Pelvic Surgery Failure Increases with Time

Surgery to repair pelvic organ prolapse fails over time for many women, a new study concludes. Pelvic organ prolapse occurs when the tissues that support the uterus, bladder and cervix are damaged or relax over time. The organs may push down into the top of the vagina. This can cause pain, bleeding and urinary problems. The study included 215 women. All had an operation called sacrocolpopexy to support the organs with a synthetic material called surgical mesh. Half also had another procedure to stop problems with urine leakage. The rate of failure increased each year in both groups. For example, symptoms returned within 2 years for 14% of the women who had both procedures. The return of symptoms occurred in 21% after 4 years and 29% after 7 years. Treatment failures were slightly lower for those who had the single procedure. The Journal of the American Medical Association published the study. HealthDay News wrote about it May 14.

By Robert H. Shmerling, M.D.
Harvard Medical School

What Is the Doctor's Reaction?

It's a common problem that few women want to talk about: pelvic organ prolapse.

It develops when the tissues in the pelvis loosen. This may allow the cervix, uterus and bladder to enter the vaginal canal near the entrance to the vagina. This problem also goes by other names. They include pelvic relaxation, cervical prolapse and uterine prolapse.

Pelvic organ prolapse is more common as women get older. The risk of prolapse is also greater for women who are obese or have had several vaginal births.

Symptoms include:

• Discomfort in the pelvis, lower abdomen or back
• A bulging of pink tissue into the vagina
• Bleeding from the vagina
• Urinary problems, such as:
  • Frequent urination
  • Urinary tract infections
  • Leakage of urine during heavy lifting, coughing or sneezing (called stress urinary incontinence)
• Pain or urine leakage during sex

Surgery is often needed to treat this condition. During the operation, surgeons often insert a firm, synthetic material called "surgical mesh." The purpose is to hold the vagina and pelvic organs in place. (You may have heard about problems with surgical mesh from advertisements by malpractice attorneys. Problems linked to some types of surgical mesh have led to recalls and lawsuits.)

Surgeons sometimes perform another procedure at the same time. It's called urethropexy. The purpose is to help prevent stress urinary incontinence.

More than 225,000 operations for pelvic organ prolapse are done each year in the United States. Still, much about these procedures is uncertain. For example:

• How effective is the standard operation (called abdominal sacrocolpopexy)?
• How long do the benefits of surgery last?
• How effective is urethropexy in preventing urinary incontinence?

A new study attempts to answer these questions.

Study results appear this week in the Journal of the American Medical Association. Researchers analyzed the long-term results of surgery for women with pelvic organ prolapse. They found that after 7 years:

• Pelvic organ prolapse had returned in up to 27%.
• Up to 29% of the women had a return of the symptoms that led to their surgery.
• Most of the women had stress urinary leakage. This included 62% of the women who had urethropexy to prevent the problem and 77% of those who did not have this surgery.
• For about 10% of the women, the mesh used in the surgery fell to pieces over time.

These findings are disappointing. The failure rate is unacceptably high. It also appears to increase over time. The results suggest it's better to have urethropexy as part of the operation for pelvic organ prolapse. But even those who added this procedure had a high rate of urinary leakage after seven years.

What Changes Can I Make Now?

You may be able to reduce the chances you'll have symptoms of pelvic organ prolapse. Here's what you can do:

• Avoid heavy lifting.
• Maintain a healthy weight.
• Don't smoke. The chronic cough of many smokers is thought to contribute to some cases of pelvic organ prolapse.

These measures may be particularly important if you are obese or have had several vaginal births. If so, your risk of pelvic organ prolapse is higher than average.

If you already have pelvic organ prolapse, know your treatment options. Keep in mind that if you have no symptoms, you may not need treatment. Other options include:

• Exercises to strengthen muscles of the pelvis -- These are often called Kegel exercises.
• Insertion of a pessary into the vagina -- This ring-shaped device provides support to the cervix and uterus and helps keep them in place.
• Surgery -- This includes the type of operation described in this latest research. However, other procedures also are done. They include hysterectomy (removal of the uterus). The choice depends on your goals and preferences. Things to consider include your symptoms, your age and whether you want to have children in the future.

Talk with your surgeon if you've had surgery for pelvic organ prolapse and have concerns about the success of your surgery or about a surgical mesh recall.

What Can I Expect Looking to the Future?

I hope that in the future we will have more effective procedures to offer women with pelvic organ prolapse. This might include a new type of surgical mesh, or it may be a completely different type of operation. Effective ways to prevent the problem would be even better.

Regardless of how the treatment of pelvic organ prolapse changes in the future, we'll need to study it. This research shows how important it is to conduct long-term research on standard treatments, especially for conditions that are as common and important as pelvic organ prolapse.