When you have major surgery of any sort, often all of your focus will be on getting through those first few days in hospital. Many women do not realise going home can be the bigger hurdle. I see many women after gynaecological surgery who feel they need some help with rehabilitation. This can include exercises to help their pelvic floor muscles, return to overall strength and fitness, or just advice about what they should (or should not) be doing. In this, the second of two blog posts, I talk about rehabilitation after gynaecological surgery. If you missed it, here is a link to my previous blog post on postnatal recovery.
Just to be clear, not all gynaecological surgeries are created equal. By that I mean there are major gynaecological surgery procedures and more minor procedures.
More minor gynaecological surgery or procedures include insertion of urethral “slings” or tapes for stress urinary incontinence (bladder leakage with coughing, sneezing and exercise), laparoscopies, hysteroscopies, ablations and insertion of a Mirena. Some of these procedures are done in the doctors’ rooms or only require day surgery, or possibly an overnight stay in hospital at the most. You may be a little bit tender, but most women feel ready to return to gentle activity within a few days. This is not to say women having these procedures may not require rehabilitation. Some will, for various different reasons, but the majority will not.
When I am referring to rehabilitation following gynae surgery, I am particularly meaning following major surgical procedures – like a prolapse repair. Your doctor might refer to this surgery under various terms: anterior repair, posterior repair, vaginal repair, sacro-colpopexy, sacrospinous suspension are common operations in this category. They may include removal of your uterus (hysterectomy), removal of your tubes (salpingectomy) or ovaries (oophorectomy) as well.
With modern surgical technology, these procedures do not always require a large surgical cut and may be done laparoscopically (via small incisions and the aid of a camera and special instruments) or even robotically. As a result, many women may only have 1-2 nights in hospital following their operation. However, do not be fooled. These are major operations and recovery should be carefully prescribed. Even if you do not have a large external cut, there has been a large amount of change and repair done internally, which needs time to heal and get stronger.
To help understand why a gradual recovery and rehabilitation is often needed, it can be useful to know about the stages of tissue healing.
Stage 1: In the early hours following surgery the body’s main goal is to stop blood loss. In this stage of homeostasis, a clot (a very weak mesh) forms over the wound.
Stage 2: Over the next hours to weeks following surgery, the tissues experience inflammation. The immune system sends large numbers of white blood cells to the affected area to help with healing. This is why the area can feel tender, swollen red and warm. While your stitches will hold things together to some extent, the tissues are still very weak. Just like a fresh cut on your finger, if you put too much stretch or pressure on them you can damage the repair.
Stage 3: From 2-6 weeks after surgery, the tissues enter a proliferative stage. They start to form stronger collagen bonds across the wound, and the wound becomes smaller. These bonds gradually get stronger (by 3 weeks the collagen tissue is only about 20% of normal strength) but can still be damaged from too much activity.
Stage 4: As you gradually do more activity the new collagen bonds slowly get stronger. This maturation stage can continue for months to years following surgery. The tissues gain about 80% strength from 12 weeks following surgery, but this can take longer. This is the maximum strength they will gain.
Thus it can take 3 months or more for tissues to regain reasonable strength following surgery. While this is a fairly average timeline for healing, many different factors can affect how quickly tissues heal. Your age, overall health, diet, stress levels, weight, smoking or alcohol use can all affect how quickly your tissues heal.
If it just takes time why would I need rehabilitation?
There are many benefits to rehabilitation and even pre-habilitation. Many women find it really helpful to see me before their surgery to help prepare them for what to expect afterwards. They can start doing pelvic floor muscle exercises (much easier to learn beforehand when everything is not feeling sore and swollen) and begin to adopt good bladder and bowel habits. It can also be very helpful to know in advance about the types of activities you can and cannot do after surgery and for how long. It’s not much good finding out you cannot drive or lift the washing basket for 6 weeks only just prior to surgery if you live alone! This can be a great time to start some regular gentle exercise, improve your diet and stock the freezer with plenty of healthy meals for afterwards. The fitter, healthier and better prepared you are beforehand, the greater your chances of a better recovery.
The actual evidence for what is/isn’t safe after gynaecological surgery is rather scarce. A number of studies have looked at the pressure is created in the abdomen or vagina with different activities – but they have all been done on healthy, asymptomatic women, not on women after major gynaecological surgery. Also, while the studies show trends towards greater pressures with lifting heavier loads (especially below the knees or above the shoulders) doing high impact exercise, and coughing or sneezing, all of the studies show a huge amount of individual variation. In other words, what creates a large amount of pressure in one woman may not in another. How does this then apply to women after surgery?
It is almost impossible to give One-Size-Fits-All kind of advice for women after gynaecological surgery. What your body can cope with and the failure point for your repair can depend on many different factors, as we saw with tissue healing. Your overall fitness, strength, and what you are used to doing can also make a big difference. Even more reason why 1:1 rehabilitation can be beneficial in the early days and weeks. The most important things you can do are to take things slowly, listen to your body and recognise the signs of doing too much. These can include general fatigue, feelings of pressure, aching or heaviness in the pelvis or any loss of bladder or bowel control.
So saying though, here is a basic general guideline on what to expect after surgery:
0-6 weeks: Once you go home take things very easily.
Avoid any lifting or housework for the first 2 weeks. After that, limit lifting to no greater than 3-4 kg and only perform light household tasks for short periods.
Do not bend, squat or strain in any way.
Spend short periods resting lying down every day.
Start pelvic floor exercises as taught by your Physiotherapist.
6-12 weeks: You can now start doing a little more. You will probably see the surgeon at about this time for a review.
Continue pelvic floor exercises.
Gradually increase your walking or other low impact exercise as allowed by your surgeon.
You can start doing a little more housework but still avoid lifting when possible, and nothing over 5-10 kg depending on your surgeon’s advice.
12 weeks onwards: You can now gradually return to most activities.
Often you will have a lifetime lifting limit of 15 kg or less and many surgeons will not recommend high impact exercise.
Still avoid straining at bowels.
I often recommend a great little book to my patients, Pelvic Floor Recovery by Sue Croft (an Australian Physiotherapist). This contains all this information and more and has been written specifically for women recovering from gynaecological and colorectal surgery. I stock copies in my practice and it can also be bought online.
The major messages here are:
Prepare well in advance for your surgery and consider at least one pre-habilitation consult with your Women’s Health Physio.
Take things slowly and listen to your body during recovery. Everyone is different and recovers at different rates.
Please contact me at Life Cycle Physiotherapy if you have any questions.