Posthysterectomy prolapse of the fallopian tube is a rare event and can be confused with granulation tissue at the vaginal apex. Predisposing factors for the development of fallopian tube prolapse include development of a hematoma and an abscess at the vaginal apex. Approximately one-half of patients undergoing vaginal hysterectomy form some granulation tissue at the vaginal vault. In patients in whom granulation tissue persists after attempts to cauterize it or pain is experienced with attempts to remove it, fallopian tube prolapse should be suspected. A biopsy of the area is warranted and usually reveals tubal epithelium if a fallopian tube is present.
If fallopian tube prolapse is diagnosed, it should be repaired with surgery. The surrounding vaginal mucosa should be opened and undermined widely. The tube is ligated high and removed, followed by closure of the vaginal mucosa.
Vaginal Cuff Dehiscence Patients with cuff dehiscence present with pain, vaginal bleeding, vaginal discharge or gush of ﬂuid 2 to 5 months after surgery. The most common initiating event is coitus. Immediate examination for cuff integrity is necessary. Treatment typically requires surgical repair in the operating room.
Before discharging the patient, instructions should be reviewed. Printed postoperative instructions are helpful to the patient and a suggested set of instructions are as follows: 1.
Avoid strenuous activity for the first 2 weeks, and increase activity level gradually.
2.
Avoid heavy lifting, douching, or sexual intercourse until instructed by the physician.
3.
Bathe as needed using shower or tub baths.
4.
Follow a regular diet.
5.
Avoid straining for a bowel movement or urination. For constipation, use Milk of Magnesia or Metamucil (1 tsp in juice).
6.
Call the physician if excessive vaginal bleeding or fever occurs.
7.
Schedule a return appointment at the time specified by the physician.
The physician should provide telephone numbers for emergencies both during and after office hours. Typically, the first postoperative visit is scheduled about 4 weeks after discharge from the hospital. At the time of that visit, the patient should be ambulating well, and vaginal discharge or bleeding should be minimal. Speculum examination of the cuff should be gentle and cursory, but the patient should be assured that the healing process is proceeding normally. Finally, the patient’s questions should be answered and advice given on increasing her activity level, including sexual activity, work, and normal household activity.
General Pelvic Symptoms and Quality of Life
Patient satisfaction after hysterectomy is related to the initial indication for surgery and patient expectation. The Maine Women’s Health Study evaluated the effect of hysterectomy for nonmalignant disorders on quality of life (13). They documented a marked improvement in pelvic pain, urinary symptoms, and psychological and sexual symptoms at 1 year in the majority of patients. In the Maryland Women’s Health Study patients were followed for up to 2 years after hysterectomy for nonmalignant conditions (64). Symptoms related to the underlying indication for surgery, and associated symptoms of depression and anxiety and quality of life, improved after hysterectomy. Each study reported that about 8% of patients had new symptoms, such as depression and lack of interest in sex or lack of improvement in quality of life. Although women with pelvic pain and depression did not show the same level of improvement as other groups, there was significant improvement over baseline. Patient satisfaction is very high after hysterectomy (64).