Vaginal hysterectomy +/- Vaginal Repair(s)

Vaginal hysterectomy +/- Vaginal Repair(s)

It has been recommended that you have a vaginal hysterectomy with or without vaginal wall repair(s).

This leaflet explains some of the benefits, risks and alternatives to the operation. We want you to have all the information you need to make the right decision. Please ask your surgical team about anything you do not fully understand or want to be explained in more detail.

We recommend that you read this leaflet carefully. You and your doctor (or other appropriate health professional) will also need to record that you agree to have the procedure by signing a consent form, which your health professional will give you.

About vaginal hysterectomy
Vaginal hysterectomy is often suggested to treat problems including:

Prolapse (when the womb slips down into the vagina, which can sometimes pull the bladder and bowel with it).
Heavy or painful periods (following the use of drug treatment or minor surgical procedures that have been unsuccessful).
Rarely for very early cancer or pre-cancer of the cervix (neck of the womb)

A hysterectomy is an operation to remove the uterus (better known as the womb) including the cervix (neck of the womb). Occasionally one (or both) of your ovaries are also removed (this is called an oophorectomy), but the ovaries are not usually removed with a vaginal hysterectomy.

Figure 1: Female reproductive organs

A vaginal hysterectomy is performed entirely through incisions (cuts) within the vagina. No incision (cut) is made on your abdomen (tummy). If the muscles supporting the bladder become weak then the bladder can bulge backwards into the vagina. This is called a bladder prolapse or cystocele. In the same way if the rectum (back passage) bulges forward into the vagina we call it a rectocele. These types of prolapses can be repaired through the vagina at the same time as the vaginal hysterectomy. Occasionally, these repairs are performed and ‘strengthened’ using a synthetic graft material such as mesh. Your consultant will explain this to you in more detail if he or she feels that this is appropriate.

Occasionally your consultant may also carry out an incontinence procedure for patients with stress urinary incontinence (leaking with coughing, sneezing and other activities) at the same time. For example, the TVT procedure, for which there is a separate information sheet available.

Why might prolapse occur?
The vagina and womb is held in position by the body’s natural supporting structures. A vaginal prolapse happens when these supporting structures become weakened and the womb and the vagina slips down from its normal position.
The condition occurs more commonly with increasing age but may also be associated with inherited muscle weakness, previous hysterectomy, obesity, changes in your hormone levels and childbirth (particularly vaginal birth).

About the procedure
To remove your womb through your vagina we will use surgical instruments inside your vagina. Your surgeon will use these instruments to separate the vaginal wall from the neck of the womb (the cervix) so that we can get access to your womb above.
Your cervix and womb are then cut away from the bands of the tissue (supporting ligaments) that hold them in place. Sometimes we will cut the womb into smaller pieces to make it easier to take out, particularly if the womb is enlarged. Rarely the tubes and ovaries will be removed vaginally although removal of the ovaries is most often performed at abdominal hysterectomy rather than vaginal procedures. Sometimes your surgeon will use the help of a laparoscope (a special telescope) to see inside you during the operation. This type of surgery is known as keyhole surgery and makes it easier to take out your ovaries through your vagina. It is also sometimes used at the start of a hysterectomy to check if it is possible to remove your womb through your vagina rather than your abdomen.

Your surgeon will sew up the top of the vagina and a ribbon gauze (known as a pack) may be put in your vagina to apply some pressure to the cut surfaces to reduce bleeding.
The operation takes approximately 1-2 hours.

What effect will a hysterectomy have on me?
Most women find that their health and well-being improve and they can still lead an active life. It means that you will have no more periods and that you cannot become pregnant. If your ovaries are removed you may experience menopausal symptoms such as hot flushes, night sweats and vaginal dryness. These symptoms can be relieved by taking Hormone Replacement Therapy (HRT). If your ovaries are not removed they will work until your menopause, although there is some evidence that this may be brought forward a few years.

How will it affect my sex life?
Information on sexual function after vaginal surgery is difficult to obtain. In general most women will find that when sex is resumed (which typically is probably between 2-4 months post-operatively) it is initially uncomfortable. With time this usually settles and for the majority of women sexual function is either the same as before or indeed improved. However, there will be a small group of women (perhaps 1 in 10 although no local data available) who will experience long-term problems with discomfort, pain or reduced sensation during sexual intercourse after surgery.

Benefits of the procedure
The aim of your surgery is to improve or resolve the symptoms of prolapse (the feeling of a lump within the vagina) or stop your heavy periods.
Compared to laparotomy (surgery through a larger incision (cut) in the abdomen), a vaginal hysterectomy has significant benefits such as:

• less pain and discomfort during recovery
• faster recovery times for the patient and an earlier return to normal daily activities
• shorter hospital stay
• reduces the risk of complications associated with open surgery
• No abdominal scars

Serious or frequent risks
Everything we do in life has risks. A hysterectomy has some risks associated with it.
The general risks of surgery include problems with:

• The vaginal wound (for example, bruising or infection);
• Breathing (for example, a chest infection);
• The heart (for example, abnormal rhythm or, very rarely, a heart attack); and
• Blood clots (for example, in the legs or occasionally in the lung)

Those specifically related to vaginal hysterectomy include problems with:

• Failure to complete procedure vaginally resulting in abdominal surgery;
• Bleeding / haemorrhage (excessive bleeding may require blood transfusion in 1-2 per 100 women);
• Vault haematoma (a collection of blood at the top of the vagina but inside the abdomen);
• Damage to bowel or bladder;
• Long-term problems with bladder function including stress incontinence and voiding problems (difficulty passing urine). This latter problem can occasionally result in the need to use catheters for variable periods; rarely patients are taught how to self catheterise themselves on a daily basis for variable periods of time.
• Urinary tract infection;
• Pelvic abscess/pelvic infection/vaginal infection;
• Risk of future prolapse symptoms. Removing the womb does not protect you from future prolapse of the vaginal walls or top of the vagina (known as vault prolapse); As many as 1 in 3 women that have an operation for prolapse will require further surgery for prolapse in later life.
• Painful sexual intercourse and reduced sensation during sex;

Sometimes, more surgery and an extended stay in hospital is needed to put right these types of complications.

Most people will not experience any serious complications from their surgery. The risks increase for elderly people, those who are overweight and people who already have heart, chest or other medical conditions such as diabetes or kidney failure. As with all surgery, there is a small risk that you may die.

You will be cared for by a skilled team of doctors, nurses and other health-care workers who are involved in this type of surgery every day. If problems arise, we will be able to assess them and deal with them appropriately.

Other procedures that are available
Pelvic floor exercises can be done to improve the tone of the muscles surrounding the vagina.

Pessaries (plastic rings) can be inserted into the vagina to hold up the uterus or bladder. These are usually only used as a temporary measure, or if you are not fit enough for surgery.

Before your operation
As soon as you know that you need a hysterectomy you should try to get yourself into the best physical shape, this helps you recover more quickly.
Stop smoking, eat a healthy diet and take regular exercise.
Make plans for your family whilst you are in hospital and arrange for some extra help for the first couple of weeks when you are discharged home.
If you have loose or broken teeth or crowns that are not secure, you may want to visit your dentist for treatment. The anaesthetist will usually want to put a tube in your throat to help you breathe. If your teeth are not secure, they may be damaged.

If you have long-standing medical problems, such as diabetes, hypertension (high blood pressure), asthma or epilepsy, you should consider asking your GP to give you a check-up.

There is a risk that your procedure will be cancelled if there is a chance of very early pregnancy. In order to be sure you are not pregnant at the time of the procedure you must not have sex or you must use reliable contraception between the first day of the last NORMAL period to the date of procedure.

Your pre-surgery assessment visit
We will ask you to go to a pre-surgery assessment clinic where you will be seen by members of the medical and nursing teams of the Gynaecology Unit. The aim of this visit is to record your current symptoms and past medical history, including any medication you are taking. Your heart and lungs will be examined to check that you are well enough for surgery. Blood tests and x-rays will usually be taken or arranged during this clinic.

The members of the gynaecology team will check that you agree to have the planned surgery. If you have been given a consent form please bring it with you, alternatively you may be given a consent form in clinic. Make sure that you have read and understood this information before your clinic visit. If you have not understood any part of the information, you will be able to ask any questions you may have about your planned surgery.

Pre-operative preparation

Day of your surgery:

• If your surgery is scheduled in the morning you must have nothing to eat or drink from midnight (this includes water) unless instructed by your doctor.
• If your surgery is scheduled for the afternoon, you must not eat or drink from 7.30am.

Being admitted to the ward
You will usually be admitted on the day of your surgery so we and you can prepare for the surgery. We will welcome you to the ward and check your details. We will fasten an armband containing your hospital information to your wrist.

To reduce your risk of blood clots in your legs after surgery, we will usually give you heparin or clexane injections and ask you to wear support stockings before and after your surgery. You may also have a drip inserted to give you fluids straight into your veins before your operation. We will usually ask you to continue with your normal medication during your stay in hospital, so please bring it with you.

Your anaesthetic
We will carry out your surgery under a general anaesthetic (this means that you will be asleep during your operation), or spinal anaesthetic (where you will be awake, but an injection in your back will make you numb from the waist down).

Your pre-surgery visit by the anaesthetist
After you go into hospital, the anaesthetist will come to see you and ask you questions about:

• your general health and fitness;
• any serious illnesses you have had;
• any problems with previous anaesthetics;
• medicines you are taking;
• allergies you have;
• chest pain;
• shortness of breath;
• heartburn;
• problems with moving your neck or opening your mouth; and
• any loose teeth, caps, crowns or bridges.

Your anaesthetist will discuss with you the different methods of anaesthesia they can use. After talking about the benefits, risks and your preferences, you can then decide together what is best for you.

Also, before your operation a member of the theatre nursing staff may visit you. He or she will be able to answer any questions you may have about what to expect when you go to theatre.

On the day of your operation

Nothing to eat and drink (nil by mouth)
It is important that you follow the instructions we give you about eating and drinking. We will ask you not to eat or drink anything (including chewing gum or sucking sweets) for six hours before your operation. This is because any food or liquid in your stomach could come up into the back of your throat and go into your lungs while you are being anaesthetised. You may take a few sips of plain water up to two hours before your operation so you can take any medication tablets.

Your normal medicines
It is important to let us know, before you are admitted, if you are taking anticoagulant drugs (for example, warfarin, aspirin or clopidogrel).

• You should stop Aspirin and other non-steroidal anti-inflammatory medications 7 days prior to surgery. If you take anticoagulant medication i.e. warfarin or clopidogrel this will need to stopped a few days (warfarin) or a week (clopidogrel) before surgery.
• Hormonal medications such as the oral contraceptive pill may be continued.
• Medications for diabetes and heart conditions may also be continued.

Also provide us, and the anaesthetist, with a list of all the medications you are taking or have recently taken, including medicines prescribed by your family doctor and those bought “over the counter” without prescription, and also any herbal medications.
Keeping an up-to-date list of medications with you is highly recommended.

Please contact us if you are unsure which medications you must stop. If we do not want you to take your normal medication, your surgeon or anaesthetist will explain what you should do.

We will need to know if you don’t feel well and have a cough, a cold or any other illness when you are due to come into hospital for your operation. Depending on your illness and how urgent your surgery is, we may need to delay your operation as it may be better for you to recover from this illness before your surgery.

Your anaesthetic
When it is time for your operation, a member of staff will take you from the ward to the operating theatre. They will take you into the anaesthetic room and the anaesthetist will get you ready for your anaesthetic.

To monitor you during your operation, your anaesthetist will attach you to a machine to watch your heart, your blood pressure, and the oxygen level in your blood.

There are different options for the type of anaesthesia for your operation. Your anaesthetist will discuss the choices with you.

General anaesthetic
General anaesthesia usually starts with an injection of medicine into a vein. A fine tube (venflon) will be placed in a vein in your arm or hand and the medicines will be injected through the tube. Sometimes you will be asked to breathe a mixture of gases and oxygen through a mask to give the same effect.

When you are anaesthetised, the anaesthetist will place a tube down your airway and use a machine to ‘breathe’ for you. You will be unconscious for the whole of the operation and we will continuously monitor you.

Spinal anaesthetic
A spinal anaesthetic involves the injection of a local anaesthetic drug through a needle into the small of your back to numb the nerves from the waist down to the toes for 2 – 3 hours. You will be asked to either sit on the side of the bed with your feet on a low stool or lie on your side, curled up with your knees tucked up towards your chest. You will remain awake during this procedure. You may feel some discomfort in your lower back or legs whilst the anaesthetic is being injected. The anaesthetic staff will support and reassure you during the procedure. As the spinal begins to take effect your anaesthetist will measure its progress and test its effectiveness. Usually a spinal should cause you no unpleasant feelings and usually takes only a few minutes to perform. Once the injection is finished you will normally be asked to lie flat as the spinal works quickly and is usually effective within 5 – 10 minutes. Your skin will initially feel numb to touch and your leg muscles will feel weak. Once the injection is working fully you will be unable to move your legs or feel any pain below the waist.

Pain relief after surgery
Pain relief is important as it stops suffering and helps you recover more quickly.

We will usually give you tablets, suppositories, or injections to make sure you have enough pain relief. When you are comfortable and have recovered safely from your anaesthetic, we will take you back to the ward. The ward staff will continue to monitor you and assess your pain relief. They will ask you to describe any pain you have using the following scale.

0 = No pain
1 = Mild pain
2 = Moderate pain
3 = Severe pain

It is important that you report any pain you have as soon as you experience it.

You may also have:

• PCA (patient controlled analgesia)
  This is a pain relief method using a machine that allows you to control your pain
  relief yourself. Small doses are given into a vein for immediate effect. The machine
  has a lock-out period so you can’t overdose yourself.
• A local block
  This is an injection of some local anaesthetic near the nerves that supply the lower
  half of your body. There are a number of different ways of doing this; an epidural, a
  spinal injection or a caudal injection. These will numb the part of your body being
  operated on and give good pain relief during and after your operation.

What are the risks of anaesthetic?
Your anaesthetist will care for all aspects of your health and safety over the period of your operation and immediately afterwards. Risks depend on your overall health, the nature of your operation and how serious it is. General anaesthesia is safer than it has ever been. If you are normally fit and well, your risk of dying from any cause while under anaesthetic is less than one in 250,000. This is 25 times less likely than dying in a car accident. Side effects of having a general anaesthetic include drowsiness, nausea (feeling sick), muscle pain, sore throat and headache.

Side effects of having a spinal anaesthetic are headache, low blood pressure, itching of the skin due to the drugs injected and temporary difficulty in passing urine. Rare complications of a spinal anaesthetic are temporary loss of sensation in your legs, ‘pins and needles’ or muscle weakness in your legs. Permanent damage to the nerves is very rare. We will discuss with you the risks of your anaesthetic.

After your surgery

• After your operation we will take you to the recovery room where you will remain until you are properly awake. Once the medical team are happy with your progress, we will usually take you back to the general ward. You will need to rest until the effects of the anaesthetic have passed.
• You will have a tube (catheter) to drain urine from your bladder into a bag next to your bed. This will usually be removed the following day
• You will have a drip in your arm to keep you well-hydrated. Once you are eating and drinking normally your drip may be removed.
• Your anaesthetist will arrange for you to have painkillers for the first few days after the operation, as we mentioned earlier.
• A vaginal pack made of gauze may be inserted to help control any post-operative bleeding and support the vagina after the operation. This is normally removed within 24 hours after the operation. It is often a couple of days before you have your bowels opened as you have not been eating etc. As this operation is in close proximity to the bowel the nurses will monitor your bowel actions daily. You may need a mild laxative to help bowel movements.

Our medical team will consult with you to explain how the surgery went and what the findings were.

Leaving hospital
Length of stay
How long you will be in hospital varies from patient to patient and depends on how quickly you recover from the operation and the anaesthetic. Normally you will be discharged after 2-4 days.

Medication when you leave hospital
Before you leave hospital, the pharmacy will give you any extra medication that you need to take when you are at home.

Convalescence
How long it takes for you to fully recover from your surgery varies from person to person. For most women this takes 6-8 weeks. For the first 2 weeks back home you should rest and relax. You can make a cup of tea, help with washing up, dusting and easy household tasks but should not attempt to vacuum, iron or carry loads of washing for at least 6 weeks.

You should avoid standing for long periods of time and continue the exercises that you were shown in hospital for the next 6 weeks. Try to take a short walk every day, look after your posture and rest whenever you need to.

You should consider who is going to look after you during the early part of this time. You may have family or close friends nearby who are able to support you or care for you in your home during the early part of your recovery period. You might consider going to stay with relatives or you may want to make your own arrangements to stay in a convalescent home while you recover. After you return home, you will need to take it easy and should expect to get tired to begin with.

If you experience fever-like symptoms, excessive pain, or any of the following you should contact us on the number at the bottom of this leaflet or call your GP:

• persistent bleeding from the vagina that is smelly or becomes heavier than a normal period and is bright red
• persistent redness, pain, pus or swelling around any wounds
• a fever or more than 38°C, or chills, which may indicate infection
• pain or burning on passing urine or the need to pass urine frequently, as this may indicate a urinary tract infection
• increasing nausea
• increasing abdominal pain with vomiting

Stitches
We usually use dissolvable stitches. Some stitches can take a number of weeks to dissolve and may be felt in the vagina for up to three months.

Vaginal Bleeding
You may still have a vaginal discharge when you go home. This should decrease gradually over the next few weeks. If you have increased bright red bleeding or develop an offensive smelling discharge you should visit your GP immediately.

Urine
Your bladder is very close to the area of your surgery and may take a week or two to settle down as your muscle tone improves. Continuing pelvic floor exercises can help. If you start to experience any pain or burning sensation on passing urine, then you should consult your GP. If you have had a vaginal repair, do not worry if your stream of water may splash against your thighs, this is normal and as you recover from your operation this will subside.

Weight Gain
A gain in weight after your operation is not inevitable. If you follow a healthy diet and take increasing amounts of regular exercise as you begin to feel fitter then your weight should not increase. Any increase in appetite is probably due to the fact that you feel more relaxed and fitter than you have done for a long time.

Tearfulness and depression
Emotions are closely linked to surgery so do not worry if you feel tearful or depressed at times. Frustration at not being able to do the things you want to can also affect your feelings. As you begin to feel fitter these feelings should lessen. If the problem persists then you should consult your doctor.

Personal hygiene
You will normally bathe or shower while you are in hospital, and this can continue as normal after you leave hospital. We would recommend showering instead of baths if possible.

If you have any bleeding we recommend that you use sanitary pads (not tampons) and these should be changed regularly.

Diet
You should eat a healthy diet and drink plenty of fluid to avoid constipation and straining for bowel motions. Try to eat a well balanced diet containing:

• Plenty of high fibre content and plenty of fresh fruit, salad, green vegetables, and wholemeal bread.
• Adequate protein foods such as eggs, cheese, meat, and fish.

You should avoid stodgy foods such as cakes, pastries, and sweets.

Exercise
We recommend that you avoid strenuous exercise for up to 6 weeks. As a guide a kettle of water is the maximum weight to lift at least for the first 4 weeks after operation. Do not do any heavy lifting, e.g. furniture, for up to 3 months after your operation. If you have young children, or grandchildren, try to avoid picking them up in the early weeks of your convalescence and encourage them to sit gently on your lap.

Walking is good for you and a normally fit person should aim for 10 minutes walk daily after you have been home for 3 to 4 weeks. This can be increased according to your general health. You must not resume sporting or keep fit activities until at least 6 weeks after your operation. It is important to resume these activities gently.

Sex
Ideally you should refrain from sexual intercourse until 6 weeks to ensure everything has healed well. This is to protect the vaginal area where surgery has been performed. A gentle sexual partner can help to resume satisfactory intercourse. Using a lubricating jelly may help if you are a little tense on resuming intercourse. The majority of women find it reassuring to know that their own sexual response should be changed very little by this operation. Some of the stitches to the vagina may still feel prickly for up to 3 – 4 months, so your partner may be more comfortable if he wears a condom during this time.

Driving
We recommend you do not drive for 4-6 weeks after your operation. You should not drive until you feel confident that you could perform an emergency stop without discomfort. It is your responsibility to check with your insurance company regarding their specific policy details.

Work
How long you will need to be away from work varies depending on:

• how serious the surgery is;
• how quickly you recover;
• whether or not your work is physical; and
• whether you need any extra treatment after surgery.

Most people will not be fully back to work for a minimum of 6 weeks. Please ask us if you need a medical sick note for the time you are in hospital.

Smear tests
You will no longer need smear tests if you have had a hysterectomy.
If you have had a hysterectomy because of very early cervical cancer, or severe pre-cancerous changes at the cervix, you probably may still need to have smear tests. Your consultant will discuss this with you.

Outpatient appointment
Before you leave hospital we may give you a follow-up appointment to come to the outpatient department, or we will send it to you in the post.
In many cases a post-operative appointment will be arranged for you between 3-6 months after the surgery.

Contact details
If you have any specific concerns that you feel have not been answered and need explaining, please contact the following:

Worcestershire Royal Hospital
Gynaecology Nursing Staff, Lavender Ward (phone 01905 760586)
Hospital Switchboard (phone 01905 763333)

Alexandra Hospital
Gynaecology Nursing Staff, Ward 14 (phone 01527 512100)
Hospital Switchboard (phone 01527 503030)

Kidderminster Treatment Centre
Gynaecology Nursing Staff, Lavender Ward (phone 01905 760586)
Ward 1 (phone 01562 512356)
Hospital Switchboard (phone 01562 823424)

Other information
The following internet websites contain information that you may find useful.
www.patient.co.uk
Information fact sheets on health and disease
www.rcoa.ac.uk
Information leaflets by the Royal College of Anaesthetists about ‘Having an anaesthetic’
www.nhsdirect.nhs.uk
On-line health encyclopaedia
www.worcsacute.nhs.uk
Worcestershire Acute Hospitals NHS Trust

If your symptoms or condition worsens, or if you are concerned about anything, please call your GP, 111, or 999.

Patient Experience
We know that being admitted to hospital can be a difficult and unsettling time for you and your loved ones. If you have any questions or concerns, please do speak with a member of staff on the ward or in the relevant department who will do their best to answer your questions and reassure you. 

Feedback
Feedback is really important and useful to us – it can tell us where we are working well and where improvements can be made. There are lots of ways you can share your experience with us including completing our Friends and Family Test – cards are available and can be posted on all wards, departments and clinics at our hospitals. We value your comments and feedback and thank you for taking the time to share this with us.

Patient Advice and Liaison Service (PALS)
If you have any concerns or questions about your care, we advise you to talk with the nurse in charge or the department manager in the first instance as they are best placed to answer any questions or resolve concerns quickly. If the relevant member of staff is unable to help resolve your concern, you can contact the PALS Team. We offer informal help, advice or support about any aspect of hospital services & experiences.

Our PALS team will liaise with the various departments in our hospitals on your behalf, if you feel unable to do so, to resolve your problems and where appropriate refer to outside help.

If you are still unhappy you can contact the Complaints Department, who can investigate your concerns. You can make a complaint orally, electronically or in writing and we can advise and guide you through the complaints procedure.

How to contact PALS:
Telephone Patient Services: 0300 123 1732 or via email at: [email protected]

Opening times:
The PALS telephone lines are open Monday to Friday from 8.30am to 4.00pm. Please be aware that you may need to leave a voicemail message, but we aim to return your call within one working day.

If you are unable to understand this leaflet, please communicate with a member of staff.  

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