Vaginal info

Vaginal surgery information

Preoperative and Postoperative Instructions for Vaginal Surgery

Introduction

These instructions are for patients undergoing any type of vaginal surgery. I would like you to read it prior to your surgery so that you will be informed about normal preoperative and postoperative processes. Refer to it regularly to answer most of your questions. It is my goal to do my very best surgery and aid you with recovery.

Following these instructions will help us get through your surgery with the best chance of success. A key concept is to think of this type of surgery as though I am putting things back into place. They have to heal in place. Healing without straining or stressing the surgery is essential. Your new vagina will be happier if she isn’t rushed!

Read this entire handout. Highlight areas of concern and where you want more information. Bring it to your pre-op appointment to be sure we thoroughly answer any questions that you may have.

Definitions

Anterior Repair The “anterior” side of the vagina is the bladder side. This is repaired when the bladder has fallen. This condition is referred to as a “cystocele”. Symptoms include a bulge at the vaginal opening or difficulties urinating. Often the urethra (the tube that urine comes out of) is kinked because the bladder has fallen. This kinking leads to difficulty emptying the bladder. We usually repair this bulge by using your own “good” tissue. We rarely use mesh, but if it is necessary, you will receive thorough consent for mesh to be part of your anterior repair. You will not see the stitches of the repair. This incision is 2-3 inches long and it is in your vagina. Multiple dissolving stitches are placed. As they dissolve during your recovery, you will have some discharge and occasionally may see a bit of the suture. This is normal.

Posterior Repair – The “posterior” side of the vagina is the rectal side. The posterior wall of the vagina separates the vaginal tube from the rectal tube. When there is a weakening in this area, we call it a “rectocele”. When it is present, there is often a bulge at the vaginal opening. Often this creates a larger “pocket” at the end of the rectum where stool can build up. Women can find it difficult to empty their bowels due to this condition and often find it necessary to use their fingers to push in their vagina to empty their rectum. This is called “splinting”. When the rectocele is repaired, we fix the defective wall in the vagina by re-attaching tissue that may have been disrupted during childbirth. You will not see all the stiches. Most of the suturing is inside the vagina, but you may have some between the vagina and the rectum. Again, all of these stitches are dissolvable.

Vaginal Suspension If your uterus is falling out of your vagina, it has likely dragged your vagina out with it. Simply taking the uterus out is not enough to fix this problem. The top of the vagina needs to be reinserted and tacked up so that it does not remain outside. We need to put your vagina back into your vagina. We try to find the most secure means of achieving the desired outcome. We may choose to tack it to a ligament on your pelvic bones (sacrospinous ligament) or use your uterosacral ligaments to obtain proper restoration of the vagina. You won’t see these sutures either, but you may feel them. Patients often report a dull buttock pain or the sensation like they have to move their bowels for about a month after surgery. This pain (in the buttocks area) can be lessened by the use of over-the-counter pain medication such as ibuprofen or naproxyn.

Sling – A lot of bad press has been on TV and on the internet about mesh, including the sling. It is true that several persons have been harmed by the inappropriate use of mesh. But, there are some patients that can benefit from the use of mesh in the form of a sling. The truth about slings is that they have been placed in hundreds of thousands of
patients and they work great. They have been FDA approved for about 15 years. Surgery to place the sling is likely less risky than many other incontinence procedures. Slings have a high success rate and have lasting results. The risks of a mesh sling include erosion of the sling into the vagina or bladder less than 2 percent of the time. A sling is
recommended if you have urinary incontinence.

There are two types that we use. One type passes the sling behind the pubic bone (retro- pubic) and the other passes it lower within the pelvic bone (trans-obturator). You will not see the sutures under the sling, but you may see some surgical glue above your pubic bone or in your groin. The glue will wear off in a week or two.

Preoperative process

Office – Insurance is very tricky these days. Everyone has a different health plan and there are different rules for coverage. FWMG attempts to help you understand the cost of your surgery. We will get approval for your surgery and if there is a share of cost, we will relay this to you. We do need to receive your payment portion before surgery. This is usual and customary practice for all medical offices. Be aware that you may receive several charges: the doctor’s charge, the assistant’s charge, the anesthesia charge, the hospital charge and a pathology charge. Our office can help estimate these charges and / or direct you to someone who can. Our office will also assist you with disability
forms. Routine disability is 6-8 weeks off work for vaginal reparative surgery.

You will have an appointment designated as your “pre-op” appointment. You are to have read this information before your appointment. At this appointment, I will make certain that we both have a complete understanding of your surgery. We will thoroughly discuss the risks, benefits and alternatives. We will also review the recovery period and the expected outcome. I will order appropriate lab tests and write orders for the hospital. I will also write your prescriptions. Pain medications (and hormones, if appropriate) should be obtained before surgery and be waiting for you upon your arrival at home. No one should be forced to deal with a pharmacy after surgery!

Special people need special approval. So, if you are a heart patient, or have a serious lung condition, you may be asked to see your heart doctor for approval for surgery. The anesthesia doctors need to know that you are safe for surgery.

Hospital – You may go to the hospital before the day of surgery to get your pre-op labs done. This will allow you to have a dry run at the hospital and become familiar with the lay out. In general, if you are under 50 years old and healthy, this may not be necessary and you can get it all done on the day of surgery.

Your surgery can take 1-3 hours. It may be closer to 3 hours if you are having multiple procedures, for example, a hysterectomy in addition to the bladder work. This is sometimes referred to as “the works”, A.K.A. “the blue plate special”. If you are only having a sling, it may only take 30 minutes. You will likely stay 2 nights, but if your surgery is less involved and you are stable and doing well, we can release you after 1 night. Your insurance company determines many nights that you are approved for.

The days before surgery

Have you made arrangements for your arrival to and from the hospital?
Are the kids taken care of?
Your spouse?
The pets?
Your job?

There are many, many things to be done in preparation for surgery. It all requires a good plan. Planning, delegating and completing tasks helps decrease your anxiety and this is essential for you as you recover from surgery. Forge a proper plan that gets you out of responsibility for as many things as possible. Here are some other tasks to be done prior to your surgery:

  • Get your medications from the pharmacy.
  • Have your comfortable bed ready when you come home. Fresh linens will be nice and welcoming for your arrival home.
  • Clean your house and make arrangements for cleaning during your recovery.
  • Stock up on items you may want…. books, movies, puzzles, etc.
  • Pay your bills.
  • Have petrol in the car…but remember if you had a big surgery, you should not drive for 2 weeks.
  • Buy any gifts and cards for people that need them during your recovery.
  • DO NOT EAT OR DRINK ANY FOOD OR WATER FOR 12 HOURS BEFORE YOUR SCHEDULED SURGERY.

The hospital will contact you and do a phone interview with you or may do it if you go to the hospital to have your pre-operative testing done. They will ask a history of your medical illnesses, past surgeries, medications and allergies. Please be as accurate as possible with your information.

The day of surgery

Confirm that you have not had anything to eat or drink. You will need to arrive at the hospital 2 hours before your scheduled surgery time. If you take high blood pressure medicine, you should take it with a sip of water. All other medications can wait until later in the day. One of the several tasks of the nurses is to confirm that you understand
the surgery you are about to undergo. This is to make sure we do not do the wrong surgery and that everyone is in agreement with what is going on. You will be asked to sign a written surgical consent at the hospital which is very similar to the one that you signed in the office.

The nurses will also place an intravenous line in your hand or arm (start an “IV”) through which fluids and other medications can be given.

You will meet the Anesthesiologist before surgery. The doctor will review all of your paperwork and results and be certain that you are medically competent to undergo anesthesia. I will also see you in the preoperative holding area. I hope I get a chance to meet your family members or friends, as I will speak to them immediately following your surgery. You will be placed in both compression stockings and pneumatic devices a.k.a.  “leg squeezers”. These comfortable devices massage your legs before, during and after surgery. They are placed to help prevent harmful blood clots from forming in your legs during your surgery and recovery. They will stay on until you are regularly walking without assistance. You will also be given a dose of intravenous antibiotics before surgery. This is done to help prevent infection. When you are wheeled into the operating room (OR), the anesthesia doctor will begin your anesthesia. You may feel slightly woozy or tipsy; most patients describe this as a pleasant experience. We put you gently off to sleep and carefully position you. All efforts are made to keep you warm and  comfortable. Then, before any surgery is done in the OR, we have a “surgical pause” or a “time out”. The purpose of this is for all of the doctors and nurses that are involved in your surgery to concur that the consent form that you signed matches the exact operation you will undergo. When all agree, we proceed with your surgery.

Postoperative care

When you wake up from your surgery, if you are staying in the hospital, you will likely have a catheter in your bladder and some packing in your vagina. The packing will be removed on the first day after surgery and the catheter may be removed on the first or second day. We will advance your diet from liquids to solids when you feel up to it and when we think your bowels are awake enough to handle food. In order to be discharged from the hospital, you need to accomplish the following:

  • Have adequate pain control
  • Tolerate a regular diet
  • Void well – with or without a catheter
  • Have no signs of bleeding or infection.

You will stay in the hospital one or two nights. The insurance company approves the amount of stay for the average patient, but if your recovery is prolonged for some reason, and you have a medically justified reason to stay, they will cover additional days. Some of you may need to go home with a catheter tube in the bladder to drain the urine. When
the bladder is restored to its original position, many times the brain has to learn how to void (urinate) again. Sometimes this may take a one to two weeks! Try not to be too stressed out about this. Eventually everyone is successful. I understand that it is can be inconvenient to have the catheter, but it happens to some people when we put your bladder back into its original position. If you leave the hospital with a catheter, I will see you back in the office within a week to attempt to remove it. We do what is called a “voiding trial”. If you can remember to do so, clamp the rubber part of the catheter off 3 hours prior to your office appointment. Your bladder can then fill. When I take the catheter out in the office, you can try to void. You can do it!

At home

You will need to have a loved-one drive you home. You will receive written information from the hospital about your postoperative care as well. If my instructions are different from the hospitals, please follow my instructions. Your home should be clean and prepared for your arrival. Rest, walk, drink plenty of fluids and avoid constipation.

You will have a vaginal discharge and maybe some light bleeding. You will have some discomfort and soreness. Take your usual medications. Use your prescription pain medications as well as over-the-counter medications for pain. Eat a healthy diet and let your body be the guide. You should shower or bathe in the tub every day. If you get in the tub, make sure you can get out of it! I will send you home from the hospital with a Sitz bath to use every time you void. It should really be called a spritz bath. If you experience constipation, do NOT use an enema. You can take oral medications such as Milk of Magnesia, dulcolax or any other oral laxative. Stool softeners such as colace are good to take too. Soft bowel movements every day or two is ideal.

Activity is limited during the post op period. NO driving for 2 weeks. NO lifting anything over 5-10 pounds for 6 weeks. NO intercourse for 6 weeks. Outercourse is ok, though. You cannot be a “couch potato”. You should be walking every day. Twenty minutes three times a day is ideal. Try to get up every hour or two to keep your circulation going. Nap and walk for the first two weeks. Let yourself heal. You have already made arrangements, so please try and enjoy your recovery. I will see you in the office in 2 weeks and discuss what you can do after the first two weeks.

Worrisome symptoms include: Temperature over 100 degrees, heavy vaginal bleeding, nausea and vomiting, and feeling worse and worse instead of better and better. It is helpful to have a working thermometer available to take your temperature if you feel like you may have a fever. Also, if you cannot urinate, or feel like you are not emptying your bladder completely, I would like to hear from you. Office hours are from 8:00 until 5:00pm. You will be given a phone number to call during office hours for emergencies. This number is only for post op patients and should only be used for medical problems and concerns. If it is the weekend, a holiday or after-hours, please call the office. A recorded message will begin. As the recorded message starts, press “0” to talk to the medical exchange personnel. There is always a doctor on call, but you will talk to the answering service first. Make it clear that you are a post-op patient and that you have an urgent matter that you need to discuss with the doctor on-call. In the case of an emergency or if you are feeling very sick, please go to the ER (Emergency Room) at Clovis Community Hospital. If it can wait until office hours, call us on the post-op patient phone line at 8:00am and we will make an appointment for you to be seen.

Shopping List Considerations

  • Sanitary pads
  • Motrin, Ibuprofen, Aleve, Tylenol or any of their generic equivalents
  • Milk of Magnesia
  • Stool softeners
  • Refills of your prescription medications

Catheter care

The catheter inserts into your bladder through your urethra and has a small inflated balloon on the end of it, thus keeping it in place. It should not fall out. The silicon catheter is then attached to a bag that collects your urine. The bag can be easily emptied. Before you leave the hospital, the nurse will review all of this. You may also receive a prescription for antibiotics in order to prevent infection. I realize this may be  intimidating, but it is quite simple to manage.

Follow up appointments

  • Routine appointments are at 2 and 6 weeks.
  • We can squeeze you in for any problems or concerns.