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Contact & Location Details

Telephone: 9344 5099
Facsimile: 9344 5299
Call Service: 9387 1000
Email: office@drmarcuscarey.com

Main rooms and addresses for all correspondence and appointments:

Suite B, Level 2, Frances Perry House Consulting Suites (located in the Women's Hospital)

20 Flemington Road, Parkville, Victoria 3052

Dr Marcus Carey

Dr Marcus Carey is a Urogynaecologist working in both public and private practice in Melbourne. He is a Consultant Urogynaecologist at the Women's Hospital in Parkville, Melbourne. Dr Carey's private practice is located at Frances Perry Private Hospital located in the Women's Hospital, Parkville. He also operates at the Epworth Freemason's Hospital in East Melbourne.
Direct:
(03) 93445099
office@drmarcuscarey.com

Karen

Karen is Dr Carey's medical secretary.
Direct:
(03) 93445099
office@drmarcuscarey.com

Hayley

Hayley is Dr Carey's medical secretary. Hayley is also a registered nurse.
Direct: (03) 93445099
office@drmarcuscarey.com

Information Regarding Prolapse and It's Treatments

Treatments

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Prolapse

Prolapse Information
Information on Prolapse and Available Treatment

What is a prolapse?

Prolapse of the vagina or uterus occurs when there is a failure of support for the pelvic organs. Prolapse can effect the bladder (referred to as a cystocele), uterus or the rectum (rectocele). It occurs when the ligaments and muscles that support the pelvic organs become stretched, weakened or torn. It is a very common disorder that may be experienced by young, middle aged and older women.

While aging is a factor, there are other contributing causes. These include loss of muscle tone, menopause, pregnancy and childbirth, obesity, family history, pelvic trauma or previous surgery, repeated heavy lifting, chronic constipation, chronic coughing, smoking and certain medical conditions such as diabetes. It may also occur with other pelvic floor disorders such as urinary incontinence.

Prolapse Surgery

Vaginal prolapse is a common condition and can cause symptoms such as a sensation of a vaginal bulge, pelvic pressure and discomfort, constipation, and difficulty emptying the bowel or bladder or problems with sexual intercourse.  Prolapse results from weakening or damage to the pelvic ligaments, muscles, nerves and tissues that are responsible for supporting the pelvic organs (vagina, uterus, bladder, uterus and rectum).

Prolapse is not a dangerous or lifethreatening condition, but it may be quite uncomfortable, distressing and bothersome. An operation is only indicated when the prolapse is symptomatic (i.e. causes problems or is uncomfortable). The majority of women will have improvement of their symptoms following an operation.

Many different operations can be used for prolapse. The type of surgery that is recommended will depend on many factors (e.g. your age, the severity of your prolapse, whether of not you have had a hysterectomy or previous failed prolapse surgery). Prolapse surgery can be performed along with surgery for urinary incontinence and about 35% of women who have prolapse surgery will also need surgery for urinary incontinence. The most common operations used by Dr Carey for prolapse are detailed below.

Some women will be suitable to try a vaginal pessary (vaginal ring) instead of surgery. This is a device that supports the vagina and will be changed every 3 to 6 months (see ‘Non-surgical' treatments for prolapse’ for more details about using a pessary). Dr Carey is able to fit a vaginal pessary if you choose this option.

Vaginal repair using sutures (colporrhaphy)

Prolapse may be repaired with sutures (stitches) without needing synthetic graft reinforcement (mesh free surgery). Repairing a prolapse with sutures is often referred to as a colporrhaphy or native tissue repair. This type of surgery is usually recommended for women with prolapse of the front and/or back walls of the vagina. A prolapse of the front wall of the vagina is referred to as a cystocele and a prolapse of the back wall is referred to as a rectocele. A vaginal repair using this technique can be performed in combination with other procedures (e.g. surgery for urinary incontinence and hysterectomy).

What happens during surgery?

  • Prolapse surgery can be performed with a regional (spinal) anaesthetic or general anaesthetic.
  • There will be incisions inside the vagina and the tissue supporting the vagina will bestrengthened with stitches. This may be at the front or the back walls of the vagina orboth, depending on the type of prolapse you have.
  • Sutures provide reinforcement of the weakened vaginal tissue.
  • An additional stitch (sacrospinous fixation stitch) may be required at the top of the vagina or into the cervix to support the vagina. This stitch may cause some temporary discomfort in the buttock that may persist for up to three months.
  • The vagina is then closed with stitches that will dissolve after two weeks.
  • At the end of the operation a catheter will be inserted into the bladder to drain urine and a gauze pack will be placed in the vagina to prevent bleeding. These will remain in place over night.
  • Antibiotics will be given during the surgery.

The illustration above demonstrates a vaginal repair of the front wall of the vagina (repair of cystocele). A. an incision is made in the vaginal wall. B. the vaginal wall is separated off the underlying bladder wall. C. the vaginal wall is split into two layers. D and E. the deeper layer is composed of fibrous tissue (pubocervical fascia) and is repaired with stitches and further reinforced by overlaying one side on the other. F. the vaginal wall incision is the closed with stitches.

The illustrations above demonstrate a vaginal repair of the back wall of the vagina (repair of rectocele). An incision is made in the vaginal wall. The vaginal wall is separated off the underlying wall of the rectum. The deeper layer is composed of fibrous tissue (rectovaginal fascia) and is repaired with stitches. The vaginal wall incision is closed with stitches.

Surgical Vaginal Support (S-POP)

For some women having their prolapse repaired, Dr Carey may recommend placing a surgical vaginal support (S-POP; Surgical-Pelvic Organ Pessary) into the vaginal at the completion of surgery. The use of a surgical vaginal support (S-POP) is a new approach to surgery. The purpose of the S-POP, which remains in the vagina for 3 to 4 weeks following surgery, is to provide extra support for the vagina during the healing period. Dr Carey or a nurse will remove the S-POP during the post-operative check-up 3 to 4 weeks following surgery. Removal of the S-POP is usually not uncomfortable.

The S-POP may cause a discharge from the vagina approximately 2 weeks after surgery. This discharge will disappear after the S-POP is removed. The S-POP may move down slightly after 3 weeks. If you feel the S-POP has moved down you may gently push it up to a more comfortable position. If the S-POP is causing significant discomfort or concern you should contact Dr Carey’s rooms or the nursing staff on level 6 at Frances Perry House for advice.

The illustration below demonstrates the placement of the S-POP into the vagina at the completion of prolapses surgery.

Hysterectomy

Some women with prolapse require a hysterectomy as part of their surgical treatment. Usually this is only required if there is a moderate or marked prolapse of the uterus. Hysterectomy, if required, is usually performed through the vagina so that no abdominal incisions are required. Sometimes the hysterectomy is performed by key-hole surgery (laparoscopy or robotics) or through an incision in the lower abdomen.

Usually the ovaries are not removed during hysterectomy for prolapse. The ovaries be will removed during the hysterectomy only if there is a specific reason (e.g. family history of ovarian cancer). For some women, a subtotal hysterectomy is recommended in order to preserve the cervix and ovaries, and to avoid making an incision at the vaginal apex.

Prolapse surgery using synthetic and biological graft (mesh).

Effective from 4 Janurary 2018 the TGA (Therapeutic Goods Authority) has withdrawn approval for the transvaginal use of synthetic and biological grafts during prolapse surgery. 

What are the risks associated with Transvaginal Synthetic Graft Material?

The synthetic graft material (mesh) that was most often used for prolapse surgery is a medical grade polymer called polypropylene. 

The most common problem experienced is a small exposure of the graft material into the vagina, causing vaginal discharge or spotting. This occurs in about 1 in 20 cases. The vaginal tissues heal over the exposure in some cases but if the exposure persists then a small operation will be required to remove the exposed graft material. This can be as a minor day procedure.

In some women, mesh can be associated with serious complications such as extensive vaginal mesh exposure along with recurrent vaginal discharge, bleeding and infection. Pelvic, vaginal, perineal, rectal and groin pain may be experienced and this can become chronic. Transvaginal mesh may be associated with painful sexual intercourse and inability to have sexual intercourse. Mesh can be associated with vaginal scarring and narrowing. Some women will require further remedial surgery to treat these complications. Dr Carey has extensive experience in remedial surgery to deal with pelvic mesh related problems.

What is a Pessary?

A pessary is a plastic device that can be used to help support prolapse. It is used for women who do not want surgery. Pessaries come in different shapes and sizes and can be fitted tohelp women with different degrees and types of prolapse. Pessaries are safe to use and are latex free. Once you decide that you would like to try a pessary, you will be fitted for the correct size and shape to help support the prolapse without causing any discomfort or pain. The pessary that fits best will be able to support the prolapse, feel comfortable and allow you to urinate and have bowel movements without difficulty.

Pessaries should be removed and cleaned on a regular basis. Most pessaries are easy to remove, clean and replace daily or weekly. Some pessaries are difficult to remove and require you to be seen in Dr Carey’s rooms for removal and replacement. A pessary can be tried for any woman who is bothered by her prolapse but does not want to have surgery or for women with other medical conditions that makes surgery more risky. Pessaries can be used for as long as the woman desires.

Sacral Colpopexy

(Laparoscopic, robotic or abdominal surgery to re-support the top of the vagina)

Sacrocolpopexy is an operation that suspends the vagina or uterus, using a synthetic graft, from the front of the sacrum (tail bone). This provides good support to the top of the vagina or uterus. A repair inside the vagina may also be required at the same time. The operation can be performed in combination with other procedures.

Studies from our hospital show that this operation is successful to support the top of the vagina or uterus in over 90% of women. This operation is usually reserved for women with severe prolapse who have already had a hysterectomy. It may also be used to support a prolapsed uterus in younger women if they wish to retain their uterus.

What happens during surgery?

The surgery is performed under general anaesthetic (you are completely asleep). The operation may require an incision on your abdomen or be performed laparoscopically or using a robotic system (key-hole surgery). Dr Carey usually performs this operation laparoscopically or using a robotic system but he will advise you which method is best for you.

The top of the vagina (the vaginal vault) is suspended with a synthetic graft from the back of the sacrum (tail bone). This provides very strong support for the vagina. A surgical repair of the vagina may be required, depending on the type of prolapse you have. At the end of the operation, a catheter will be inserted into the bladder to drain urine. This will remain in place over night. A cystoscopy (looking inside the bladder) will usually be performed at the end of the surgery to check that no damage has occurred to the bladder or ureters (the tubes running from the kidneys down to the bladder).

The illustration below demonstrates the vagina suspended from the sacrum with synthetic graft (sacral colpopexy).

Suture and Sacral Hysteropexy

(Laparoscopic, robotic or abdominal surgery to re-support the uterus)

Suture hysteropexy is an operation that suspends the prolapsed uterus fron the uterosacral ligaments using sutures (mesh free surgery). The uterosacral ligaments are the normal supporting ligaments of the uterus and upper vagina. Tears, breaks or detatchments of the uterosacral ligaments can cause prolapse. The suture hysteropexy operation repairs the damaged uterosacral ligaments. This provides support for the uterus and upper part of the vagina. A repair inside the vagina may also be required at the same time. The operation can be performed in combination with other procedures. For women who have advanced prolapse Dr Carey may offer the sacral hysteropexy operation. This operation suspends the vagina or uterus, using a synthetic or biological graft, from the front of the sacrum (tail bone). 

What happens during surgery?

The surgery is performed under general anaesthetic (you are completely asleep). The operation may require an incision on your abdomen or be performed laparoscopically or using a robotic system (key-hole surgery). Dr Carey usually performs this operation laparoscopically or using a robotic system but he will advise you which method is best for you. The uterus is suspended from the uterosacral ligamnets using sutures (mesh free surgery). This provides support for the uterus. A surgical repair of the vagina may be required, depending on the type of prolapse you have. At the end of the operation, a catheter will be inserted into the bladder to drain urine. This will remain in place over night. A cystoscopy (looking inside the bladder) will usually be performed at the end of the surgery to check that no damage has occurred to the bladder or ureters (the tubes running from the kidneys down to the bladder). During the sacral hysteropexy  procedure,  the uterus is suspended with a synthetic graft from the back of the sacrum (tail bone). This provides very strong support for the uterus.

 

 

The illustration above demonstrates the uterus suspended from the sacrum by a synthetic graft

Colpocliesis

Colpocliesis is very simple operation that supports the uterus and vagina by partial closing the vagina using sutures (stiches). This operation is not often used and is usually reserved for elderly women who haven’t been able to successfully use a vaginal pessary (vaginal ring). This operation is relatively quick to perform often taking only around 20 minutes and can be performed under local anaesthesia with sedation for some women. At is not possible to have sexual intercourse following a colpocliesis and this operation is not suitable for women who wish to remain sexually active.

What happens during surgery?

The surgery is performed under can be performed under local anaesthesia and sedation, a spinal anaesthetic or general anaesthetic. The surgery involves a partial closure of the vagina in order to prevent prolapse of the uterus and other pelvic organs (bladder and the rectum). A portion of the front and back walls of the vagina are removed and sutured together using stitches resulting in a partial closure of the central part of the vagina cavity. Women generally make a rapid recovery following a colpocliesis operation and typically leave hospital the day after surgery.

Possible complications of prolapse surgery
  • There are general risks involved with having an operation, including the anaesthetic, bleeding and blood transfusion, infection within the pelvis or wound and clots in the legs that can travel to the lungs. Antibiotic are given during surgery and continued after your operation to reduce the risk of infection. Medication (e.g. Fragmin or Clexane) to thin your blood is given during surgery and while you are in hospital to reduce your risk of developing blood clots. It is very uncommon to experience serious bleeding or need a blood transfusion.'
  • Generally there is improved sexual function after prolapse surgery. However, about 2% of women may experience painful intercourse after surgery and this may require minor corrective surgery or the use of vaginal dilators.
  • Whenever synthetic graft is used, there is a small risk (in Dr Carey’s practice this occurs in 1 in 40 women) of a small portion of the synthetic graft becoming exposed the vagina. This is usually treated with vaginal oestrogen cream or pessaries if the vaginal skin is thin or a small vaginal operation to remove the small amount of exposed synthetic graft (the entire graft will not need to be removed).
  • Occasionally bladder problems can occur after surgery (e.g. difficulty with bladder emptying, cystitis or urinary leakage). These problems usually settle soon after surgery. However, if incontinence remains a problem then a small operation or medication may be required.
  • Pain may occur immediately after surgery but this generally settles after a few days or weeks. It is rare for women to experience long-term pain following prolapse aurgery.
  • Rare complications from prolapse surgery include injury to a nearby structure (e.g. bowel, bladder, ureter, nerve). Dr Carey may inspect the bladder with a telescope (cystoscopy) at the completion of surgery to exclude any bladder or ureter injury. Long-term rare complications after laparoscipic or abdominal prolapse surgery include bowel obstruction from adhesions and abdominal hernia (weakening and bulging of the abdominal or laparosopic incisions). Further surgery may be necessary if a complication occurs.
Additional information about vaginal surgery when a synthetic graft (mesh) has been used

In Australia, the Therapeutic Goods Authority (TGA) has withdrawn approval for the transvaginal use of synthetic and biological mesh for prolapse surgery, effective from 4 Janurary 2018. In the USA, the Food and Drug Administration (FDA) has issued the following safety communication regarding the use of mesh. The FDA wants to inform you about the complications that can occur when surgical mesh is used to treat Pelvic Organ Prolapse (POP) and Stress Urinary Incontinence (SUI), and provide you with questions to ask your surgeon before having these procedures.

This is part of our commitment to keep healthcare professionals and the public informed about the medical products we regulate. FDA has received reports of complications associated with the placement of mesh through an incision made in the wall of the vagina. Although rare, these complications can have serious consequences. The reports have not been linked to a single brand or model of mesh.

The most frequent complications included erosion through the vagina, infection, pain, urinary problems and recurrence of the prolapse and/or incontinence. In some cases, erosion of the mesh and scarring of the vagina led to discomfort and pain, including pain during sexual intercourse. Some patients needed additional surgery to remove the mesh that had eroded into the vagina. Other complications included injuries to nearby organs such as the bowel and bladder, or blood vessels.

Background

A pelvic organ prolapse (POP) occurs when a pelvic organ, such as your bladder, drops (“prolapses”) from its normal position and pushes against the walls of your vagina. This can happen if the muscles that hold your pelvic organs in place become weak or stretched from childbirth or surgery. More than one pelvic organ can drop at the same time. Organs that can be involved in a pelvic organ prolapse include the bladder, the uterus, the bowel and the rectum. Pelvic organ prolapse can cause pain or problems with bowel and bladder functions or interfere with sexual activity. Stress urinary incontinence (SUI) is a type of incontinence caused by leakage of urine during moments of physical stress.

Talking to your doctor

Before having an operation for POP or SUI, be sure to let your surgeon know if you’ve had a past reaction to mesh materials such as polypropylene. Questions you should ask the surgeon before you agree to surgery in which mesh will be used:

  • What are the pros and cons of using surgical mesh in my particular case? Can my repair be successfully performed without using mesh?
  • If a mesh is to be used, what’s been your experience with implanting this particular product? What experience have your other patients had with this product?
  • What’s been your experience in dealing with the complications that might occur?
  • What can I expect to feel after surgery and for how long?
  • Are there any specific side effects I should let you know about after the surgery?
  • What if the mesh doesn’t correct my problem?
  • If I have a complication related to the mesh, can the mesh be removed and what could the consequences be? If I have a complication related to the mesh, can the mesh be removed and what could the consequences be?
  • If a mesh is to be used, is there patient information that comes with the product, and can I have a copy?
Recovery time and instructions following surgery

Most women stay in hospital for one, two or three nights. It is important to rest after the operation and allow the area to heal. 

Generally it is recommended to:

  • Restrict you level of physical activity for two weeks.
  • From two to four weeks do light activity only.
  • You avoid heavy lifting (nothing heavier than 5 kg) for four weeks, including shopping bags, washing baskets and children. 
  • You abstain from sexual intercourse for six weeks. 
  • You avoid playing sport and impact exercises such as jogging or jumping for four
  • weeks. 

You may:

  • Drive a car after two weeks; however, check this with you car insurance provider.

Pain relief:

  • If you experience pain after discharge we suggest that you take pain control medication (e.g. Panadol) every four hours as required until two weeks.
  • Ensure you take some time each day to rest.

Maintain good bowel habits:

  • Try do drink approximately 1.5 litres of fluids each day.
  • Maintain a healthy diet.
  • Use Metamucil, Movicol or similar preparations (available at the chemist) if required to maintain regular bowel function and to keep your bowel motions soft.

Some vaginal loss may occur after you leave hospital but this should be minimal and light pink, and may last for three weeks. Occasionally, some women experience a sudden moderate dark blood loss (like ‘prune juice’) at one to two weeks after surgery that should then stop. This occurs from discharge of a blood collection under the vaginal wall. Any stitches that you still have in when you go home will fall out once they dissolve in about 10 days (and up to three weeks). These do not need to be removed.

Dr Carey will be happy to answer any questions you may have and can give more specific advice. Before deciding to have surgery you should read carefully all the information about your operation and also consider obtaining a second opinion. If you experience complications after you leave hospital, contact Dr Carey or Frances Perry House for advice. In an emergency you may attend the Royal Women’s Hospital emergency department or attend your closest hospital emergency department.

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