APP

report at least one 
PELVIC FLOOR DISORDER

Genetics

Pregnancy Pelvic
and child floor
injury
birth
Increased
Risk abdominal
Age Factors pressure

Obesity Constipation

Types of Pelvic Floor Dysfunction

• Supportive dysfunction

• Hypertonus dysfunction

• Both types can cause pelvic pain, pelvic pressure, back
pain, hip pain, or urinary/fecal incontinence

• Sexual dysfunction

185

Compounded Medications

• There are very few trials evaluating treatment efficacy in this
population

• Medication options are based on the limited available data,
clinical experience, and extrapolation from alternate pain
syndromes

• Counsel patients these medications are often off-label
• Limitations often limited availability of compounding

pharmacies and high cost

Lidocaine Ointment

• Lidocaine 2 - 5%
• Can help facilitate PFPT, intercourse, self dilation
• Some women report burning, so start slow!
• Rarely use alone, but may use in combination with other

medications

Estrogen +/- Testosterone

• Atrophic vaginitis can trigger/exacerbate PFD
• Apply estradiol 0.01 - 0.02% +/- testosterone 0.05% - 0.01% in

compounded base once to twice daily
• Expect 50% improvement by 12 weeks

186

Gabapentin

• Gabapentin 4 - 10% topical preparations applied 1 – 3 times
daily

• May take 4 - 6 weeks to see a result

Baclofen

• Baclofen 5 – 10mg suppositories inserted one to three times
daily

• May insert vaginally or rectally
• If too expensive, may instead prescribe 5 - 10mg tablets, crush,

and place in a neutral base (ex. KY jelly, coconut oil)
• Many women prefer to then place in the freezer

Diazepam

• Data are limited and conflicting
• Diazepam 5-10 mg one to three times daily
• Suppositories come in set doses; may consider a cream

instead so the patient can titrate if overly sedated
• Typically administer at night to assist with sleep

187

Amitriptyline

• Amitriptyline 2% cream applied once daily
• May avoid oral side effects including fatigue, weight gain,

constipation, and drying of mucous membranes
• Other studies have reported a modest effect of amitriptyline

cream in combination with 2% baclofen cream or 0.5%
ketamine cream

Pearls

• Compounding pharmacies can make combinations of
medications to decrease the number of separate applications

• For patients with sensitive skin, some pharmacies can give
patients the base alone to trial PRIOR to filling the Rx  to
ensure the base does not cause a reaction

Summary

• Pelvic floor dysfunction is common and can lead to a multitude
of negative symptoms

• A multi-modal approach is often required for optimal relief
• Compounded medications can offer excellent results in

assisting pelvic floor dysfunction

188

Thank you.

[email protected]
@drcaraking

189

Notes

There’s More to Consider than 
just Pelvic Floor Muscles…

Nicole (Niki) Cookson, PT, DPT, WCS

Objectives

• Describe musculoskeletal anatomy of spine, pelvis and hips
highlighting relationship to pelvic floor muscles 

• Discuss screening and evaluation of spine, pelvis and hip
• Describe how large muscle dysfunction treatment can influence the

pelvic floor

Pelvic PT Consultation

95.3% of women with lumbopelvic pain have some form of pelvic floor dysfunction
• 71% PFM tenderness
• 66% PFM weakness
• 41% pelvic organ prolapse

Must include focused MSK exam
• Posture
• Breathing
• Spine
• SI joints
• Hips
• Balance

Prather(2014); Dufour et al.(2018)

190

Posture

• Diaphragm position in relation to 
pelvic diaphragm (levator ani) 

↑thoracic kyphosis/↓ lumbar lordosis ‐ POP
↑ lumbar lordosis ‐ FI and constipation 

Mattox et al.(2000); Brusciano et al.(2009)

Breathing Mechanics

• No gold standard to confirm mechanical dysfunction
• Look for quality, symmetry, rate
• Hi lo screen 

Kiesel (2017); Roussel et al (2007)

Diaphragm and PFM Exhale
Abdominals recoil
Inhale PFM recoil
Abdominals expand
Mayo Clinic patient education image
PFM expand

Hodges(2007); Talasz(2011); Wiebe(2013)

191

Diaphragmatic Breathing

Balance Decreasing mobility/incontinence

• PFM foundation of the house

Toilet training

• SLS for 10 seconds
• Trendelenburg

Fritel (2013); Fuentes‐Ma´rquez et al.(2018); Roll for Control (2005)

Strength testing

• Need to look global first 

• Hip strength connected to PFM strength

• Obturator internus – hip rotator
• Glute max/med/min – hip abduction/extension
• Piriformis
• Adductors 

• Potential for overflow and compensation

• Weak hips = weak PFM   OR Weak hips = hypertonic PFM

Tuttle (2016); Tu et al (2008)

192

Lumbar Spine

• Iliohypogastric, Ilioinguinal (L1)
• Lateral femoral‐cutaneous (L2)
• Genitofemoral (L1‐2) 
• Femoral (L3)
• Obturator (L2,3,4)
• Psoas (major, minor)
• Iliacus
• Quadratus lumborum
• Abdominals

Lumbar Spine

• Discogenic
• Radicular pain/radiculopathy 
• Lumbar plexopathy

• PFM contribute to stability and load transfer
• High incidence of PFD in women with LBP

Defour et al. (2018); Prather (2014)

Lumbar Spine

• Range of motion 
• SLR, slump test
• Intervertebral motion (pain, hypo/hypermobile)
• Palpation
• Pain generator or dysfunction from spine?

193

Lumbopelvic Core 

Look for coordination of :
• TrA
• Diaphragm
• Pelvic floor muscles
• Multifidus 
• Gluteals

Mayo Clinic patient education image

Hip Joint

• Shared anatomy and function with PFM
• PFM provide stability and allow motion at hip
• Co‐contraction of glute max and levator ani
• Potential for compensation

• Intra‐articular       vs         Extra articular

Osteoarthritis Tendinopathy
Labral pathology Piriformis syndrome
FAI Bursitis

Prather(2014); Tu et al (2008)

Hip Pain – location, location, location

• Anterior (arthritis, hip flexor, bursitis, labral tear, impingement)
• Lateral (GT bursitis, ITB, meralgia paresthetica/lateral femoral cutaneous nerve)
• Posterior (spinal stenosis, DDD, external rotator pathology)

194

Hip pain 

• Gait – antalgic, Trendelenburg
• Range of motion, FADIR, FABER
• Palpation soft tissue structures
Surgical hx: hip arthroplasty, fx
Pain generator in hip? 

Pelvic Girdle (SI joints and pubic symphysis)

• PFM contraction stabilizes SI joints
• PFM insertion/origins
• Posterior Femoral cutaneous (S2‐5)
• Pudendal (S2‐4)

Apte(2012); Dufour et al.(2018)

Pelvic Girdle

• Alignment, motion
• Pain provocation tests the best 

(Gillet's, sacral thrust, P4, compression/distraction)

Palpation: 
• ligaments (long dorsal, sacrotuberous, sacrospinous)
• muscles (piriformis, psoas/iliacus, coccygeus, glutes, multifidi, erector 

spinae, adductors)

195

Pelvic Girdle

• Pudendal nerve                                            

• sacrotuberous/sacrospinous
• Alcock’s canal 
• ischial spine

• Surgical/medical history?

• Sacrospinous fixation
• TVT, TOT
• Pelvic rami fx
• Uterine nociception – uterosacral lig.
• Sacral insufficiency fx

Coccyx

• Major ligamentous and muscle attachment site 

Coccyx

Lumbar spine movement ↔ coccyx movement ↔ PFM motion

Lumbar extension, coccyx extension, lengthening of PFM 
Lumbar flexion, coccyx flexion, PFM contraction 

Mayo Clinic patient education image

Maigne(2000);Nathan(2010)

196

Coccyx

• Why?  PFM myofascial pain, ligamentous injury, hypo/hypermobility, coccygeal 
disk disease, asymmetry of pelvic girdle leading to hypertonicity

• Screen for injuries/falls
• Injury during delivery?

• Typically good response to PT treatment.

• Treat the dysfunction found (PFM, bony pelvis, myofascial, etc)
• Manual therapy (internal and external)
• Address asymmetry 
• Kinesthetic work (sEMG biofeedback, ultrasound imaging)
• Pain modulation

Scott et al.(2017)

Clinical pearls

Local treatment can manage pain and improve function,   however 
treating the ROOT of the dysfunction is more of a long term strategy.  

→ Look for the driver.
PMF tension = Pain generator? Compensation? 
PMF weakness = Injury? 

Comiter(2003);Ramsden(2003); Nelson et al.(2012) 

Clinical pearls……

Watch your patient walk and move. 
Screen for orthopedic and MSK concerns

• Unilateral sensation changes/dysfunction? Lumbar spine
• Sensation changes in perineum?  Pudendal nerve

• ↑ pain during single leg stance ac vi es                 Pubic dysfunction

197

Clinical Pearls…..

• One‐sided PFM tenderness/hypertonicity  SI joint dysfunction, Hip
• Obturator alone is painful/tight/tender 

• Positional dyspareunia MSK origin

“Orthopedics in a Cave”  ‐Ruth Sapsford, PT

Case

198

Find your people

Pelvic PT’s should have: 
• Excellent orthopedic skills
• Incorporate treatment of MSK conditions with PFM dysfunction
• Part of PT evaluation must be MSK screen/testing
• Need to be less vagina‐centric!

Vetting questions for pelvic PT’s

• How much of their practice is PFD?
• External and internal PFM exam? Treatment?
• Comfortable treating spine/hip/SI, etc?
• More than just biofeedback?

Key Points

• Screen orthopedic/MSK in women with pelvic floor disorders 
• Correlation between pelvic floor dysfunction and lumbopelvic pain
• Pelvic PT = PFM + orthopedics

199

Notes

Enhanced Recovery After Surgery:
Developing your protocol

Cara R. King, DO, MS
Section Chief of Minimally Invasive Gynecologic Surgery

Assistant Professor, University of Wisconsin-Madison

Disclosures

• I have no conflicts of interest

Objectives

• Define and provide overview of enhanced recovery after
surgery (ERAS) in gynecologic surgery

• Describe key elements in creating protocol at your institution
• Provide resources to assist in protocol creation and

implementation

200

“Wait and see” More active
approach approach

Team reacts to Referred to
postoperative ERAS or ”fast
track” protocol
events

Impact of Surgery

Catabolic state

Increased Increased Impaired Tissue Distorted
cardiac insulin coagulation hypoxia pulmonary and
demands
resistance GI function

Can increase morbidity and prolong recovery

Goal of ERAS Allow patients to
resume activities
Preoperative sooner
Intraoperative
Postoperative Cost savings

201

Phases of Care: PREoperative

• Thorough counseling and education
• Optimization of co-morbid conditions
• No mechanical bowel preparation
• Oral carbohydrate loading
• No overnight fasting
• Avoidance of long-acting sedatives
• Acetominophen/neurontin

Scheib et al, JMIG, 2019

Phases of Care: INTRAoperative

• Antimicrobial prophylaxis
• Thrombosis prophylaxis
• Routine antiemetics
• Epidural analgesia
• High O2 concentrations
• Preventing hypothermia
• Avoidance of pelvic drains
• Goal-directed IV fluids/euvolemia
• Wound infiltration with local anesthetic/nerve blocks

Scheib et al, JMIG, 2019

Phases of Care: POSToperative

• Avoidance of nasogastic tubes
• Avoidance of ileus
• Prevention of PONV
• Multimodal analgesia
• Early oral intake
• Nutritional supplements
• Early mobilization, physical therapy
• Thrombosis prophylaxis

Scheib et al, JMIG, 2019

202

ERAS Works!

• Length of stay:
• TAH pre-protocol 5 days  post-protocol 3 days
• TLH pre-protocol same day discharge 9%  post-protocol
56%

• Postop pain and narcotic use: 20.8% to 97.4% drop in
narcotic use

• Bowel function: First defecation 24 hours sooner in ERAS
group

• Ambulation: 75.6% ambulating within 3 hours of surgery
• Complications or Readmissions: No significant difference

Mukhopadhyay et al, BMJ, 2015; Keil et al, Anesth, Analg, 2018; Hansen et al,
AJOG, 2007

ERAS Works!

• Patient satisfaction
• Positive outcomes for abdominal, laparoscopic, and vaginal
procedures
• LaPasse et all evaluated patients at POD 7 and POD 30 
97% reported satisfaction with their care

• Economics cost analysis
• ERAS implementation has been shown to decrease average
hospital costs by 18%-21% per patient

203

Developing your ERAS Protocol

Our Experience

Key Stakeholders

Gynecology Residents/ EPIC (EMR)
Clinic Fellows
MyChart
Inpatient Bedside
RN Staff

Preop Anesthesia Nutrition
RN Staff

PACU RN Pharmacy
Staff

204

Identify a
champion in each
of these areas!!

Stakeholder Tasks

Department Tasks

Gynecology Clinic -Changes to clinic template
Management -Updates with surgical pre/postop process workflow
MAs and RNs -Nutrition survey

Preop RN Staff -Medication administration

PACU RN staff -Early mobilization, PO intake

Inpatient RN Staff -Early mobilization, PO intake
-Multimodal pain regimen

Anesthesia -Identify multimodal pain regimen
-Assist with CHO loading timing, fluid management

Stakeholders Mission

Department Tasks
Pharmacy
-Identify current narcotic use in Gyn surgery
Nutrition -Engage in changes with pre/postop Rxs

EPIC (EMR) -Provide recommendations for malnutrition survey
MyChart Bedside -Assist with CHO loading
-Edit preoperative and postoperative order sets
-Patient education videos

205

Protocol Implementation

• Preoperative / Clinical
• Preoperative Education:

• Provided through group preoperative class
• Booklet provided created with input from ALL stakeholders

Tell them they’re going home!

Preoperative Class

• Group Preoperative Class (~60 minutes)

• Includes 6-8 patients
• Patient’s home care providers included
• Nutrition screen

• Preoperative Clearance with provider (20 minute)

• Same day as class
• Prescriptions provided

Protocol Implementation

• Inpatient Procedures
• Week prior: If positive nutrition screen  Nutrition consult

• Use high-protein drinks the week before surgery
• Day prior:

• Phone call from Preop RNs
• Bowel prep only when necessary
• Carbohydrate loading drink

206

Protocol Implementation

• Day of Surgery
• May ingest fluids until 4 hours prior to anesthesia

• Alternate literature: Light meal 6 hours prior to anesthesia, with
clear liquids up to 2 hours prior to anesthesia

Protocol Implementation

• Day of Surgery
• Preoperative medications

Celecoxib P J 32 RQFH
Gabapentin 600 mg PO once
Acetaminophen 1000 mg PO once

• FPMRS patients:
• Ua Screen (+/-)

Protocol Implementation

• Intraoperative Steps to Prevent Side Effects
• Nausea & Vomiting

• Risk factors= female gender, gynecologic surgery, MIS

• Transdermal Scopolamine patch
• Decadron 4mg IV
• Ondansetron 4-8mg IV

207





















Microscopy KOH

Saline • Destroys cellular elements

• Mobile Trichomonads • Whiff test – can detect fishy
(flagella) odor of BV

• Clue cells • Hyphae, pseudohyphae,
yeast

Bacterial Vaginosis (BV)

• Altered vaginal microbiome

• Shift in vaginal flora from Lactobacillus (which produce H2O2  acidic
pH) to more diverse bacteria, including anaerobes

• Production of amines = fishy odor, increased discharge

• Anaerobes produce proteolytic carboxylase enzymes that break down
vaginal peptides into volatile malodorous amines and increase vaginal
transudate and squamous epithelial cell exfoliation

• Increased pH >4.5

• Facilitates adherence of Gardnerella vaginalis to exfoliating epithelial
cells

Altered vaginal microbiome

• Gardnerella vaginalis • Mobiluncus
• Prevotella • Megasphera
• Porphyromonas • Sneathia
• Bacteroides • Clostridiales (BVAB 1, 2, 3)
• Peptostreptococcus • Fusobacterium
• Mycoplasma hominis • Atopium vaginae
• Ureaplasma urealyticum

217

Biofilm

• G. vaginalis adheres to vaginal epithelium  becomes the
scaffolding to which other species adhere

• Makes it difficult to eradicate

BV epidemiology

• Most common cause of vaginal discharge in women of
childbearing age: 40-50%

• NHANES prevalence based on results from vaginal swabs
including both symptomatic & asymptomatic women

• 29% in women 14-49%
• 50% in African-American women

Risk factors

• Sexual activity
• Other STIs (conversely is a risk factor for HIV acquisition)
• Race: African-Am>Hispanic>European-Am
• Douching
• Tobacco use

218

Symptoms

• Off-white, thin, homogeneous discharge
• Fishy odor
• More noticeable after sex, during menses
• Does NOT cause dysuria, dyspareunia, pruritus, burning,

erythema/edema – if present, suggests mixed vaginitis

Diagnosis

Amsel’s criteria • Vaginal fluid sialidase (OSOM
blue)
• Thin, gray-white,
homogeneous discharge • DNA probe for G. vaginalis
coating vaginal walls (Affirm VP III)

• Elevated pH>4.5 • Do NOT use Pap or vaginal
cx to diagnose!
• Clue cells on NS wet prep

• Fishy odor with KOH added

Treatment

• Indicated for symptomatic infection
• Prevention of postop infection in asymptomatic women prior to

abortion or hysterectomy
• Resolves spontaneously in up to 1/3 non-pregnant and ½

pregnant women
• ???screening asymptomatic pregnant women with hx prior

preterm birth
• No need to treat asymptomatic sexual partners

219

Metronidazole

• Metronidazole 500 mg bid x 7 days

• 2 gm po no longer recommended
• No alcohol due to Antabuse effect during duration of tx + 1 day

• Metronidazole vaginal gel 0.75% 5 gm qhs x 5 days
• Ok to use for pregnant women, oral tx more effective against

subclinical upper genital tract infection
• Side effects: metallic taste, nausea, transient neutropenia,

disulfiram-like effect with alcohol, prolongation of INR in those taking
warfarin, peripheral neuropathy

• allergy uncommon

Clindamycin

• Clindamycin 2% 5 gm x 7 days (do NOT use latex condoms)
• Clindamycin 300 mg bid x 7 days
• Clindamycin ovules 100 mg intravaginally qd x 3 days
• Vaginal therapy associated with increased prevalence of clinda-

resistant anaerobic bacteria post-treatment (as opposed to
metronidazole – post-tx resistance not seen)
• Oral therapy can be associated with C. difficile colitis
• If breastfeeding, oral clinda can change infant’s GI flora & cause
diarrhea, Candidiasis, colitis

Alternative treatment regimens

• Tinidazole 1 gm qd x 5 days
• Secnidazole 2 gm po x 1 (more expensive)
• ???oral or vaginal probiotics

220

Recurrence vs. reinfection

• ~30% have recurrence w/in 3 mo
• >50% have recurrence w/in 12 mo
• May just be persistent infection
• Biofilm may play a role

Symptomatic recurrence

• Initially treat with 7 day course of oral or vaginal metronidazole
or clindamycin

• +/- subsequent vaginal boric acid 600 mg suppositories qhs x
21 days

• Can cause death if ingested so needs to be secured away from
children

Long-term suppression

• >3 BV episodes in prior 12 mo
• Maintenance regimen of metronidazole gel twice/week x 4-6 mo
• Recurrent BV occurred in 26% on suppressive metronidazole

gel regimen vs. 59% on placebo

• Secondary vaginal Candida common side effect
• Clinda gel less effective, more associated with vaginal yeast

221

Sequelae

• Pregnant women at higher risk of preterm delivery
• Endometrial bacterial colonization
• Plasma cell endometritis
• Postpartum fever
• Post-hysterectomy vaginal cuff cellulitis
• Post-abortal infection
• Risk factor for acquisition of HSV, GC, Chlamydia, Trich
• ?conducive to persistent HPV

Candidiasis

• Inflammation, itching, erythema in the setting of Candida
species

• Part of the normal flora in ~25% women (10-20% reproductive
age, 6-7% menopausal women, 3-6% prepubertal girls)

• NOT: opportunistic infection or STI
• 2nd most common cause of vaginitis after BV
• Accounts for 1/3 vaginitis cases

Candida species

• Candida albicans: 80-90%
• Candida glabrata accounts for most of remainder
• C. parapsilosis
• ½ women may have another condition, e.g. BV, Trich

222

Microbiology

• Probably colonize vagina from GI tract

• Possibly increasing prevalence due to widespread treatment
• Symptom severity less

• Sometimes sexually transmitted or relapse from vaginal
reservoir

• Symptomatic disease related to overgrowth and penetration of
superficial epithelial cells

• Asymptomatic Sx disease due to host inflammatory response and
yeast virulence

Risk factors

• Uncontrolled diabetes
• Antibiotic use (up to ¼ to 1/3 women)
• Increased estrogen (OCPs, pregnancy, E2)
• Immunosuppression (steroids, HIV)
• Contraceptive devices (sponges, diaphragms, IUDs)
• Sexual behavior
• ???hygiene, e.g. douching, use of tampons vs. pads

Presentation

Symptoms Signs
• Pruritus
• Burning • Erythema
• Soreness
• Irritation • Fissures
• External dysuria
• Dyspareunia • Typically white, thick, curd-like
• Worse the week prior to menses discharge but could also be
thin and loose, watery,
homogeneous

• odorless

223

Diagnosis

• pH<4.5
• Vaginal discharge +KOH 10%

wet mount

• Pseudohyphae, hyphae,
budding yeast

• Culture for yeast if
symptomatic and negative
wet mount

• Self-diagnosis can be
inaccurate

Recurrent vulvovaginal Candidiasis

• 4 or more infections in 12 mo
• Probability of recurrent vulvovaginal Candidiasis: 10% by age

25, 25% by age 50

224

After non-diagnostic initial evaluation

• Avoid empiric blind therapy • Meds:

• Repeat vaginal pH • antibiotics (Candida)

• Increased pH: vaginal atrophy, • Hygiene: mechanical, chemical,
lichen planus or sclerosus, DIV, or allergic irritation
pemphigus
• Scented pantiliners, spermicides,
• Normal pH: contact or irritant Betadine, soaps/perfume, latex,
dermatitis, seborrheic or topical antifungals, chemical
eczematoid dermatitis, psoriasis, preservatives
vulvodynia
• New partner?
• Acute vs. chronic?
• BV, Trich, Gonorrhea, Chlamydia
• Acute: infection

• Chronic: inflammation

Vulva vs. vagina?

Vulva Vagina
• Vulvar dermatitis
• psoriasis, • Seminal plasma allergy
• Eczema
• DIV
• VIN

225

Notes

Managing Postoperative 
Complications

Two Weeks, Three Months, One Year

Maureen Sheetz, APRN, CNP
Christina Lewicky‐Gaupp, MD

Christina Lewicky‐Gaupp, MD

Associate Professor
Director, Resident Surgical Skills Curriculum
Medical Director, PEAPOD Peripartum Clinic
Department of Obstetrics and Gynecology
Division of Female Pelvic Medicine & Reconstructive 

Surgery 
Northwestern University Feinberg School of Medicine

Maureen Sheetz, APRN, CNP

• Northwestern Medical Group, Chicago

• [email protected]

• Female Pelvic Medicine and Reconstructive Surgery
• Education

BSN: Marquette University, Milwaukee, WI
MSN: University of Illinois at Chicago, Chicago, IL

Women’s Health Nurse Practitioner
Certificate in Sexual Counseling: University of Michigan,   

Ann Arbor, MI
• Board Certified in Women’s Health
• AASECT certified in Sexual Counseling

226

Disclosures

• None

Objectives

• Describe commons concerns 
and complications at 2 
weeks post‐operatively

• Describe complications 
associated with 3 month 
post‐op visit

• Describe complications 
associated with 1 year post‐
op visit

Common Urogynecologic Surgeries

INCONTINENCE PROLAPSE

• Retropubic or Transobturator • Vaginal Hysterectomy w/Ligament 
Midurethral Sling (RMUS) Suspension

• Burch Colposuspension • USLS
• Anal Sphincteroplasty • SSLS
• Sacroneuromodulation
• Sacrocolpopexy with or without 
Hysterectomy

• Open
• Laparoscopic
• Robotic

• Colpocleisis

227

2 Week Post‐op Visit: Common Concerns

• Fatigue
• General post‐op pain
• Bowels
• Vaginal discharge 
with malodor
• Ecchymosis

2 Weeks: Retropubic Midurethral Sling 

Common Concerns

• Slow urine stream
• New onset urgency frequency
• Suprapubic bruising/tenderness

Actual Complications

• Prolonged post‐op urinary retention
• Urinary tract infection
• Continued stress urinary 

incontinence or is it urinary urgency 
incontinence? 
• Bacterial vaginosis
• Incision separation
• Neuropathy

2 Weeks: RMUS

Common Concerns
• Slow urine stream  nothing to worry about, be patient, try to relax
• New onset urgency frequency  should resolve over time, offer an anticholinergic
• Suprapubic bruising/tenderness  comfort care, ice packs

Actual Complications
• Prolonged post‐op urinary retention  teach ISC, consider sling lysis
• Urinary tract infection  always culture, appropriate antibiotics
• Continued stress urinary incontinence or is it urinary urgency incontinence?  perform CST, UDS, consider 
anticholineric if appropriate
• Bacterial vaginosis (BV)  metronidazole
• Incision separation  operative revision
• Neuropathy  trigger point injections, consider physical therapy

228

2 Weeks: Vaginal Hysterectomy w/Ligament 
Suspension and AP Repair

Common Concerns

• Post‐op pain
• Unilateral buttock pain associated 
with SSLS

Actual Complications

• De novo SUI
• Cuff abscess
• DVT or VTE
• Vaginal hematoma
• Agglutination
• Ileus/Small bowel obstruction
• Neuropathy

2 Weeks: Vaginal Hysterectomy w/Ligament 
Suspension and AP Repair

Common Concerns

• Post‐op pain
• Unilateral buttock pain associated with SSLS  comfort care, NSAIDs

Actual Complications

• De novo SUI  placement of sling, pessary
• Cuff abscess  imaging, antibiotics, hospitalization
• DVT or VTE  dopplers, anticoagulation
• Vaginal hematoma  monitor for infection
• Agglutination  vaginal estrogen
• Ileus/Small bowel obstruction  bowel rest, hospitalization, NGT, operative intervention
• Neuropathy  consider suture removal

2 Weeks: Hysterectomy w/Sacrocolpopexy

Laparoscopic or Robotic
Common Concerns

• Post‐op pain
• Back pain, low 
midline

Actual Complications

• Ileus/Small bowel 
obstruction

• Wound  or port site 
infection

• DVT or VTE
• Osteomyelitis
• Pelvic abscess

229

2 Weeks: Hysterectomy w/Sacrocolpopexy

Laparoscopic or Robotic

Common Concerns

• Post‐op pain
• Back pain, low midline  comfort care, NSAIDs

Actual Complications

• Ileus/Small bowel obstruction  bowel rest, hospitalization, NGT, operative intervention
• Wound  or port site infection  debridement, antibiotics
• DVT or VTE  dopplers, anticoagulation
• Osteomylitis  surgical intervention with ortho or neurosurgery
• Pelvic abscess  imaging, antibiotics, hospitalization

2 Weeks: Colpocleisis

Common Concerns

• Post‐op pain
• Can’t sit flat on buttocks 
• Patient reported hemorrhoids

Actual Complications

• Perineal wound infection
• Perineal wound dehiscence
• Vaginal hematoma
• Neuropathy

2 Weeks: Colpocleisis Complications

Common Concerns

• Post‐op pain
• Can’t sit flat on buttocks  no sitting on donuts, comfort care, NSAIDs
• Patient reported hemorrhoids  ensure it’s not perineal incision, suppositories, stool softeners, 
hemorrhoid ointments, fiber

Actual Complications

• Perineal wound infection  antibiotics, perineal care with sitz baths
• Perineal wound dehiscence  surgical revision, packing, antibiotics
• Vaginal hematoma  monitor for infection
• Neuropathy  trigger point injections, consider physical therapy

230