What Happens in Hysterectomy & Urethral Sling Procedure

Dr. Kelly teaches you everything you wanted to know (or didn't know you didn't know) about what happens in hysterectomy & urethral sling procedures.
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Everything you wanted to know (& likely some stuff you didn’t) about what happens in a hysterectomy & urethral sling procedure

What gets taken out?

How does it get taken out?

How is whatever’s left, supported ‘in there’?

Learn more with this 4 minute video

Tip: You can speed it up if you don’t have 4 minutes. Or read about it below, if that’s your style. You be you, friend.

Let’s start with the anatomy review.

illustration of front and side view of pelvis with vagina. The orientation is a VERY short tube, the urethra, from the bladder to the outside world, and the pelvic floor muscles, which are about 1cm thick at this region, surround that urethra.
In a pelvis with traditionally female anatomy, the bladder is nestled in front, just behind pubic bone, with the urethra leading from the bladder down and out. The vagina is behind the urethra and bladder, uterus & ovaries (if we have them) on top of the vagina, and the rectum in the back.

Prolapse is a term for when one of the pelvic organs ends up outside of the vaginal or rectal canals.

If there’s a smaller protrusion into the vaginal cavity, due to tissue thinning, but hasn’t actually left the vagina, technically it is called a -cele…but everyone calls those prolapses, too, so we’ll use common terms here, as well as medical.

Wait…’thinning of the vaginal wall’? Gross. What causes that?

It’s not gross. It’s life. As we age, our tissues change. The vagina is a tissue, so it thins over time. This thinning can be accelerated by life demands, childbirth, injury, hormonal status and genetic factors. It can happen whether we’ve had children OR NOT, and if it happens to you, you have not done anything wrong.

If it happens to you, you have not done anything wrong.

Thinning of the anterior vaginal wall can allow for the bladder or urethra to collapse back into the vagina. Technically a ‘urethrocele’ or ‘anterior prolapse’, but commonly called a prolapsed bladder.

Thinning of the top of the vagina can allow the uterus to peek downwards. Smaller ones are technically a ‘cystocele’, and larger ones (where uterus is outside of the vagina) are called technically uterine prolapse.

Thinning of the back of the vagina can allow the rectum to push forward. Smaller deficits are technically a ‘rectocele’, and larger ones (where the rectum [part that holds the poop] comes out of the anus [the part that opens for poop to come out]) technically rectal prolapse.

Remember that Pelvic PT has the same success rate as surgery for Pelvic Prolapse, with literally NONE of the side effects.

So Try PT first.
But if surgery is in your future,
empower yourself by knowing the following:

To know what happens in a hysterectomy,

First, we have to know the lingo:

  • If the uterus is removed, it is called a hysterectomy.
  • When the uterus and cervix are removed, it is called a total/complete hysterectomy.
  • If the uterus and cervix AND ovaries and fallopian tubes are removed, that is a radical hysterectomy.
  • When the ovaries are also removed, it is called a hysterectomy with oophrectomy.
  • If the ovaries and Fallopian tubes are removed, it is called a hysterectomy with salpingo-oophrectomy.
  • When the cervix is left, it is called a subtotal or partial or supracervical hysterectomy.

The uterus can be removed in various ways

  • Through the vagina, transvaginal, which is the most minimally invasive.
  • Through the stomach, transabdominal, which is the most invasive, but gives the surgeon the best visualization.
  • All in one piece, or morcellated, in pieces, and removed in a bag (yes, kind of gross, but medicine is gross sometimes, and you need to understand the lingo).
  • Laparoscopic, which uses instruments via small abdominal incisions to remove the uterus or assist with a transvaginal approach.
  • Robotic: Uses robotic technology to perform a procedure similar to laparoscopic.

If the vagina was left (which it usually is), it needs to be secured

This is important. If you do not secure the remaining vagina internally, you have a very high chance for vaginal prolapse in the years following your hysterectomy.

Yes, via its connections to the deep pelvic fascia, the uterus plays a role in stabilizing the vagina. So if you take it out, you have to stabilize the vagina artificially

This stabilization happens in 2 main ways

Sacrocolpoplexy (posterior support)

  • This is the most common way, with the best long term outcomes.
  • They secure the remaining vagina, via a Y-shape of mesh, to the front of your sacrum.

Sacrospinous fixation (posterior support)

  • Secures the remaining vagina to the sacrospinous ligament
  • This is usually only done on one side.
  • If your vagina is ‘more posterior’, there are higher failure rates with this approach (so talk to your surgeon).

Uterosacral Ligament Support (less common)

  • Bilateral support
  • 4% risk of neuropathy

Downsides of Vaginal Support

You want your vagina supported. BUT…how do you think your ischiococcygeus muscle (also just called your coccygeus, you genius, you), is going to react to somebody suturing a vagina to it?

Answer: it is usually pissed off, and tends to spasm, commonly causing pelvic discomfort (in bike seat, or tailbone parts), and can even lead to new leakage in 40% of women (23-50% in studies) post-surgical.

This symptom CAN be addressed with pelvic floor PT, so it’s important to know that it is a potential side effect, and you should go to PT as soon as possible if you are having new (or continued) leakage or pain post-procedure.

In the US, the only insurers who regularly require a physician script for care are Medicare and Medicaid services, and certain other Christian Medicare programs. Contact your local PT clinic to see if your insurance requires MD authorization.

If your insurance does require a physician order, and if you ask, and your surgeon declines, and says “it will just get better on its own, in time.” (vomit. but I hear it every day) If that happens, I want you to stay calm and say “Fine, but I want you to document it in my chart that I requested PT for this problem and that you denied my request.” Works every time. There is literally no downside to PT.

If a surgeon says “I want you to wait until you are healed more before starting PT”, that could be logical. This would be the case especially if there was tension on the repair sites, maybe the tissue (or you in general) weren’t so healthy, etc. But there is LOTS a pelvic PT can do externally to help reduce symptoms, that wouldn’t put ANY strain on the repair, so just be sure to have an open honest conversation about the ‘whys’ for waiting.

Okay. Wow. What about the urethral slings or tape?

Oooh, those are super cool. Check this out:

  • They can be from your own tissue, from a cadaver donor or surgical mesh (choice is surgeon preference, and based upon your body)
  • They should have NO TENSION ON THE URETHRA

Urethral slings are low-ish as far as invasiveness and come in two flavors:

Transvaginal Sling/ Transvaginal Tape (TVT)

You have small incisions anterior, on either side of your urethra

Transobterator Sling/ Transobturator Tape (TOT)

You have small incisions underneath, on either side of the vagina.

Any side effects of the Sling Procedures?

Generally, just local discomfort.

For same reasons as vaginal stabilization post-hysterectomy, we sometimes see hypertonicity of pelvic floor muscles post-sling procedure, and pelvic floor PT is highly effective at reducing the hypertonicity, and the concomitant pelvic pain or leakage that is associated with it.

In rare cases, if the tape is compressing the urethra, the client is unable to pee on their own, post-procedure. In this case, the standard of care is to have the tape loosened, or removed, as quickly as possible. Otherwise, there is a risk of needing to self-catheterize.

Studies show that when the tape is compressing the urethra, there are excellent outcomes if it is loosened in the first 7-10 days, so don’t wait to check in with your surgeon.

So if you’ve had this procedure done, and peeing is not getting easier after a day post-procedure, you need to get your cute butt back to the surgeon’s office, pronto.

Thanks for Reading!

This post was more about hysterectomy and urethral sling procedures, and if you’re reading it, you will likely benefit from some pelvic floor physical therapy!

If in-person PT isn’t in the cards for you, check out my Pelvic Floored Signature Lecture Series. This self-paced, online course offers in-depth training of how your current pelvic floor muscle status could be contributing to your pain, incontinence, constipation, pelvic organ pressure, or sexual dysfunction complaints. The program includes 12 mini lectures, and 12 progressive exercise programs that I developed based upon current research, as well as my 16 years of experience in pelvic health. You can stream them as often as you’d like from the privacy of your home, for a fraction of the cost of a standard course of Pelvic PT care.

Many other courses will follow, so stay tuned!

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Thanks for reading!

xoxo, Dr. Kelly

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