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Urogynecologic surgery: Perioperative care issues

Urogynecologic surgery: Perioperative care issues
Literature review current through: May 2024.
This topic last updated: Apr 03, 2024.

INTRODUCTION — Urogynecologic surgery is frequently performed to treat symptoms of incontinence and pelvic organ prolapse. As an example, in the United States, 20 percent of female patients are estimated to undergo some type of urogynecologic procedure in their lifetime [1]. While certain elements of urogynecologic surgery are common to all operations, these procedures have unique components that must be addressed by the surgical team.

This topic will review pre-, intra-, and postoperative care issues specific to patients undergoing urogynecologic procedures. Information on general planning for benign gynecologic surgery is reviewed separately. (See "Gynecologic surgery: Overview of preoperative evaluation and preparation".)

In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. We encourage the reader to consider the specific counseling and treatment needs of transgender and gender-expansive individuals.

PREOPERATIVE — Preparation for urogynecologic surgery includes counseling regarding the unique procedure-related risks, evaluation and testing as directed by the patient's history and symptoms, understanding patient preferences, and recognition of clinical scenarios that require additional action.

Counseling — Preoperatively, the surgeon has a detailed discussion of the risks, benefits, and alternatives to surgery with the patient and their support team, and clearly documents the conversation in the medical record. This conversation addresses potential complications common to all pelvic surgeries and identifies issues unique to each patient's surgical plan.

Universal issues in female reconstructive pelvic surgery — Common potential complications related to female reconstructive pelvic surgery that are discussed and written in the surgical consent include:

Persistent (unresolved) symptoms of incontinence or prolapse – (See "Stress urinary incontinence in females: Persistent/recurrent symptoms after surgical treatment".)

New or worsened urinary symptoms – This includes new or worsened stress urinary incontinence (SUI), overactive bladder symptoms, urgency incontinence, or urinary retention. SUI may occur after procedures that alter urethral support, such as anterior colporrhaphy (see "Pelvic organ prolapse in women: Choosing a primary surgical procedure", section on 'Urinary incontinence'). Any of these symptoms may require medical treatment and/or additional surgery. (See "Female urinary incontinence: Treatment", section on 'Urgency incontinence/overactive bladder (OAB)' and "Postoperative urinary retention in females".)

New or worsened sexual symptoms (eg, dyspareunia) – (See "Sexual function in females with pelvic floor and lower urinary tract disorders".)

A review of standard surgical risks, including infection, bleeding, and injury, is presented separately. (See "Informed procedural consent" and "Gynecologic surgery: Overview of preoperative evaluation and preparation".)

Procedure-specific issues — Patients considering procedures involving synthetic mesh augmentation, uterine morcellation, and intraperitoneal surgery receive additional counseling regarding issues unique to these procedures.

Synthetic mesh augmentation – Use of synthetic mesh in gynecologic surgery is controversial and national laws may govern availability. Medical societies and regulatory agencies around the world have released statements regarding synthetic mesh use in gynecologic surgery [2-8]. While some countries have banned the use of transvaginal synthetic mesh for prolapse repair (except in studies), use of transvaginal synthetic mesh for surgical treatment of stress urinary incontinence is permitted. These issues are presented in detail in related content. (See "Transvaginal synthetic mesh: Use in pelvic organ prolapse".)

Planned use of synthetic mesh should be included in preoperative consent discussion. We incorporate the small (<5 percent) chance of mesh complication into our preoperative discussion with the patient. While vaginal mesh kits have been removed from the market, published results from long-term follow-up of a large multicenter randomized controlled trial reveals that mesh hysteropexy demonstrated 18 percent fewer failures (aHR 0.58; 95% CI 0.36-0.94; p = 0.03) than native tissue apical repair with hysterectomy with no increased rates of mesh exposure over the course of the study [9]. However, there were no differences in patient-reported outcomes between groups. Synthetic mesh complications and their management are presented in detail separately.

(See "Transvaginal synthetic mesh: Complications and risk factors".)

(See "Transvaginal synthetic mesh: Management of exposure and pain following pelvic surgery".)

Uterine morcellation – Uterine morcellation may be necessary during laparoscopic or vaginal procedures. The clinical concern with morcellation is that disrupted uterine tissue can potentially disseminate cancer cells intraperitoneally if an occult malignancy is present in the specimen and the specimen is not morcellated in a containment system. For laparoscopic procedures, the availability of power morcellation for removal of the uterus varies based on geographic location; it is not currently used in the United States. While power morcellation, if available, may be selected by some patients [10], additional options to avoid morcellation or minimize risk, such as surgical morcellation within a containment system, should be considered and discussed with the patient. As alternate options for tissue extraction are available, we no longer perform laparoscopic power morcellation for supracervical hysterectomy. Issues surrounding power morcellation and extraction options, such as scalpel and in-bag techniques, are discussed elsewhere. (See "Uterine tissue extraction by morcellation: Techniques and clinical issues".)

Concomitant salpingectomy and/or oophorectomy – Patients undergoing intraperitoneal surgery who do not desire future childbearing have the option of elective bilateral salpingectomy or salpingo-oophorectomy to reduce their risk of ovarian cancer. The evidence regarding prophylactic salpingectomy and salpingo-oophorectomy continues to emerge. The approach depends on the patient's baseline risk for ovarian cancer.

Typical ovarian cancer risk – For patients at typical risk of ovarian cancer undergoing intraperitoneal procedures, our practice is to offer elective salpingectomy as evolving evidence demonstrates the majority of serous ovarian cancers begin in the fallopian tubes [11,12]. The etiology of ovarian cancer and risks, benefits, and success rates of opportunistic salpingectomy are discussed separately. (See "Opportunistic salpingectomy for ovarian, fallopian tube, and peritoneal carcinoma risk reduction".)

We generally do not perform oophorectomy in typical-risk patients. Discussion of risks and benefits of oophorectomy depends on the age of the patient:

-Age <65 years – For patients under the age of 65, we do not recommend oophorectomy because continued ovarian hormone production benefits overall survival and reduces cardiovascular disease [13,14]. (See "Opportunistic salpingectomy for ovarian, fallopian tube, and peritoneal carcinoma risk reduction".)

-Age ≥65 years – For patients 65 and older, the long-term survival with or without oophorectomy appears to be similar, which differs from younger patients who undergo oophorectomy [15,16]. For individuals who continue to desire bilateral salpingo-oophorectomy, we counsel them regarding the 12 percent risk of unsuccessful removal with an isolated vaginal approach [17]. For those who definitively desire oophorectomy at the time of vaginal repair, we review the possible need for laparoscopic assistance to safely complete the removal or use vessel-sealing devices vaginally, which in our experience improve visibility and feasibility of adnexal removal. (See "Elective oophorectomy or ovarian conservation at the time of hysterectomy".)

Increased ovarian cancer risk – For patients with abnormal findings or individuals at increased risk of ovarian cancer, we offer bilateral salpingo-oophorectomy [12]. (See "Risk-reducing salpingo-oophorectomy in patients at high risk of epithelial ovarian and fallopian tube cancer".)

Indeterminate risk – We refer patients with an indeterminate risk of ovarian cancer to a genetic counselor for assistance with this decision. (See "Genetic testing and management of individuals at risk of hereditary breast and ovarian cancer syndromes".)

Timing with regards to childbearing — There are limited data on the impact of subsequent pregnancy and birth on outcomes of surgery for pelvic organ prolapse and urinary incontinence. A systematic review of 215 births reported among 27 publications reported recurrent prolapse rates of 15 percent for vaginal birth and 10 percent after cesarean birth [18].

Surgery after childbearing is complete – In general, we encourage patients to wait until they have completed childbearing prior to undergoing surgical repairs.

Surgery before childbearing is complete – In rare situations, such as individuals with severe symptoms uncontrolled by conservative measures, complete anal sphincter disruptions, or obstetric fistulas, these procedures are offered prior to completion of childbearing with counseling that subsequent pregnancy and delivery may disrupt the repair, cause worsening of symptoms, and make repeat correction more difficult.

Birth following pelvic reconstructive surgery – Data regarding the impact of vaginal delivery after pelvic floor surgery are sparse. The risks of recurrence of pelvic floor conditions and damage to a successful repair must be weighed against the risks of cesarean section and should be individualized to the patient.

Pelvic organ prolapse, fistula, or anal sphincter repair – We generally advise cesarean birth for delivery after pelvic reconstructive surgery for prolapse, fistula, or sphincter repair, assuming the surgery was successful at alleviating symptoms. Women whose pelvic floor condition persists despite repair are counseled regarding the unknown risks of worsening symptoms. Additional discussions are available in related content.

-(See "Effect of pregnancy and childbirth on urinary incontinence and pelvic organ prolapse".)

-(See "Obstetric anal sphincter injury (OASIS)".)

-(See "Fecal and anal incontinence associated with pregnancy and childbirth: Counseling, evaluation, and management".)

Urinary incontinence – Data regarding vaginal delivery after midurethral slings are also limited; however, small case series suggest recurrent incontinence rates of approximately 25 percent, with retreatment less than 5 percent [19,20]. We do not consider prior midurethral sling an absolute contraindication to subsequent vaginal delivery, although we encourage less invasive treatment options for stress incontinence (eg, urethral bulking agents) to alleviate symptoms prior to definitive surgical treatment for SUI. (See "Effect of pregnancy and childbirth on urinary incontinence and pelvic organ prolapse", section on 'Patients who have undergone surgical repair'.)

Evaluation — The selection of preoperative tests and studies is determined by the patient's history, physical examination, and planned procedure.

General — Many preoperative components are the same for urogynecologic surgery, benign gynecologic surgery, and general surgery. All patients need medical optimization including smoking cessation, surgical counseling, procedure consent, and plans for thromboprophylaxis and prevention of surgical site infection.

(See "Gynecologic surgery: Overview of preoperative evaluation and preparation".)

(See "Informed procedural consent".)

Regarding preoperative thromboprophylaxis, systems are available that assess the patients underlying venous thromboembolism (VTE) and bleeding risks (table 1). While the American College of Obstetricians and Gynecologists has published a risk assessment and treatment table for gynecologic surgery, the information is based on older data and includes limited discussion of the balance of VTE risk compared with bleeding risk [21]. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients".)

(See "Antimicrobial prophylaxis for prevention of surgical site infection in adults".)

We do not ask patients to perform a mechanical bowel preparation (MBP) prior to surgery as there is no proven benefit [22-24]. MBP is uncomfortable and inconvenient and potentially causes harmful electrolyte imbalances and dehydration. Similarly, antibiotic bowel preparation is not recommended. As noted above, appropriate preoperative antibiotics are given to prevent surgical site infection (table 2 and table 3) [25]. A large cohort study that compared preoperative cefazolin alone with cefazolin plus metronidazole reported decreases in surgical site infection after hysterectomy (from 2.1 to 1.4 percent) [26]. Based on this study, we add metronidazole to the prophylactic regimen for patients undergoing hysterectomy at the time of prolapse repair, although not all society guidelines support this approach [27]. In addition to perioperative antibiotics, all surgical patients are provided an antimicrobial surgical scrub wash (eg, Hibiclens) to shower with three times prior to surgery (two times the day before and once the morning of).

Procedure-specific — Additionally, specific evaluations related to incontinence, prolapse, combined, obliterative, and repeat procedures are reviewed in detail in each topic.

(See "Surgical management of stress urinary incontinence in females: Preoperative evaluation for a primary procedure".)

(See "Pelvic organ prolapse in women: Surgical repair of apical prolapse (uterine or vaginal vault prolapse)", section on 'Preoperative evaluation and preparation'.)

(See "Pelvic organ prolapse and stress urinary incontinence in females: Surgical treatment", section on 'Preoperative evaluation'.)

(See "Pelvic organ prolapse in women: Obliterative procedures (including colpocleisis)", section on 'Preoperative evaluation and preparation'.)

(See "Stress urinary incontinence in females: Persistent/recurrent symptoms after surgical treatment", section on 'Evaluation'.)

Testing — We obtain baseline laboratory tests only when clinically indicated. For patients with normal testing within three to six months of surgery and no clinical indication for reassessment (eg, history of anemia, vaginal bleeding, poorly controlled diabetes), repeat testing is not necessary. A database study including over 12,300 patients undergoing sling procedures reported similar odds of complication among those who did and did not undergo preoperative testing [28].

Increased risk of anemia or surgical bleeding – For patients at risk for anemia or undergoing procedures with higher risk of bleeding (eg, complicated hysterectomy, sacrocolpopexy), a baseline complete blood count, blood type, and antibody screening is reasonable to perform.

Diabetes – We perform lab testing for patients with diabetes without HbA1C testing in the preceding three months and consider delaying surgery and consulting with the patient's diabetologist for HbA1C >7 to 8 percent. Two studies reported up to a threefold increased risk of overall and severe complications in patients with HbA1C >8 percent [29,30]. For patients with normal testing within three to six months of surgery and no clinical indication for reassessment (eg, history of anemia, vaginal bleeding, poorly controlled diabetes), repeat testing is not necessary. A database study including over 12,300 patients undergoing sling procedures reported similar odds of complication among those who did and did not undergo preoperative testing [28].

HPV testing and cervical cytology – Screening for HPV and pap testing is performed based upon the American College of Obstetricians and Gynecologists' guidelines [31]. Thus, tests are ordered only as indicated by the patient's medical history and surgical plan. (See "Preoperative medical evaluation of the healthy adult patient" and "Gynecologic surgery: Overview of preoperative evaluation and preparation", section on 'Medical comorbidities'.)

Urinary tract infection (UTI) – We take the following approach to screening and testing for UTI:

Patients without current UTI symptoms – Patients without current UTI symptoms are managed based on their history of recurrent UTI.

-No history of recurrent UTI – These patients undergo urinalysis prior to cystoscopy or bladder instrumentation. If the urinalysis is suggestive of infection, the urine specimen is then sent for culture. Asymptomatic patients with positive cultures are treated based on the culture result as indicated prior to surgery.

-With recurrent UTI history – Asymptomatic patients with history of recurrent UTI are routinely tested, regardless of current UTI symptoms. Testing includes urine culture given high rates of colonization and UTI recurrence [32]. Treatment with antibiotics is based on the culture results.

Patients with UTI symptoms – These patients undergo urinalysis and treatment based on results.

-Abnormal urinalysis – Patients with UTI symptoms and an abnormal urinalysis on the day of the procedure are counseled regarding the increased risk of upper UTI and complications from UTI, and empirically treated with broad-spectrum urinary antibiotics (eg, sulfamethoxazole/trimethoprim) until culture sensitivities return. One study of 284 preoperative patients reported a higher rate of postoperative UTI in patients who had a positive urine culture on the day of surgery [33]. In addition, patients in whom foreign materials are being implanted (eg, mesh, urethral bulking injections) may need to be rescheduled as eradication of some bacteria in the presence of a foreign body may be impossible.

-Normal urinalysis – Individuals with UTI symptoms who have a normal urinalysis receive routine preoperative antibiotic prophylaxis but do not require additional antibiotic coverage. (See "Gynecologic surgery: Overview of preoperative evaluation and preparation", section on 'Surgical site infection prevention'.)

Additional information on the screening, symptoms, and treatment of UTI in females is presented elsewhere. (See "Acute simple cystitis in adult and adolescent females".)

Urodynamic studies — We do not perform preoperative urodynamic studies in patients with uncomplicated SUI that is demonstrable on physical examination as there is no evidence of improved treatment outcome [34-36]. Individuals with uncomplicated SUI who demonstrate stress incontinence on noninstrumented cough stress testing, do not respond to conservative therapy, and have no evidence of UTI or urinary retention can undergo anti-incontinence surgery, such as midurethral sling procedure [36,37]. (See "Surgical management of stress urinary incontinence in females: Preoperative evaluation for a primary procedure", section on 'Women with uncomplicated SUI'.)

We perform preoperative urodynamic testing on the subset of patients who would benefit from an improved understanding of urethral or detrusor function to guide surgical decision-making, improve counseling regarding surgical outcome, or establish baseline function prior to intervention. Patients who may benefit from urodynamic testing include those with:

Symptoms that are inconsistent with examination findings

History of prior anti-incontinence procedures, reconstructive surgery, or pelvic radiation

Stage 3 to 4 pelvic organ prolapse

Symptoms of complicated SUI, mixed incontinence, or urinary retention

Potential neurogenic causes of incontinence

(See "Surgical management of stress urinary incontinence in females: Preoperative evaluation for a primary procedure", section on 'Urodynamic testing'.)

Specific patient groups

Abnormal uterine bleeding — Patients with abnormal uterine bleeding are evaluated for cervical and/or endometrial pathology prior to incontinence or prolapse surgery. Cervical cytology and human papillomavirus testing (as indicated) is obtained if not current. (See "Screening for cervical cancer in resource-rich settings" and "Cervical cancer screening tests: Techniques for cervical cytology and human papillomavirus testing", section on 'HPV testing'.)

Postmenopausal patients with uterine bleeding may undergo either endometrial biopsy or ultrasound as an initial evaluation [38]. We prefer transvaginal ultrasound as it involves minimal patient discomfort and provides additional information regarding adnexal structures. If endometrial thickening is identified on ultrasound or if scheduling of the ultrasound is a challenge for the patient, we perform an endometrial biopsy in the office. Premenopausal patients require tissue sampling as the endometrial thickness varies throughout the menstrual cycle. Discussion of endometrial evaluation with biopsy and/or ultrasound is presented separately. (See "Overview of the evaluation of the endometrium for malignant or premalignant disease".)

Bladder symptoms — We perform preoperative cystourethroscopy in individuals with specific bladder symptoms or concerns unrelated to incontinence (ie, hematuria [39], history of bladder stones, bladder pain, and suspicion for injury or foreign body from prior procedure). Patients who do not have bladder-specific symptoms do not require preoperative cystourethroscopy. In comparison with the preoperative evaluation, we routinely perform cystourethroscopy intraoperatively for anti-incontinence or anterior/apical prolapse repair surgeries to evaluate ureteral patency and urothelial integrity. (See "Diagnostic cystourethroscopy (cystoscopy) for gynecologic conditions" and 'Intraoperative cystourethroscopy' below.)

Obliterative procedures — For patients with a uterus who are planning an obliterative vaginal procedure such as colpocleisis, we discuss preoperative endometrial assessment (either by ultrasound or sampling) because obliterative procedures make any future assessment of postmenopausal uterine bleeding difficult. Since colpocleisis is often performed in individuals who are unable to tolerate more invasive procedures, this population has a high prevalence of other comorbidities. In our practice, we balance the risk of mortality related to undiagnosed uterine or cervical cancers with the life expectancy based on other chronic medical conditions. We also assess for symptoms of postmenopausal bleeding; individuals with postmenopausal bleeding undergo endometrial assessment. (See 'Abnormal uterine bleeding' above and "Overview of the evaluation of the endometrium for malignant or premalignant disease".)

High risk of gynecologic cancer – Patients at high risk for gynecologic cancers (ie, morbidly obese, history of cervical or endometrial dysplasia/hyperplasia, history of breast/ovarian or other genetically linked cancers) warrant either preoperative endometrial biopsy or hysterectomy (with or without oophorectomy) at the time of obliterative procedure.

Low risk of gynecologic cancer

For low-risk patients over age 80 without vaginal bleeding, we tend to not perform screening because these patients typically have complex medical comorbidities, screening may not be beneficial for this group [40], and there is a small risk of complication from endometrial biopsy [41].

For low-risk patients under age 80 without vaginal bleeding, we prefer to evaluate the endometrium with ultrasound assessment of endometrial thickness and sample only if abnormal (see "Overview of the evaluation of the endometrium for malignant or premalignant disease"). Endometrial biopsy is an alternate option.

For low-risk patients of any age without vaginal bleeding who elect screening, we obtain a transvaginal ultrasound to ensure the endometrial thickness is 4 mm or less [42]. A meta-analysis reported that using a 3 to 5.9 mm cutoff has the highest diagnostic odds of identifying endometrial carcinoma or atypical hyperplasia [43]. Thus, in our practice, for those with an endometrial thickness greater than 4 mm or a nondiagnostic imaging study, we proceed with endometrial tissue sampling prior to surgery. We do not generally perform concomitant curettage or biopsy at the time of LeForte colpocleisis due to high inaccuracy of frozen section. (See "Pelvic organ prolapse in women: Obliterative procedures (including colpocleisis)", section on 'Preoperative evaluation and preparation'.)

Pessary removal — Pessaries are often used preoperatively to treat prolapse or incontinence symptoms. Studies have reported increased rates of bacterial vaginosis in individuals using pessaries [44] and bacterial vaginosis has been associated with increased rates of postoperative infection [45]. Therefore, if possible, we ask our patients to remove the pessary and use metronidazole gel 0.75%, one applicator in the vagina daily, for the five days prior to surgery to minimize the risk of postoperative infections. If it is not possible to remove the pessary prior to surgery, we add metronidazole to the perioperative cefazolin antibiotic prophylaxis.

Prolapse — We discuss the following issues, and perform the tests and treatments as discussed, with patients planning prolapse repair.

Test for occult SUI – Patients planning surgery for prolapse that extends beyond the hymen undergo a preoperative full-bladder prolapse reduction cough stress test to assess for occult SUI. Patients with a positive reduction cough test are offered concomitant midurethral sling at the time of prolapse repair to minimize symptomatic postoperative SUI. Information on the cough stress test is presented separately. (See 'Urodynamic studies' above.)

Shared decision-making – The decision to proceed with concomitant midurethral sling procedure is based on shared decision-making and balance between risks of complications and benefit of UI treatment. In our practice, patients without SUI symptoms or with concerns regarding retention or sling complications are offered a staged approach with treatment as needed after surgical recovery. However, those with bothersome symptoms and evidence of SUI on examination often prefer concomitant management of their SUI at the time of prolapse repair.

Concomitant sling surgery – While concomitant midurethral sling decreases overall rates of UI, the number needed to treat is approximately 6 in order to prevent one patient from needing treatment within one year of surgery [46].

Staged sling surgery – A trial comparing concomitant midurethral sling with no sling at the time of vaginal prolapse repair in patients with documented preoperative stress incontinence revealed that approximately one-third did not require additional SUI treatment within one year of surgery [47]. Additionally, long-term outcomes (five years) after vaginal prolapse repair demonstrate low retreatment rates (8 percent), regardless of concomitant sling or no sling at the time of prolapse repair.

Renal evaluation for patients with stage III or IV prolapse – We perform a renal ultrasound plus laboratory evaluation of blood urea nitrogen and creatinine preoperatively to assess baseline function and document pre-existing abnormalities [48]. (See "Assessment of kidney function".)

Patients with stage III or stage IV uterine prolapse may develop ureteral kinking due to the relationship between the ureter and the uterine vessels. Additionally, these patients can develop high-pressure urinary obstruction due to urethral kinking, regardless of uterus being present. This obstruction of ureter and/or urethra increases the risk for hydroureter, hydronephrosis, and ultimately impaired renal function. In a cohort study of 180 patients with a Pelvic Organ Prolapse Quantification value of +1 or greater at points C, Aa, or Ba, 30 percent had some hydronephrosis [48].

Consideration of ureteral stents – To facilitate identification of the ureters at the time of surgery in individuals with advanced prolapse, some surgeons place temporary ureteral stents. Evidence to support the efficacy and safety of this practice is limited.

Use of temporary stents – In our practice, we selectively place temporary ureteral stents based on upper tract evaluation and in cases where visualization or palpation of the ureter may minimize the risk of injury during apical suspension procedures (eg, uterosacral ligament suspension in a patient with stage IV prolapse), anticipated adhesions, or difficult visualization of ureters during abdominal or minimally invasive procedures.

-(See "Placement and management of indwelling ureteral stents", section on 'Prophylactic'.)

-(See "Urinary tract injury in gynecologic surgery: Epidemiology and prevention", section on 'Prophylactic ureteral catheters (stents)'.)

Other options – Lighted stents are commercially available for laparoscopic or robotic-assisted procedures. Use of indocyanine green injected through temporary ureteral stents can also facilitate visualization of ureters using "Firefly" technology during minimally invasive procedures.

Vaginal atrophy — Patients with vaginal atrophy and/or lower urinary tract symptoms are offered low-dose vaginal estrogen for symptom reduction [49]. Low-dose vaginal estrogen had not been shown to improve postoperative outcomes related to prolapse anatomy [50]. (See 'Vaginal estrogen therapy' below.)

We ask patients with vaginal atrophy to use low-dose topical vaginal estrogen for four to six weeks preoperatively based on limited tissue [51] and postoperative symptom data [52,53]. Trials have reported reduced risk of UTIs in patients with a history of recurrent UTI [52] and improvement in symptoms related to vaginal atrophy [50], although objective questionnaire outcomes and surgical outcomes were not impacted [53].

We discuss the available formulations of vaginal estrogen with the patient (table 4), base the product prescribed on patient preference and insurance coverage, and generally advise patients to restart vaginal estrogen two weeks after surgery. Additional discussions of vaginal atrophy and low dose vaginal estrogen formulations are available separately. (See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Treatment", section on 'Vaginal estrogen therapy'.)

Smokers — Smoking is associated with significantly higher rates of postoperative complications, particularly infections (including urinary and deep wound) and hospital readmissions [54]. All patients who smoke should be strongly encouraged to quit as smoking cessation at least four weeks prior to surgery may improve outcomes. (See "Overview of smoking cessation management in adults", section on 'Preoperative management'.)

Retention of cervix — Patients who retain their cervix, with or without the uterine corpus, should continue cervical cytology testing as indicated. (See "Screening for cervical cancer in resource-rich settings".)

INTRAOPERATIVE — Intraoperative steps specific to urogynecologic procedures include reassessing the patient's anatomy, positioning the patient, prepping multiple operative sites, confirming available instruments, inserting a bladder catheter, and performing intraoperative cystourethroscopy. Many programs have implemented enhanced recovery after surgery (ERAS) programs to guide fluid and medication management; such programs have been associated with improved patient surgical outcomes and satisfaction [55,56]. (See "Enhanced recovery after gynecologic surgery: Components and implementation".)

At the start of the procedure, we routinely conduct a surgical time-out [57]. Next we perform an examination under anesthesia to confirm the anatomic defects and surgical plan, assess for any unexpected pathology, and evacuate the lower rectum of stool to minimize soiling during the procedure. We then focus on patient positioning to maximize surgical access and minimize risk of patient injury. All operative surfaces are prepped and draped. Chlorhexidine 2% scrub is preferentially used over iodine due to lower infection rates and no increased vaginal irritation [58,59]. We typically perform bladder catheter insertion at the beginning of the procedure and cystourethroscopy at the end of the procedure, except in cases of vaginal hysterectomy, where we place a foley catheter after successful entry to the anterior cul de sac. At the conclusion of vaginal reconstructive procedures, we typically insert vaginal packing as studies suggest that this is well tolerated and may lead to decreased hematoma formation and bleeding [60,61]. When the surgery is complete, we dictate or electronically document the details of the procedure and take care to document any pathology, note absence of suture placement in the rectum, and describe the cystourethroscopic findings, including presence of ureteral efflux bilaterally.

Other issues common to all gynecologic surgeries, such as informed consent, thromboprophylaxis, and prevention of surgical site infections (table 2), are discussed in more detail in related content.

(See "Gynecologic surgery: Overview of preoperative evaluation and preparation".)

(See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients".)

(See "Antimicrobial prophylaxis for prevention of surgical site infection in adults".)

Positioning — For any surgery, assessment of correct patient positioning at the start of the case is essential to prevent patient injury and ensure adequate surgical access. Additional considerations are important for urogynecologic procedures, specifically. As examples, stirrups for leg elevation must be supportive and noncompressive as the patient may be in dorsal lithotomy position for several hours. Female pelvic reconstructive surgeries may involve moving the operative table, arm boards, or patient's legs; care must be taken to ensure that no soft tissue or limb is trapped during these maneuvers. When Trendelenburg position will be used, the physiologic impact of this position is discussed with the anesthesia team and measures are taken to prevent the patient from sliding off the operative table. Obese patients may be positioned with their buttocks slightly overhanging the operative table to allow entry to the vaginal canal. Additional instruments may be needed to accommodate increased abdominal thickness or vaginal depth. (See "Gynecologic surgery: Overview of preoperative evaluation and preparation" and "Gynecologic surgery: Overview of preoperative evaluation and preparation", section on 'Patients with obesity'.)

Prevention of nerve injury, particularly for patients in dorsal lithotomy position, is reviewed in detail separately. (See "Nerve injury associated with pelvic surgery".)

Positioning needs can vary between vaginal and abdominal, laparoscopic, and robotic procedures:

Vaginal surgery – Candy cane stirrups (figure 1) or boot stirrups (figure 2) are acceptable based on surgeon preference. The use of candy cane stirrups appears to increase rates of transient femoral neuropathy [62] and worse physical function at six weeks when compared with boot stirrups [63]. Thus, we use Allen stirrups for longer reconstructive procedures where risks of prolonged nerve compression are higher. Regardless of stirrup choice, it is important that knees and hips remain flexed at 90° angles and that the knee/leg does not rest on the stirrups (figure 1). We use foam padding of the knee and surrounding area to ensure no direct contact with the post of the stirrup. This neurologically neutral position prevents overflexion of the hip/knee joints or compression against the stirrups, which can result in femoral or lateral peroneal nerve injuries. The position of arms is dictated by the preferences of the anesthesiology team because the location of the arms does not impact vaginal access. We typically secure the arms to padded arm boards to ensure they remain in a neurologically neutral position for the duration of the surgery to the abdomen.

Open, laparoscopic, or robotic procedures – We prefer supportive, boot-type stirrups (eg, Allen stirrups) for these patients because they allow for easy transition from vaginal to abdominal procedures (figure 2). We prefer to pad and tuck the patient's arms in military position (ie, arms at sides with palms facing toward lateral thighs) to protect the arms and facilitate the surgeon's access to the abdominal surgical field (figure 3). Tucking the patient's arms reduces the risk of nerve and vascular injuries that can occur when arms are fixed to boards that are then moved too far cephalad during the procedure and facilitate access and movement of the surgeon. (See "Overview of gynecologic laparoscopic surgery and non-umbilical entry sites", section on 'Patient positioning and preparation'.)

Surgical preparation of skin and vagina — Adequate skin and vaginal preparation is indicated to reduce the risk of operative site infection. We use a 2 percent chlorhexidine gluconate solution with 70 percent isopropyl alcohol for the abdominal preparation and 4 percent chlorhexidine gluconate with a lower isopropyl alcohol concentration for the vaginal preparation [58,64,65]. While povidone-iodine (PVP-I) is commonly used in the United States for vaginal preparation, chlorhexidine is commonly used elsewhere because it may provide a greater reduction in skin flora than PVP-I and is not inactivated in the presence of blood. Either PVP-I or chlorhexidine gluconate with a low concentration of isopropyl alcohol is acceptable for vaginal preparation [25,65].

(See "Gynecologic surgery: Overview of preoperative evaluation and preparation", section on 'Skin preparation'.)

(See "Gynecologic surgery: Overview of preoperative evaluation and preparation", section on 'Vaginal preparation'.)

If hair removal is needed, we use clippers rather than shaving to reduce the risk of surgical site infection. (See "Overview of control measures for prevention of surgical site infection in adults", section on 'Hair removal'.)

Bladder catheter — Bladder catheter drainage is performed in most urogynecologic procedures as it decompresses the bladder during surgery and allows intraoperative assessment of the patient's fluid balance. The timing of catheter insertion varies with the procedure. For patients undergoing open, laparoscopic, or robotic procedures, we generally insert a bladder catheter on the sterile field at the start of the surgery. For patients undergoing vaginal hysterectomy, we insert the bladder catheter after anterior colpotomy to facilitate visualization of the vesicovaginal junction. However, this practice varies, and it is reasonable to drain the bladder prior to the anterior colpotomy. The bladder catheter is removed to perform cystourethroscopy and then reinserted at the conclusion of cystourethroscopy. Removal is attempted after removal of any vaginal packing as soon as the patient is ambulatory, generally on postoperative day 0 or 1 [66].

Postoperative bladder catheter removal is discussed elsewhere. (See 'Catheter removal and voiding trial' below.)

Retractor use in surgery — Adequate visualization is essential to all surgical procedures. Self-retaining retractors can be advantageous in urogynecologic procedures because the operative field may be quite small and limit the ability of assistants to use handheld retractors. Retractor selection varies by type of procedure, surgeon preference, and retractor availability. For open abdominal surgery, we use a self-retaining retractor such as the O'Sullivan-O'Connor (figure 4) or Turner-Warwick given their ease of placement and ability to vary blade position (picture 1 and picture 2). Some surgeons prefer the Bookwalter retractor (figure 5) because of the versatility of the retractor blade location and the variable depth of the blades; however, this requires attachment to the surgical table and tends to add more time to set up than the self-retaining retractors. Regardless of which self-retaining retractor is used, care must be taken to avoid bowel entrapment (any of the blades) and compression of the femoral nerve (lateral blades). (See "Nerve injury associated with pelvic surgery".)

For vaginal surgery, we do not typically use a separate retractor as we generally have two surgical assistants to expose for the primary surgeon. However, in settings where surgical assistants are limited or exposure is difficult, vaginal retracting systems (eg, Lone Star) provide exposure and visualization without taking up significant space. When using a self-retaining vaginal retractor, the hooks must be anchored deeply enough to avoid tearing the tissue when tensioned. Other retractors for vaginal surgery include the Magrina-Bookwalter [67], Rigby vaginal retractor (figure 6) and the Gelpi perineal retractor (figure 7).

Intraoperative cystourethroscopy — Intraoperative cystourethroscopy is done to rule out cystotomy, diagnose intravesical or intraurethral suture or mesh, verify bilateral ureteral patency, and evaluate for fluid extravasation after bladder surgery [68]. We typically perform intraoperative cystourethroscopy during all incontinence procedures, during any procedure involving apical and/or anterior prolapse repair, and any time there is concern for urogenital tract injury [69]. While urine dyes are not necessary to document efflux, they may facilitate visualization during cystoscopy. A variety of methods are available [70]. Cystourethroscopy does not need to be performed if surgery is limited to the posterior compartment (eg, isolated rectocele repair). There is no consensus regarding the role of cystourethroscopy during simple hysterectomy [68]. In these cases, if we have any concern for ureteral patency or bladder injury, we perform an intraoperative cystourethroscopy using a 70-degree lens and 17 French sheath or a flexible cystoscope.

Discussions on performing cystourethroscopy and its use during gynecologic surgery are presented in detail separately.

(See "Diagnostic cystourethroscopy (cystoscopy) for gynecologic conditions".)

(See "Urinary tract injury in gynecologic surgery: Identification and management", section on 'Debate of universal versus selective cystoscopy'.)

Vaginal packing — We routinely place a vaginal pack following pelvic reconstructive surgery (eg, anterior and posterior colporrhaphy, pubovaginal slings) or when suboptimal hemostasis is present [60]. Vaginal packing is well tolerated and may decrease bleeding and hematoma formation [60,61]. In contrast, we do not place a vaginal pack for isolated hysterectomies, midurethral slings, or abdominal prolapse repairs (ie, abdominal, laparoscopic, or robotic sacrocolpopexy) [71]. One trial of 190 patients randomly assigned to postoperative vaginal pack or no pack after vaginal hysterectomy (with or without pelvic floor surgery) reported no differences in postoperative pain scores or incidence of hematoma formation between the groups [60]. However, there was a nonsignificant trend toward fewer hematomas in the patients with vaginal packs. In a trial of 77 patients randomly assigned to vaginal pack or no pack after pelvic reconstructive surgery, the patients who received a vaginal pack had lower pain scores documented by the nursing staff and used less postoperative ketorolac [61]. Because there have been case reports of retained vaginal packs, it is imperative to document in the operative report that a vaginal pack has been placed and then document removal (typically postoperative day 1). A suture tied to the pack and taped to the patient's leg or the urethral catheter can be an extra reminder the pack is in place. Some institutions require placement of an armband on the patient when the pack is placed and the armband is removed at the same time as the vaginal pack.

Local analgesia — Local anesthetics are commonly injected to facilitate surgery while long-acting local agents do not appear add additional benefit.

Short-acting agents – The authors routinely use lidocaine or bupivacaine, both with epinephrine, for vasoconstriction and hydrodissection at the time of midurethral sling placement. The authors also use vasoconstricting agents, generally dilute vasopressin and, less often, lidocaine with epinephrine, for other vaginal repair procedures.

Long-acting liposomal agents – We do not use liposomal bupivacaine because the body of evidence suggests no benefit for urogynecologic surgery, although not all studies agree [72-79]. Additionally, studies have failed to demonstrate the cost-effectiveness of long-acting analgesics compared with shorter-acting analgesic agents. A 2017 meta-analysis that included participants (female and male) undergoing elective surgery at any site reported lower pain scores for liposomal bupivacaine compared with placebo at 72 hours but similar pain scores when compared with local infiltration of bupivacaine hydrochloride [80].

POSTOPERATIVE

Common issues — Common postoperative issues after urogynecologic surgery include pain control, catheter removal and voiding function, bowel function, estrogen use, and activity restriction. Clear instructions that help patients navigate these concerns are especially important given that many patients go home on the same day or within 23 hours. Same-day discharge for pelvic reconstruction, including hysterectomy, has been shown to be safe and without increased rates of complications or 30-day readmission [81]. Patients who undergo open abdominal or complex surgeries stay in the hospital until they are ambulating and tolerating a regular diet (typically postoperative day 1 to 3). We do not routinely order postoperative laboratory evaluations in clinically stable patients as this practice has not been reported to improve clinical outcomes [82,83].

Postoperative complications related to gynecologic surgery are discussed separately. (See "Complications of gynecologic surgery".)

Pain management — We use an enhanced recovery after surgery (ERAS) protocol [55,84,85]. (See "Enhanced recovery after gynecologic surgery: Components and implementation".)

Pre- and perioperative

Preoperative – Consistent with other ERAS protocols, patients receive celecoxib 400 mg, acetaminophen 1000 mg, and gabapentin 600 mg orally once [84]. (See "Enhanced recovery after gynecologic surgery: Components and implementation", section on 'Intraoperative'.)

Perioperative – Acute perioperative pain is managed by the anesthesia team and medications are titrated according to clinical protocols. There are no specific medication requirements or strategies specific to female pelvic medicine and reconstructive surgery.

Once the patient is ready to leave the postanesthesia care unit, medication selection depends on drug availability, side effects, and patient tolerance. Our approach aims to minimize narcotic use. We give acetaminophen (max 4000 mg per day), ketorolac, and tramadol. In patients who cannot take tramadol due to selective serotonin reuptake inhibitor or monoamine oxidase inhibitors use or other contraindication, we give oxycodone. Individuals with normal renal function receive intravenous ketorolac 30 mg (in patients over age 65 we reduce the dose to 15 mg) every six hours for a total of up to 24 hours. Breakthrough pain is treated with intravenous narcotics (ie, hydromorphone 0.2 mg every four hours as needed or morphine 5 mg every four hours). (See "Enhanced recovery after gynecologic surgery: Components and implementation", section on 'Intraoperative'.)

Unique populations – Individuals with a history of chronic opioid exposure or addiction, elevated body mass index, or complex medical issues may benefit from additional consultation with the anesthesia team regarding pain control strategies.

Supporting data – In a trial of 138 patients comparing multimodal pain control (preoperative and postoperative celecoxib, gabapentin, intraoperative and postoperative intravenous and oral acetaminophen and ibuprofen, and narcotics as needed) with usual care reported that patients who received the multimodal treatment used one-third less total opioid analgesia than patients in the routine care group [84].

Detailed discussions of ERAS protocols and perioperative pain management are presented separately.

(See "Enhanced recovery after gynecologic surgery: Components and implementation".)

(See "Approach to the management of acute pain in adults".)

(See "Use of opioids for acute pain in hospitalized patients".)

(See "Nonopioid pharmacotherapy for acute pain in adults".)

Discharge — Prior to discharge home we transition from intravenous ketorolac to scheduled oral ibuprofen. Written instructions are provided to explain the use of these medications. (See "Approach to the management of acute pain in adults".)

Nonsteroidal anti-inflammatory drugs (NSAIDs) – In our practice, we typically prescribe oral ibuprofen 600 mg to be taken every six hours with food and acetaminophen 1000 mg every eight hours. (See "Nonopioid pharmacotherapy for acute pain in adults".)

As the patient’s pain lessens, she can move from scheduled ibuprofen dosing to as-needed dosing. This transition generally occurs over two to five days for minimally invasive surgeries but may take longer for open abdominal procedures.

When prescribing combination medications that include acetaminophen (eg, hydrocodone and acetaminophen, commercial name Vicodin), the clinician must ensure that the patient's intake of acetaminophen does not exceed 4 grams per 24 hours, although some use a lower threshold of 3 grams per 24 hours to minimize risk of liver toxicity [86,87].

Limited use of opioids – Due to heightened concerns over narcotic dependence and in-line with supporting data [88], we do not routinely offer narcotic medications such as oxycodone or hydromorphone. We prefer tramadol, which is associated with lower rates of dependence, and add gabapentin starting at 300 mg at night and increase as needed up to 600 mg three times a day for additional pain control prior to adding narcotics.

For patients who cannot take or have insufficient pain reduction with this regimen, we prescribe 5 mg oxycodone tablets and instruct the patient to take one to two tablets orally every six hours as needed. No more than a seven-day supply of opioid medication is given.

Additional discussions of postoperative opioid use and risks of long-term misuse are presented elsewhere.

(See "Use of opioids for acute pain in hospitalized patients".)

(See "Risk of long term opioid use and misuse after prescription of opioids for pain".)

Catheter removal and voiding trial — Prior to patient discharge, a voiding trial is performed to ensure adequate bladder function. The voiding trial is done as soon as patients are able to ambulate (outpatients) or on the first postoperative day (inpatients).

Our approach – Two systematic reviews reported similar outcomes from several void trial modalities with no method being superior [89,90]. In our practice, we take the following approach:

Most pelvic surgery patients – For most patients, we perform a retrograde voiding trial prior to patient discharge.

-Inpatient surgery – For inpatients, we first have the patient stand at the bedside to drain the bladder catheter completely. Once empty, we then retrograde fill the bladder with 300 mL of sterile water or saline followed by immediate catheter removal. The patient is allowed 10 minutes to void. The patient must void 200 mL or more to demonstrate adequate voiding function. If available, we also request a bladder ultrasound assessment of the postvoid residual volume to confirm that the residual volume is not in excess of 100 mL.

-Outpatient surgery – In the outpatient surgery setting, bladder filling can be passive (spontaneous) or active (retrograde fill) and PVR can be measured using portable ultrasound or a straight catheter to drain the residual bladder volume. If a portable ultrasound is not available, we advise performing a standard retrograde fill voiding trial prior to discharge (described in inpatient surgery above) as diuresis and duration of recovery vary widely. In addition, vaginal packing can obstruct the urethra and prevent spontaneous voiding; these patients typically have an indwelling bladder catheter until the pack is removed and then undergo standard retrograde fill voiding trial.

If bladder ultrasound is available and no vaginal packing is present, patients can undergo retrograde fill of the bladder with approximately 150 mL of normal saline at the completion of surgery. In the recovery room, the patient voids when she has a normal sensation and the PVR is assessed with portable ultrasound [91,92]. In a meta-analysis of four trials, bladder retrograde filling in the operating room rather than passive filling in the postanesthesia care unit (PACU) decreased the time to first void (mean difference -33.5 minutes, 95% CI -49.1 to -17.9, 4 studies, 403 patients) and time to discharge (mean difference -32.0 minutes, 95% CI -51.5 to -12.6, 8 trials, 1164 patients) [93]. Retrograde filling did not reduce the time to discharge when done in the PACU.

If the patient is unable to void within three to four hours [94], then ultrasound is used to measure the bladder volume and determine if the patient needs bladder emptying with catheterization. Patients who do not void adequately in the recovery area are offered instruction on self-catheterization or management with an indwelling bladder catheter. Indwelling bladder catheterization is generally preferred for bladder volumes in excess of 500 mL although there is individual variation. Those who are discharged with an indwelling bladder catheter are seen in the outpatient clinic for a repeat voiding trial in 24 to 48 hours.

Bladder surgery or injury – An exception to the above practice on voiding trials is made for individuals who have bladder surgery or injury. These patients keep the bladder catheter in place for 7 to 14 days, depending on the size and location of the injury, to minimize the risk of fistula formation [95]. There is little evidence to guide recommendations for duration of catheterization and imaging after bladder injury. For large defects or fistula repairs, we typically perform a computed tomography cystourethrogram prior to permanently removing the catheter. This is done with a retrograde fill of contrast dye to 300 mL to document the integrity of the repair prior to catheter removal. A less costly and simple office procedure to assess for vesicovaginal fistula involves a retrograde fill of indigo or methylene blue-stained saline to 300 mL via bladder catheter followed by a careful vaginal examination and/or tampon insertion to assess for extravasation and ensure the integrity of the repair. (See "Urinary tract injury in gynecologic surgery: Identification and management", section on 'Management'.)

Use of alpha receptor agonist medication – Perioperative use of alpha receptor agonists (eg, tamsulosin) has been proposed to relax the bladder outlet and reduce the risk of postoperative urinary retention. In a trial of 119 patients comparing perioperative tamsulosin with placebo, tamsulosin was associated with lower rates of postoperative urinary retention (8.8 versus 25.8 percent). The medication was started three days prior to surgery and continued for 10 days total. While this is a promising treatment option, more data are needed before universally applying this approach [96].

Unsuccessful voiding trial – Most patients with unsuccessful voiding trials are discharged home with a temporary indwelling bladder catheter or instructed on clean intermittent catheterization in the recovery area; choice often depends on patient preference. Optimal duration for an indwelling catheter following an unsuccessful voiding trial is not known. In a study of 64 patients who underwent multicompartment vaginal surgery, had an unsuccessful same-day retrograde voiding trial, and were randomly assigned to repeat voiding trials either early (postoperative days 2 to 4) or late (postoperative day 7), the early group was more likely to have a repeat unsuccessful voiding trial (23 versus 3 percent) [97]. Rates of catheter bother and urinary tract infection (UTI) were similar between the groups. However, small sample size limits the generalizability of this trial.

A small randomized controlled trial of home versus office voiding trial demonstrated similar patient satisfaction rates, no significant difference in successful voiding, and no difference in complications [98]. This approach involves instructing patients how to remove the catheter before discharge to home, written instructions, and providing supplies, including a voiding hat and 10-mL syringe, and may be preferable for some patients. Another small trial comparing indwelling continuous drainage catheters with plug-unplug catheters reported similar outcomes in time to catheter removal, rates of UTI, and overall patient satisfaction between the groups [99]. Patients with the plug-unplug catheters perceived them as easier to manage. Patients who prefer to perform clean intermittent self-catheterization, rather than have an indwelling catheter, are taught this technique instead. (See "Postoperative urinary retention in females", section on 'Voiding trials'.)

Postoperative antibiotics — There is controversy over whether to treat patients undergoing midurethral sling procedures with nitrofurantoin 100 mg orally twice a day for three days postoperatively to reduce the risk of UTI [100]. As the data regarding the benefits of prophylactic antibiotic use after midurethral sling surgery are mixed, clinicians may reasonably choose to use, or not use, postoperative antibiotics [100-102]. However, if the patient is allergic to nitrofurantoin or there are contraindications (eg, renal failure), the authors do not substitute broader spectrum antibiotics due to the additional risks of gastrointestinal upset, yeast infections, and bacterial resistance. As an alternative, clinicians may consider methenamine hippurate 1 gram twice daily as a large study demonstrated noninferiority to antibiotics when given for postoperative prophylaxis [103].

As with all surgeries, primary measures to prevent catheter-associated UTI are avoidance of unnecessary catheterization, use of sterile technique when placing the catheter, and removal of the catheter as soon as possible [95]. (See "Placement and management of urinary bladder catheters in adults".)

Although some may provide ciprofloxacin 250 mg at the time of catheter removal if it has been in place for more than two days, this is not our routine practice [104]. Although prophylactic antibiotics are generally not recommended for patients with indwelling bladder catheters [104-106], patients with an indwelling catheter after urogynecologic surgery are a unique subgroup. Studies of surgical patients who undergo short-term catheterization suggest that a brief course of antibiotics at the time of catheter removal may reduce infection risk. In a meta-analysis of six randomized and one nonrandomized controlled trials, antibiotics given around the time of catheter removal reduced the absolute risk of subsequent symptomatic UTI by 5.8 percent [104]. The patients in these studies were primarily surgical, including urologic surgery.

Bowel function — There are no evidence-based guidelines on the prevention of postoperative constipation in patients undergoing urogynecologic surgery. We prescribe oral docusate sodium 100 mg twice a day for the first postoperative week or for the duration of narcotic pain medicine use. If this regimen is not adequate to maintain regular bowel function, we encourage the patient to add milk of magnesia, prunes, or a bisacodyl suppository as needed. In a trial comparing oral docusate sodium alone with combined oral docusate sodium and polyethylene glycol 3350 (PEG3350) given for five days following urogynecologic surgery, the time to first bowel movement was the same for both groups, although the patients taking PEG3350 were less likely to use additional laxatives [107]. Thus, PEG3350 does not appear to be beneficial in this postoperative group. If these interventions do not restore bowel function, we evaluate the patient for ileus or obstruction.

We call all patients two to three days after their procedure to answer questions or concerns, verify they have had a bowel movement, and provide recommendations for additional laxative use if needed. We do not recommend use of rectal suppositories in patients who have undergone anal canal surgery (ie, hemorrhoidectomy or anal sphincter repairs), but do not limit use in rectocele repair or other prolapse surgery. If a patient has not had a bowel movement seven days after surgery, we recommend evaluation for possible disimpaction. If the patient does not have flatus or complains of nausea/vomiting in association with constipation, we recommend immediate evaluation for ileus or obstruction. (See "Postoperative ileus".)

Vaginal estrogen therapy — While vaginal estrogen is commonly prescribed for symptom reduction in postmenopausal women with pelvic floor disorders [49], its use has not been associated with improved surgical outcomes. In a placebo-controlled trial of 206 women undergoing vaginal prolapse repair, vaginal estrogen and placebo treatment resulted in similar overall surgical success rates, adverse events, and pelvic floor or sexual function symptoms at 12 months postoperatively. However, for those with bother from at least one baseline symptom of vaginal atrophy, more patients in the vaginal estrogen group experienced improved vaginal atrophy symptoms [50].

For those women using preoperative vaginal estrogen to manage symptoms of atrophy or lower urinary tract symptoms, there is little evidence to guide postoperative resumption following pelvic reconstructive surgery [108]. We take the following approaches:

Vaginal cream or tablets – Patients resume vaginal estrogen cream or tablets two weeks after surgery as that allows initial healing of any suture lines in the vagina and decreases complaints of bleeding from trauma of the applicator. Typically, patients resume twice-weekly dosing as described above (see 'Vaginal atrophy' above).

Vaginal ring – We advise delaying vaginal estrogen ring insertion for six weeks to avoid vaginal placement of a foreign body.

Activity restrictions — We advise our patients to return to daily activities as tolerated. Randomized trials have failed to identify differences in short term outcomes with activity restriction compared with liberal activity [109,110], and studies have demonstrated intraabdominal pressure increases are higher with involuntary actions such as coughing and sneezing than with activities of daily living [111-113]. Therefore, we do not recommend specific activity restrictions except that we instruct the patient to abstain from vaginal intercourse or activity that may disrupt suture lines (eg, bicycle riding or straddle activity) for six weeks or until postoperative examination confirms complete wound healing. Patients are allowed to resume driving when they are no longer using narcotic pain medication.

Smokers — The appropriate pharmacotherapy should be initiated for smokers. (See "Overview of smoking cessation management in adults", section on 'Hospitalized patients'.)

FOLLOW-UP CARE — We routinely call patients two to three days after surgery to assess pain control and bowel and voiding function, and to answer any questions. Early office evaluation is scheduled for patients with persistent or unusual concerns. We have found that this practice results in high patient satisfaction and fewer after-hours calls.

Short-interval evaluation (one to four days) is automatically scheduled for patients who had an unsuccessful postoperative voiding trial. The voiding trial is repeated in the outpatient setting (see 'Bladder catheter' above). Patients who are unable to void at this time are taught clean intermittent self-catheterization. (See "Postoperative urinary retention in females", section on 'Clean intermittent catheterization'.)

While patients are seen at any time in the postoperative period if complications arise, the routine postoperative visit is scheduled four to six weeks from surgery. At this visit, abdominal and vaginal examinations are performed to ensure the incisions have healed and there is no evidence of mesh erosion or wound complications. The Pelvic Organ Prolapse Quantification (POP-Q) examination is repeated to document postoperative prolapse correction. We also routinely assess a postvoid residual to ensure the patient's bladder is emptying well. Pain management and bowel function are assessed, and all questions are answered. In patients who live far from the clinic or are otherwise unable to easily return for a postoperative visit, a trial reported that telephone follow-up was noninferior to clinic follow-up when looking at both patient satisfaction and adverse outcomes [114]. We do not routinely refer postoperative patients for physical therapy as it has not been shown to improve surgical outcome [115].

UNIQUE POPULATIONS — Patients with the following issues have unique additional perioperative care needs which are reviewed in detail separately:

Obstetric anal sphincter laceration (see "Repair of perineal lacerations associated with childbirth" and "Delayed surgical management of the disrupted anal sphincter" and "Fecal and anal incontinence associated with pregnancy and childbirth: Counseling, evaluation, and management")

Obstetric fistula (see "Obstetric fistulas in resource-limited settings")

Urogenital tract fistula (see "Urogenital tract fistulas in females")

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Gynecologic surgery".)

SUMMARY AND RECOMMENDATIONS

Preoperative counseling – Preoperative counseling and documentation for urogynecologic procedures outline the alternatives to and general risks of surgery as well as specific risks of persistent symptoms, postoperative voiding dysfunction, de novo or worsened incontinence, and de novo or worsened sexual dysfunction. (See 'Counseling' above.)

Preoperative urodynamic testing – We do not perform preoperative urodynamic testing in patients with uncomplicated SUI. Such testing has not been reported to improve surgical outcomes. (See 'Urodynamic studies' above.)

Patients whose preoperative evaluation may benefit from urodynamic testing include those with:

Symptoms that are inconsistent with examination findings

History of prior anti-incontinence procedures, reconstructive surgery, or pelvic radiation

Stage 3 to 4 pelvic organ prolapse

Symptoms of complicated SUI, mixed incontinence, or urinary retention

Potential neurogenic causes of incontinence

Additional evaluation – Patients who require additional preoperative evaluation include those with abnormal uterine bleeding, advanced uterine prolapse, or medical comorbidities. We selectively perform additional testing on individuals undergoing obliterative procedures (evaluation of endometrium) and prolapse repair procedures (full-bladder prolapse reduction stress test, renal ultrasound, or laboratory testing). In diabetic patients with a HbA1C of 8 percent or higher, we delay surgery until improved control and medical clearance is obtained. Otherwise, preoperative laboratory testing is not necessary in uncomplicated patients undergoing low-risk procedures. However, all patients undergoing bladder instrumentation should have evaluation of the urine with a urinalysis and/or urine culture prior to surgery. (See 'Specific patient groups' above.)

Intraoperative care – Intraoperative actions specific to urogynecologic procedures include safe positioning that accommodates table and leg movement, positioning of the arms to allow surgical access and minimize injury, and selection of retractors that increase visualization in small anatomic spaces. Cystourethroscopy is performed during anterior or apical prolapse and incontinence surgeries, and any time there is a concern for ureteral, bladder, or urethral injury. (See 'Intraoperative' above.)

Common postoperative issues – Common postoperative issues that need to be addressed after urogynecologic surgery include catheter removal and voiding function, bowel function, resumption of vaginal estrogen therapy, and activity restriction. For voiding trial, no method is clearly superior to another. Clear instructions that help patients navigate these concerns are especially important given that many patients have short hospital stays. (See 'Postoperative' above.)

Unique populations – Patients with obstetric or urogenital fistulas and anal sphincter lacerations have unique additional perioperative care needs. (See 'Unique populations' above.)

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Topic 91017 Version 36.0

References

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