficial ulcers, burning, area feels different.  Women with LS in all ages, show symptoms in clitoris, prepuce, labial majora, minora, edema, scarring, color, appearance of tissue paper of skin.

Lichen Planus - Women with lichen planus report vulvar itching, burning, with vulvovaginitis symptoms on mucosal surface of vulva. Dyspareunia, painful erosive areas. Bleeding on contact, stenosis of introitus. The vulva has white raised lesion with reticular, lacy pattern. Erosive reddened area bordered by reticular white epithelium. External labia has appearance of lichen sclerosus + acetowhite. Other signs may appear in her mouth.

Vulvar Neoplasm-Melanoma - affects mostly postmenopausal women that affects the clitoris and labia majora. Usually no symptoms.

Vulvar Intraepithelial Neoplasm -  Pruritus, vulvar burning, pain, discharge, bleeding, may report urethra, vaginal and anal symptoms.  White, dk, red, ulcerated, raised warty, or nodular lesions. Labia mayora most common site, minora, clitoris and perineum. 

Vulvodynia (Vulvar Pain Syndrome) - Various levels of burning, stinging, pain, dryness, irritation, rawness. No pruritus. May report long term hx.

Vulvar Vestibulitis is a burning, dysuria, frequency, with repeated yeast infections or HPV.  Significant/severe pain with touch or attempting intercourse.

Paget's Disease

Vulvar Pruritis, usually affecting older women. The vulva appears red/tan with scaly lesions.

What is Vulvar Cancer?

Vulvar cancer is cancer that is found in and on the vulva. 

What is Vulvar Vestibulitis?

Vulvar Vestibulitis is a condition which causes redness and pain of the vestibule. Vulvar Vestibulitis is an inflammation of this skin and the mucous secreting glands found in the skin. The mucous secreting glands are called the lesser vestibular glands.  

Vulvar Vestibulitis may include all the area around the opening of the vagina but is normally seen in the lower part of the vaginal opening.

Vulvar Vestibulitis occurs in women of all ages. It can occur in women who are sexually active and also in women who have never been sexually active.  

Many women with this problem have suffered physically and emotionally for months or years, have seen a number of physicians, and have tried many unsuccessful treatments in search of relief.  

What are the signs and symptoms of Vulvar Vestibulitis?

*  Severe pain with pressure (for example: biking, exercise, tight fitting clothes ).

*  Vaginal entry such as tampon use or intercourse. 

*  Burning, stinging, irritation, or raw sensation within the vestibular area.

* Vestibular redness 

*  The urge to urinate frequently or suddenly.   

How is Vulvar Vestibulitis diagnosed (identified)?

Your doctor or health care provider will examine the vulva and vestibule to identify the common skin changes seen with vulvar vestibulitis. Pain is usually felt if the vestibule area is touched with a cotton tipped applicator. A sample of your vaginal discharge is collected and tested to rule out infection.

What causes Vulvar Vestibulitis? 

The exact cause is unknown, but many studies are being conducted to determine the cause of vulvar vestibulitis.  

The following factors have been associated with vulvar vestibulitis:

*  HPV (Human Papilloma Virus)
*  Chronic Yeast Infections
*  Chronic bacterial infections 
*  Chronic changes of pH (acid-base balance in the vagina)
*  Chronic use of chemicals/irritants such as detergents, soaps, spermicides or lubricants.

What is the treatment for Vulvar Vestibulitis?  

Treatment may include any of the following:  

*  Follow the Guidelines for Vulvar Skin Care
*  Steroid Ointments 

How it is used: A thin layer is applied to the vulvovaginal areas. 

How it Works: Decreases redness, irritation, and burning. Caution: Use only as prescribed by your doctor. Overuse may result in thinning of the skin which will make your problem worse rather than helping it.

*  Trichloroacetic Acid (TCA) may be used in some cases as determined by the severity of the symptoms you have. TCA is a chemical that is used to destroy small areas of the irritated skin allowing new healthy skin to grow in its place. 

*  Interferon Injections are used to increase your body's response to infection. 

Helpful treatment hints for Vulvar Vestibulitis:

*  Vitamin A and D Ointment  How it is used: Apply to the areas of discomfort.
How it Works: Protects the skin, decreases irritation, heals, and soothes.

*  Lidocaine Gel may be prescribed after initial treatment. 
How it is used: Apply lidocaine gel to the vulvovaginal areas of discomfort. 
How it Works: Numbs areas before intercourse.
Caution: After applying, wait until area becomes less sensitive before intercourse. Burning may occur for a short time ( 5 to 10 mins.) after the gel is applied.

*  Witch Hazel Pads (TUCS Pads) How it is used: Apply to the vulvovaginal areas of discomfort. 
How it Works: Decreases burning and irritation after intercourse and urinating.

*  Cleansing Bottle - Pour plain luke-warm water over the vulva after urinating to remove urine from irritated area.  

*  Calcium Citrate Tablets- How it is used: Take orally 1200-1800mg. elemental calcium every day. How it Works: Thought to decrease certain crystals in the urine which may cause burning. 

*  Cranberry Juice  How it is used: Drink an 8oz. glass every day. 
How it Works: Increases the acid content of the urine to decrease bladder irritation. 

*  Limit High Oxalate Foods - May decrease amount of oxalate crystals in urine. Oxalate crystals cause urinary symptoms such as the urge to urinate frequently or suddenly. 

*  Baking Soda Soak- Soak in luke warm bath water with 4 to 5 tablespoons of baking soda to help soothe vulvar itching and burning. Soak 1 to 3 times a day for 10 to 15 minutes. If you are using a sitz bath, use 1 to 2 teaspoons of baking soda.

What is a Vaginal Vault Prolapse?

The vaginal vault is the area at the top of the vagina, next to and adjacent to the cervix. It can only “fall” or descend downwards toward the introitus, or the entrance of the vagina, after a woman's womb has been removed (hysterectomy). Vaginal Vault Prolapse occurs in about 15% of women who have had a hysterectomy for uterine prolapse, and in about 1% of women who have had a hysterectomy for other reasons.

What is Pelvic Organ Prolapse?

Pelvic Organ Prolapse is a very common condition, particularly among older women. It's estimated that half of women who have children will experience some form of Pelvic Organ Prolapse in later life. Many women, particularly because they may no longer be sexually active, and fail to continue receiving their annual pelvic exams, don't seek help from their doctor. Therefore, the actual number of women affected by Pelvic Organ Prolapse is unknown. 

Pelvic Organ Prolapse may also be called; genital prolapse, pelvic relaxation, pelvic prolapse, uterine prolapse, uterovaginal prolapse, pelvic floor disorder, urogenital prolapse or vaginal wall prolapse.

What is Pelvic Prolapse?

Pelvic Prolapse is another term used for "pelvic organ prolapse."  Pelvic prolapse is a very common condition, particularly among older women. It's estimated that half of women who have children will experience some form of Pelvic Organ Prolapse in later life. Many women, particularly because they may no longer be sexually active, and fail to continue receiving their annual pelvic exams, don't seek help from their doctor. Therefore, the actual number of women affected by Pelvic Organ Prolapse is unknown. 

Pelvic Prolapse may also be called; genital prolapse, pelvic relaxation, uterine prolapse, uterovaginal prolapse, pelvic floor disorder, urogenital prolapse or vaginal wall prolapse.

What is a Prolapsed Uterus?

A Prolapsed Uterus refers to a collapsed uterus, or descended uterus, or other change in the position of the uterus in relation to the surrounding structures within the pelvis. The pelvis contains many soft tissue structures vital to normal body functions, supported primarily by the diaphragms, layers of muscles, fibrous coverings called fasciae, and various ligaments and tendons. These soft tissues of the pelvis derive their ultimate support from the bony pelvis. 

A Prolapsed Uterus may be one of three types, depending on the severity:

• First-degree prolapse occurs when the uterus sags downward into the upper
vagina.

• Second-degree prolapse occurs when the cervix is at or near the outside of the
vagina.

• Third-degree prolapse (sometimes referred to as total prolapse) occurs when the entire uterus extends outside the vagina.

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