Pelvic Surgery for Pelvic Pain Relief

If a combination of Physiotherapy and medication has been unable to relieve your pelvic pain, you may consider undergoing a pelvic surgery. Unfortunately pelvic surgeries, as with any surgery, have varying degrees of success. As a result they are often reserved for adults that suffer from chronic pelvic pain that has been unable to be treated through medication, and are finished having children. This is because it may not be possible to conceive following a pelvic surgery, and the benefits of any pelvic surgery are mostly lost in women following pregnancy and childbirth.

In this article we look at the types of most common pelvic surgeries, how to prepare for your pelvic surgery, how to improve your recovery, and potential complications. All procedures discussed may differ from the exact procedure you are offered, as your surgeon will design your procedure to specifically suit your needs.

The purpose of this article is to inform you of your options. You should always seek advice from a medical expert and do your own thorough research before proceeding with a planned surgery.


Types of Pelvic Surgery

  • Pelvic organ prolapses - Pelvic floor repair is the broad term for all surgical repairs required to resolve a pelvic organ prolapse. With all repairs there is a chance that a prolapse can recur in another place. Mesh can be used to reinforce the repair if needed. However, the current advice from the National Institute for Health and Care Excellence (NICE), suggests that "mesh for vaginal wall prolapse should only be used in the context of research." Other pelvic organ prolapse repair surgeries are discussed on our Surgical & Non-Surgical Treatments for Pelvic Organ Prolapse page.
    • Anterior vaginal repair - Repairs damage between the bladder and front wall of the vagina to improve functionality of both. 70-90% success.
    • Posterior vaginal repair - Repairs damage between the rectum and back wall of the vagina to improve functionality of both. 80-90% success.
    • Hysterectomy - If the uterus has prolapsed and there is only a small chance of recovering function, then you may have it removed.
  • Pelvic / gynaecological cancer - Cancerous cells that have not been cured through radiotherapy, chemotherapy and hormone treatment may need to be removed through a major surgery.
    • Pelvic exenteration - A complex and long procedure which removes a number of the pelvic organs in order to remove cancerous cells. Pelvic exenteration can be further classified by which organs were removed. Anterior pelvic exenteration removes the organs at the front of the pelvis; the reproductive organs and bladder. Posterior pelvic exenteration removes the organs at the back of the pelvis; the reproductive organs and bowel. Total pelvic exenteration removes all the pelvic organs, where the cancer cannot be removed through a lesser surgery. As part of these surgeries you will have a bag fitted to collect urine and faeces. This surgery can include tissue to cover where the vagina was, meaning you no longer have a vagina.
  • Scar tissue causing chronic pelvic pain - If you have undergone a previous pelvic surgery then you may have scar tissue that has formed to connect tissues or organs that would not naturally touch. This can cause tightness and pain in the pelvis. Scar tissue can also develop in response to a trauma, Pelvic Inflammatory Disease (PID), endometriosis, cancer treatments and congenital defects. Even if you have no negative symptoms from the tissue, you may be advised to have the tissue removed so as to avoid future complications.
    • Lysis of severe adhesions - If you have severe adhesions / fibrous bands of scar tissue, then these can be cut through in a surgical procedure. The aim is to provide unobstructed function for the pelvic organs.
  • Endometriosis
    • Laparoscopic removal of endometriosis deposits - Through a laparoscopy (keyhole surgery) in the lower abdomen, the surgeon cuts and removes endometriosis deposits. This surgery is more successful in providing pain relief when combined with uterine nerve ablation. Providing 5 years of relief in over half of patients.
    • Laparoscopic uterine nerve ablation (LUNA) - Although not proven to be successful in relieving pain from endometriosis when completed in isolation. This surgery has been proven to enhance the success of a laparoscopic removal of endometriosis deposits, and therefore is often completed at the same time. The surgery involves cutting the nerves in the uterus to stop pain. If the surgery is successful pain reduces significantly in the first 6 months, and continues to reduce, in some patients, over the following 5 years.
    • Presacral neurectomy (PSN) - During this surgery the presacral nerve, at the back of the pelvis, will be cut. This can be either a laparoscopic or open surgery, and is often completed alongside removal of endometriosis deposits. This surgery comes with a number of potential adverse effects. Most notable being severe constipation and bladder dysfunction.
    • Ablative therapy - There are several procedures considered for endometrial ablation. Where the lining of the uterus (womb) is destroyed or removed, whilst the uterus itself is protected. It is often used more for endometriosis that is causing extremely heavy periods, rather than pain. it is not suitable if you wish to have more children as it negatively impacts fertility and increases the risk of complications during pregnancy, and if you are also suffering from fibroids or have had fibroids removed previously. Ablative procedures include radio frequency and heat, freezing, heated fluid, a heated balloon or electrosurgery with an electrical wire loop. These all aim to destroy the lining of the uterus by items inserted. Sometimes ablative therapy is unsuccessful and a hysterectomy is required to provide relief.
    • Hysterectomy - Open operation to remove the uterus and all endometriosis that is contained. This surgery can be extended to include the removal of the ovaries and fallopian tubes if endometriosis is found there.
  • Fibroids
    • Uterine Artery Embolisation - Under local anaesthetic a catheter (thin plastic tube) will be inserted into a blood vessel in your leg. Small particles are passed through the catheter to block the blood vessels that are feeding the fibroids. The aim of the surgery is to shrink particularly large fibroids.
    • Myomectomy - This surgery removes fibroids from within your womb, with the aim to limit damage to the uterus to maintain fertility. Often completed through a keyhole surgery through the abdomen, small fibroids are cut and removed.
    • Hysterectomy - Removal of the uterus (womb) prevents future conception, however, it is occasionally the only option if you suffer from very severe bleeding or very large fibroids that keep returning. It can be completed through the vagina, and sometimes with the aid of keyhole surgery through the abdomen. Chronic pelvic pain results in 10-15% of hysterectomy's.

Preparation for Pelvic Surgery

The most successful surgeries are on people that are connected to their body and look after it the most. This means people who do not smoke, drink to excess and maintain a healthy weight. Recovery from surgery will never be immediate, however, you can reduce your risk of suffering from complications and improve the speed of your recovery by following these steps.

  • Kegel (pelvic floor) exercises - Undergoing pelvic surgery is a huge consideration. To improve the speed of your recovery and the success of any pelvic surgery, you should step up your pelvic exercises to strengthen your muscles. Some women find that they no longer require pelvic surgery after taking pelvic floor exercises more seriously, as many pelvic conditions are the result of a weak or dysfunctional pelvic floor.
  • Maintain a healthy weight - If you have a BMI over 30 you are considered as obese. This means you are more vulnerable to complications following a surgery. Your weight may be a factor in why you are requiring a pelvic surgery, as weight has a weakening effect on your pelvic floor muscles and can stress your pelvic organs. This often leads to incontinence and pelvic organ prolapses. Treat any infections you have before undergoing surgery, as you are more vulnerable than most to developing infections following surgery. You are also at a higher risk of suffering from deep vein thrombosis (DVT) and cardiac (heart) problems. The layer of fat under the skin can be an issue with reducing the view of the operation, and increases the risk to organs near to the surgical area.
  • Stop smoking - As soon as you stop smoking you will immediately benefit your health. With each day that passes your body begins to recover. You will not be able to smoke in hospital, therefore it is in your best interest to stop smoking before. Smoking increases the risk of your wounds getting infected following surgery. It also slows your healing as it reduces the amount of oxygen that goes to your tissue.
  • Cut down on alcohol - Even drinking a small amount in the days before your surgery can slow your recovery. Alcohol can weaken your immune system, leaving your vulnerable throughout your surgery and recovery. Long-term alcoholic patients are at the greatest risk - particularly from contracting pneumonia.
  • Increase your amount of exercise you do - Consider a planned surgery as an opportunity to prepare for an illness. You will feel weaker following any surgery. Your recovery depends on your overall health and general ability to recover from illness. Therefore, it is in your best interest to get as fit as you can before your surgery.
  • Control other medical conditions - If you suffer from multiple medical conditions, discuss this with your doctor to ensure they will be considered throughout your recovery. It is especially important to treat asthma and high blood pressure as best as possible throughout your preparation for surgery, and recovery.
  • Planning your recovery - As part of your preparation you should plan your recovery. Will you be staying with family when you are discharged from hospital? Will you need to sleep downstairs? Are you able to drive? Do you need to take an extended period off work? Planning these things can avoid stress when you need to concentrate on your recovery.
  • Hormonal treatment - A surgery may only be one part of your treatment plan. You may be prescribed a treatment of hormone replacement therapy ahead of your surgery, which may continue for a period after the surgery.

Recovery from Pelvic Surgery

Following your surgery you may spend a few nights in hospital, this can depend on the type of surgery, type of anaesthetic used, and any complications that occurred. You may have a catheter fitted or vaginal pack inserted. Once both are removed and you are able to go to the bathroom then you are likely to be considered fit enough to return home.

Everyone recovers at a different speed as they have different needs and different reasons why they underwent the operation. If there were no complications then you can expect to feel better each day of your recovery.

Your nurses will discuss your recovery plan during your hospital stay, and will be able to advise on the best way to look after yourself once you are discharged. An enhanced recovery programme may be available to you depending on the hospital you have your surgery at. The NHS and Royal College of Obstetricians and Gynaecologists recommend the following to improve your recovery:

  • Rest - Having a surgery is exhausting, both on your body and mind. You may be emotional and struggle to come to terms with your new condition. Rest often and take time to look after yourself. This does not mean do nothing however. It is important that you do light activities to remain mobile and avoid blood clots. Do not exert yourself and rest often.
  • Kegel (pelvic floor) exercises - Once you have recovered from your pelvic surgery, you will need to strengthen your pelvic floor to prevent a disorder from occurring in the future. Follow the advice of your surgeon, you may be able to manually exercise your pelvic floor within a few weeks. We recommend waiting until 12 weeks post surgery before using an electronic pelvic toner again. The Kegel8 range of pelvic toners and probes can be used if you have had mesh fitted, as the probes sit low in the vagina or anus. The electrical stimulation does not interfere with the synthetic mesh implants.
  • Keep moving - You will be encouraged to walk around as soon as you are able to prevent the formation of blood clots. If blood clots travel to your legs or pelvis you can suffer from painful deep vein thrombosis. If they travel to the lungs you can suffer from a serious pulmonary ebolism. Wear compression stockings when you cannot be as mobile. Moving will also release trapped wind that may be a result of your bowels slowing following the surgery. Avoid anything too strenuous and do not carry heavy weights (or children) for a month or more following your surgery. Speak to your employer about how you can gradually get back into work. Don't take too much time off as you can leave yourself feeling isolated and separated from the job. If you had no complications from surgery you may be back at work in 2-3 weeks (depending on the role). If you feel necessary to take more than 6 weeks off work, speak to your GP and employer about the reasons for this.
  • Sit up - Don't spend too much time lying down. Sitting up opens your lungs which can help you avoid getting a chest infection and make it easier to cough.
  • Keep scars clean and dry - It is important that you keep any scars clean and dry, but do not remove any dressings without the permission of your doctor. Avoid scented products which can irritate the wound. If you have any visible stitches that come away in parts, as long as the wound remains closed there is no concern.
  • Physiotherapy - To avoid recurrence of your issues, a Physiotherapist can discuss your habits with you and advise on the best exercises to maintain your pelvic health.
  • Avoid constipation - Eat a healthy balanced diet and keep your bowels in a consistent, healthy routine as soon as possible. If you begin feeling constipated speak to your doctor about ways to relieve it to avoid putting pressure on your pelvic floor whilst your recover.
  • Establish a routine - Its important that you do not stay in bed and avoid recovery. You need to be committed to your recovery and continue with your daily routine as much as possible.
  • Friends and family - Practical and emotional support is essential to a speedy recovery. Ask for help if it is not offered. Even if it is to lift your mood or do some housework for you. Surrounding yourself by positive people will help keep your outlook positive and they can support you in returning to exercise and normal daily life.
  • Pain relief - You may be sent home with some pain relief, or be advised to take paracetamol.
  • Hormonal treatment - If you have undergone a surgery which affects your genital tract, you may continue your treatment with hormone replacement therapy. Often the combined oral contraceptive in prescribed and can help to further reduce any chronic pelvic pain experienced from the endometriosis. They can also reduce the risk of the endometriosis recurring.
  • Follow-up appointments - You will be invited to a series of follow-up appointments which are used to determine whether the surgery was a success and any further treatment that you would benefit from.
  • Use sanitary towels rather than tampons - If you experience light bleeding or non smelly discharge in the weeks following your surgery, then use sanitary towels rather than tampons which can lead to infection. If your discharge becomes smelly or discoloured speak to your doctor.
  • Wait to have sex - It is often 6 weeks before you are given the go ahead from your doctor that you can have sex again. After which you should stop if you experience any pain or discomfort and contact your surgeon if it continues.

Complications of Pelvic Surgery

As with any surgery, there is a risk of infection, allergic or unexpected reaction to the anaesthetic and blood clots (deep vein thrombosis). The following complications are common to undergoing a pelvic surgery:

  • Infertility - Damage to the cervix, vagina and uterus are common with most pelvic surgeries. This can lead to the inability to become pregnant. If you do fall pregnant, you have an increased risk of suffering a miscarriage or complications during the pregnancy.
  • Nerve damage - Some surgeries intentionally cut nerves to reduce the pain sensations being sent to your brain. Occasionally more nerves are cut than necessary, or nerves are damaged by mistake.
  • Damage to the pelvic organs - Although all effort will be taken to avoid damaging any structures in the pelvis, the close proximity of the organs mean mistakes can happen. Any damage that is realised will be dealt with during the same operation here possible. Further operations may, however, be necessary. The damage can be burns from the procedure, scarring or even small tears in the walls of the organs.
  • Urine infection - If you find yourself frequently needing to urinate (urge incontinence), or you have burning or stinging when you urinate, then you may have a urine infection which can be treated with antibiotics.
  • Wound infection - If your wounds are red and there is pain around your scars, you will have irritation around the area.f you are generally feeling unwell or are suffering with a fever, you may have an infection. If you have smelly or heavy vaginal bleeding. This can be treated with antibiotics.
  • Damaged bladder or bowel - If you have increasing abdominal pain you will need to be admitted to hospital to determine the extent of damage to your bladder or bowel. You may also have a fever and be vomiting.
  • Deep vein thrombosis (DVT) - Your legs can become painful, red and even swollen if you begin suffering from deep vein thrombosis (DVT). You may have difficulty putting weight on the legs. Other symptoms include shortness of breath and coughing up blood which suggests a blood clot has travelled to the lungs (pulmonary embolism).
  • Bowel obstruction and severeconstipation
  • Poor wound recovery
  • Joining of the external bags and urethra/bowel come apart
  • Kidney failure
  • Fistula - A hole in the pelvis or abdomen as a result of undergoing cancer treatments.

Depending on the severity of your complications you may remain is hospital so medication can be administered intravenously (into a vein). This will improve your condition more quickly.

Common Symptoms of Pelvic Mesh Complications

Synthetic mesh has been used in surgery for additional support in prolapse repairs and other pelvic surgeries at an increasing rate since 2004. Surgeries which use mesh are often referred to as transvaginal mesh surgeries. These surgeries were favoured over those without mesh, which had relatively low success rates.

Before having a mesh fitted, your surgeon will have discussed the risks and benefits, highlighting that surgical mesh can make future surgical repairs challenging and increases the risk or requiring additional surgery in the future.

If you have had a synthetic mesh fitted as part of a pelvic surgery, then you may be worried about mesh related complications. The mesh can move and erode into the surrounding tissue, sometimes perforating the pelvic organs. This can be painful and often the mesh cannot be removed as it has become embedded too far. The mesh can contract and pull the surrounding tissue with it. The occurrence of this happening is seemingly quite high as publicised by many of the biggest press channels. Meaning there are many ongoing legal cases against the manufacturers of the mesh implants. The figures stated in medical papers range from 9.8% of patients to 25%.

The risk of suffering from a mesh complication increases if you are overweight, are diabetic or a heavy smoker. All as healing is much poorer.

Here are the common symptoms of pelvic mesh complications:

  • Irregular vaginal bleeding or discharge
  • Pelvic pain or swelling
  • Pain during and after penetrative intercourse (dyspareunia)
  • Issues with incontinence including burning
  • Pain that gets worse during exercise
  • Searing pain in the buttock or leg
  • Haemorrhage

If these symptoms were not experienced before the surgery, then it is more likely that they are now related to an issue with the mesh implant.

If you believe you are suffering with a mesh related complication, urgently speak to your GP and request a pelvic examination. They will be able to confirm if the mesh has eroded into the surrounding tissue, and whether there is any tenderness when pressure is applied to the mesh. Any scarring will be visible and your GP will be able to determine whether it is directly due to the surgery or whether it is from a mesh related complication. If you are diagnosed with mesh complications, you may be referred to a gynaecologist or urologist to support you in your next treatment steps.

If you are experiencing any complications from a mesh implant, you should report it to the Yellow Card scheme. This scheme has been set up by UK Government Medicines and Healthcare products Regulatory Agency (MHRA) to monitor the safety of healthcare products used with the UK.


Sources

Bladder and Bowel Community. (2018). Pelvic Floor Repair. [online] Bladder and Bowel Community, 2018 [viewed 28/06/18]. Available from: https://www.bladderandbowel.org/help-information/resources/pelvic-floor-repair/

Blanks, L. (2018). Endometrial ablation. [online] BUPA, 2018. [viewed 28/06/18]. Available from: https://www.bupa.co.uk/health-information/directory/e/endometrial-ablation

British Society of Urogynaecology. (2017). Obesity: Effect on the pelvic floor. Risk for surgery. [online] British Society of Urogynaecology, 2017. [viewed 28/06/18]. Available from: https://bsug.org.uk/budcms/includes/kcfinder/upload/files/info-leaflets/Obesity%20and%20the%20plevic%20floor%20BSUG%20July%202017.pdf

DoveMed. (2017). Separation of (Lysis of) Adhesions. [online] DoveMed, 2017. [viewed 28/06/18]. Available from: https://www.dovemed.com/common-procedures/procedures-surgical/separation-of-lysis-of-adhesions/

Ellington, D. R. Richter, H. E. (2013). Clinical Obstetrics and Gynecology. Indications, Contraindications, and Complications of Mesh in Surgical Treatment of Pelvic Organ Prolapse. [online] 56(2), p276-288. [viewed 28/06/18]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3644007/

Ferrero, S. Remorgida, V. Venturini, P. L. (2010). BMJ Clinical Evidence. Endometriosis. [online] 0802. [viewed 28/06/18]. Available from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3217755/

Guy's and St Thomas' NHS Foundation Trust. (2016). Having a pelvic exenteration. [online] Guy's and St Thomas' NHS Foundation Trust, 2016. [viewed 28/06/18]. Available from: https://www.guysandstthomas.nhs.uk/resources/patient-information/gynaecology/having-a-pelvic-exenteration.pdf

Kaercher, C. W. Genro, V. K. Souza, C. A. Alfonsin, M. Berton, G. Filho, J. S. C. (2011). BMC Women's Health. Baropodometry on women suffering from chronic pelvic pain - a cross-sectional study. [online] 11, p 51. [viewed 28/06/18]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3228674/

Keltie, K. Elneil, S. Monga, A. Patrick, H. Powell, J. Campbell, B. Sims, A. J. (2017). Scientific Reports. Complications following vaginal mesh procedures for stress urinary incontinence: an 8 year study of 92,246 women. [online] 7, 12015. [viewed 28/06/18]. Available from: https://www.nature.com/articles/s41598-017-11821-w

MHRA. (2018). YellowCard. [online] Medicines and Healthcare products Regulatory Agency (MHRA), 2018 [viewed 28/06/18]. Available from: https://yellowcard.mhra.gov.uk/

NHS Choices. (2008). Alcohol linked to surgery risk. [online] NHS England, 2008. [viewed 28/06/18]. Available from: https://www.nhs.uk/news/food-and-diet/alcohol-linked-to-surgery-risk/

NHS England. (2017). Mesh complications. [online] NHS England, 2017. [viewed 28/06/18]. Available from: https://www.england.nhs.uk/wp-content/uploads/2017/07/mesh-complications.pdf

NICE. (2017). News and features: Mesh for vaginal wall prolapse should only be used in the context of research, says NICE. [online] National Institute for Health and Care Excellence [viewed 28/06/18]. Available from: https://www.nice.org.uk/news/article/mesh-for-vaginal-wall-prolapse-should-only-be-used-in-the-context-of-research-says-nice

Royal College of Obstetricians & Gynaecologists. (2015). Recovering Well: Information for you after a Pelvic Floor Repair Operation. [online] Royal College of Obstetricians & Gynaecologists, 2015. [viewed 28/06/18]. Available from: https://www.rcog.org.uk/globalassets/documents/patients/patient-information-leaflets/recovering-well/pelvic-floor-repair-operation.pdf

Royal College of Obstetricians & Gynaecologists. (2015). Recovering Well: Information for you after a Vaginal Hysterectomy. [online] Royal College of Obstetricians & Gynaecologists, 2015. [viewed 28/06/18]. Available from: https://www.rcog.org.uk/globalassets/documents/patients/patient-information-leaflets/recovering-well/vaginal-hysterectomy.pdf

Spies, C. D. Lanzke, N. Schlichting, U. Muehlbauer, S. Pipolo, C. Von Mettenheim, M. Lehmann, A. Morawietz, L. Nattermann, H. Sander, M. (2007). Alcoholism Clinical & Experimental Research. Effects of Ethanol on Cytokine Production After Surgery in a Murine Model of Gram‐Negative Pneumonia. [online] 32(2), p331-338. [viewed 28/06/18]. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1530-0277.2007.00567.x