The primary goal of surgery is to maximize surgical outcomes by minimizing intraoperative and postoperative complications. Often, expert opinion serves as our primary guide to achieve this goal. However, the shift toward evidence-based medicine has led to significant changes in postoperative patient management. We present evidence for current postoperative recommendations, and, where evidence is lacking, discuss current practices and make recommendations. (Table 25-1).

Activities that may Increase Intra-abdominal Pressure (eg, Lifting, Stairs, etc)

Nowhere does expert opinion play a more significant role than in recommendations concerning postoperative activity. Studies have found a wide range of practices. A survey of 355 Danish gynecologists found highly variable recommendations for restrictions on lifting after vaginal repair. These ranged from avoiding lifting weights more than 15 kg for eight weeks to avoiding lifting weights more than 15 kg for two weeks.¹ In another study, 93 educational pamphlets distributed postoperatively at hospitals in the United Kingdom were reviewed and found to include lifting restrictions. The most common advice was “no heavy lifting for three months after surgery.”²

The foundation for many of these recommendations is the belief that an increase in intra-abdominal pressure that can occur with activities such as coughing, exercise, or lifting will contribute to the incidence, progression, or recurrence of pelvic floor disorders. However, in a study evaluating intra-abdominal pressure with particular activities, Weir et al. found that lifting and climbing stairs increases intra-abdominal pressure much less than Valsalva, forceful coughing, or rising from a supine to erect position, all of which patients are allowed and encouraged to do on postoperative day one.³ Similar findings were reported in another study that showed the greatest rise in intra-abdominal pressure occurred with unavoidable activities such as forceful coughing and Valsalva maneuvers (Figure 25–1).^4,5

Physicians have also argued that incision strength and integrity are directly related to the time of surgery, with incisions gaining strength over time. However, in an animal study evaluating the rupture strength of both early and late (six weeks) hernia repair with mesh, the rupture strength was nearly identical at both time periods and close to 300 mm Hg.² This is well above the pressures created by humans under physiologic conditions (Figure 25–1). Until better evidence exists to guide recommendations, lifting restrictions are made on expert opinion.

Bathing and Swimming

Recommendations concerning return to bathing and swimming vary widely. Baths are generally not recommended for two to six weeks after surgery despite no evidence showing an increased risk of wound infection with bathing.⁵ Once bandages have been removed, in the absence of complications, there is no evidence that bathing is harmful. Avoiding swimming pools is also generally recommended secondary to concerns that communal pools may expose the incision to contamination and increase the risk of infection. However, once fibroplasia has occurred, four to five days postoperatively,⁶ and wounds are closed, this concern may be unfounded.

Driving

There are two primary concerns that have served as a foundation for recommendations that limit an early return to driving. First, postoperative patients are generally prescribed a combination of analgesics that can cause sedation and impair cognitive function.⁷ Second, pain associated with the surgical incision may cause a driver to hesitate in an emergency situation.^8,9

Postoperative pain treatment regimens typically consist of nonsteriodal anti-inflammatory drugs (NSAIDs) and opioids. While NSAIDs are generally regarded as safe, the labeling of opioids warns of drowsiness and sedation in users, and the danger of operating heavy machinery. Objective evidence from a recent randomized controlled trial revealed no significant impairment in behavioral ability when comparing patients taking opioids with those taking NSAIDs. However, study participants reported that an increase in effort was necessary to perform the driving test when treated with opioids and that they experienced increased sedation and reduced alertness.⁷ Therefore, women taking only NSAIDs for pain control should be able to resume driving at least for short distances.⁵

Despite treatment with analgesic medication, pain on some level is unavoidable and many surgeons fear that it may adversely affect a patient’s ability to drive safely. In fact, in a British study that surveyed obstetricians and gynecologists on postoperative driving recommendations, the most common response for the reason to restrict driving postoperatively was the inability to perform an emergency stop (70.6%, n = 48).⁸

The duration of this restriction is dependent on multiple factors such as surgical approach, procedure, and patient healing. In a randomized study by Wright et al., driver reaction times were measured in 64 patients randomized to open versus laparoscopic hernia repair.¹⁰ Researchers found that the foot reaction times were significantly faster on postoperative days one and three (P =.01 and .0003) in patients who had laparoscopic surgery but by day six response times were not different between women undergoing open versus closed procedures.

Nunez and Giddins recommend that patients should test their driving ability by manipulating the pedals, gears, and steering wheel of a stationary vehicle.⁹ If the postoperative patient has no difficulty with manipulating the controls of a stationary vehicle, then the patient may consider a short trip with a passenger who can drive the vehicle if the patient is unable to continue.

Return to Work

There are no prospective gynecologic studies evaluating outcomes related to resumption of work after surgery. Consequently, there is a significant variation in the advice given by physicians to their patients. One study based on surveys in the United Kingdom found recommendations for return to work after hysterectomy ranged from one to ten weeks with a mean of six weeks.¹¹ The primary factors that influence a patient’s return to work are physician recommendations, the nature of the work, and the operative procedure performed.

Multiple studies have revealed that patients are more likely to return to work earlier if they receive preoperative counseling and postoperative reinforcement.^11,12 Of course, the physical demands associated with the job also play a key role in the convalescence period and physician recommendations.¹¹ Patients whose jobs consisted of office activities returned to work sooner than those whose work consisted of heavy manual labor. The activities associated with an office job are unlikely to produce a rise in intra-abdominal pressure beyond that which is produced from daily activities.³

The type of procedure including surgical approach also has a dramatic impact on a patient’s postoperative recovery. One study evaluating quality of life (QoL) measures between vaginal and abdominal hysterectomy found the vaginal hysterectomy group had less pain, better QoL, and better mobility the first six weeks of the recovery period.¹³ As a general rule, the more minimally invasive the procedure, the quicker the patient will be able to return to work. In fact, Oikkonen et al. found that 30% of patients reported they were capable of returning to work on postoperative day seven after laparoscopic cholecystectomy.¹⁴ Physician preoperative counseling should reflect these factors and include postoperative reinforcement.

Return to Sexual Activity

There are no prospective studies that have evaluated outcomes associated with return to sexual function. Ottesen et al. published the results of a nationwide survey of gynecologists in Denmark and found that the median time recommended to abstain from vaginal intercourse was four weeks.¹ The potential risks associated with premature initiation of intercourse include infection, mesh erosion, bleeding, pain, and, in the case of hysterectomy, disruption of the vaginal vault closure.

One of the most troubling complications is vaginal vault dehiscence. Research on the topic is limited to retrospective studies and reports are inconsistent. A case series by Iaco et al. found that four of five patients who experienced dehiscence reported that intercourse was the inciting event.¹⁵ The mean time from surgery for these women was 2.6 months. In contrast, a retrospective study found the median time to dehiscence was 6 and 20 months for vaginal versus abdominal hysterectomy, respectively.¹⁶ Paradoxically, maximal wound tensile strength, which is 75% to 80% of unwounded skin, has been shown to occur at eight weeks.¹⁷ The significant variation in time to dehiscence suggests that other factors including suture material, surgical technique, age, and menopausal status may play a more central role than the timing of the resumption of sexual activity.

In patients who undergo a mesh procedure, a disruption of the incision during intercourse may increase the risk of infection and subsequent mesh erosion. Nonetheless, some surgeons, citing practices of other subspecialties, have recommended an early resumption of sexual activity to decrease scarring and prevent vaginal rigidity and dyspareunia. There are no studies to help guide recommendations in this situation. The decision to resume sexual activity should be mutual one between the patient and her partner. Minig et al. recommend the caregivers give a consistent message on resumption of sexual activity both preoperatively and postoperatively.⁵ Women should be encouraged to use lubricants and try different sexual positions to overcome the loss of normal lubrication from the cervix and the decrease in vaginal length that often occurs after hysterectomy.

Sexual Dysfunction

Surgical correction of pelvic floor disorders which requires maintenance of vaginal length and caliber may improve or adversely affect sexual function. A recent prospective multicenter study by Rogers et al. evaluated female sexual function after a variety of anti-incontinence and reconstructive surgeries.¹⁸ Using the Pelvic Organ Prolapse Urinary Incontinence Sexual Questionnaire (PISQ) they found a 68% improvement in sexual function six months postoperatively. The significant improvement in postoperative PISQ scores was driven primarily by a decrease in urinary incontinence episodes with intercourse.

Sexual dysfunction associated with pelvic reconstructive surgery is often attributed to narrowing of the vagina that may occur after posterior repair. A subanalysis of the previous multicenter trial revealed patients who had posterior repair were more likely to report postoperative dyspareunia (28% vs 57%, P =.02).¹⁹ However, this study did not include information regarding perineorrhaphy that would be the primary cause of decreased vaginal caliber. Levator plication, which was used in the past to augment a posterior repair, has been shown to significantly increase the rate of de novo dyspareunia and should be avoided.²⁰ In the absence of data to the contrary, a reasonable recommendation would be avoid excessive plication or excision of vaginal epithelium as well as plication of the levator ani in women who wish to resume sexual activity after surgery.

The use of mesh during pelvic floor surgery may also adversely affect vaginal caliber. Studies have shown that mesh of all types contract. Klinge et al. reported 30% to 50% contraction at four weeks.²¹ The contraction also affects the mesh arms that puts further tension on the vaginal epithelium and increases the risk of mesh erosion and pain following reconstructive surgery. A case series of 17 patients with mesh contraction found that all patients presented with severe vaginal pain and dyspareunia. In addition, mesh erosion (9 of 17), vaginal tightness (7 of 17), and vaginal shortening (5 of 17) were frequently present together.²² These complications often require mesh resection. After surgical correction, 88% of women in the previous study had a substantial reduction in vaginal pain and 64% experienced a reduction in dyspareunia.

Definitions used in studies to define voiding dysfunction and urinary retention vary widely and make the literature about its incidence difficult to interpret. One commonly used definition is the inability to adequately empty the bladder six weeks postoperatively.²³ Regardless of the definition, it is common, occurring in 2.8% to 14% of patients undergoing midurethral sling surgery²⁴ and in 5% to 20% of women undergoing urogynecologic procedures in general.²⁵ Several factors contribute to postoperative voiding dysfunction. It is hypothesized that during anterior repair, inflammation and edema from plication of the vesicovaginal muscularis, especially near the urethrovesical junction, may act to obstruct the urine outflow. Alternatively, patients who have had abdominal surgery may hesitate to contract their abdominal muscles, which can inhibit the voiding reflex. This reflex relies on the generation of sufficient intra-abdominal pressure to trigger the parasympathetic function of the bladder detrusor.²⁶ Whatever the cause, adequate drainage of the bladder is necessary to avoid overdistention of the bladder and possible infection. Evacuation of the bladder can be achieved with transurethral and suprapubic catheters as well as intermittent self-catheterization.

Bladder Drainage

In 1937 Foley described the first self-retaining transurethral catheter.²⁷ Its ease of insertion has made it ubiquitous in hospitals around the world. It can be used for a short duration to drain the bladder or to monitor output. However, even with a closed drainage system, the risk of UTI is 5% to 10% each day the catheter is in place.²⁸ The Centers for Disease Control (CDC) has published guidelines to help prevent catheter-associated urinary tract infections (Table 25-2).²⁹ Several additional interventions—suprapubic catheterization, sealed junction catheters, and prophylactic antibiotics—have been developed and utilized in an attempt to lower the incidence of postoperative urinary tract infections.

An alternative to transurethral catheterization is suprapubic catheterization, which avoids the high bacterial density of the periurethral region producing lower rates of bacterial infection. Bergman et al. showed a decrease in febrile morbidity (fever index 8.8 vs 22.3, P <.01) and more rapid return of normal bladder function in patients who received a suprapubic catheter.³⁰ Similar findings were seen in a study by Andersen et al., which found a statistically significant decrease in bacteriuria on the fifth postoperative day (20.8% vs 45.5%, P <.025).³¹ Other advantages to suprapubic catheters include improved patient comfort, patient controlled voiding trials, and the elimination of transurethral catheterization for postvoid residual volumes. These benefits make them ideal for patients who are likely to require catheterization for a longer period time. However, their small caliber makes suprapubic catheters prone to obstruction and necessitates their frequent irrigation. In addition, the invasive method of their insertion can cause rare complications such as cellulites, bowel injury, urine extravasation, and catheter fracture.

Another method of bladder drainage is intermittent self-catheterization. This approach requires that the patient have the mental and physical capacity to perform self-catheterization. Patients can start self-catheterization immediately postoperatively or after removal of a Foley catheter. Typically, patients are instructed to empty the bladder every three to four hours and as needed during the night. Intermittent self-catheterization is safe and has lower complication rates than indwelling or suprapubic catheter placement.^32,33 The incidence of asymptomatic bacteriuria or catheter-associated urinary tract infections has not been shown to be reduced with the use of sterile versus clean intermittent catheterization techniques.³⁴

Prophylactic Antibiotics

Another measure that is often implemented to decrease the risk of iatrogenic urinary tract infections associated with catheterization is prophylactic antibiotics. Symptomatic urinary tract infections and bacteriuria in patients receiving antibiotics were reduced in a randomized placebo-controlled trial. Rogers et al. found a decrease in positive urine cultures (46% vs 61%, P =.002) and symptomatic UTIs at the time of suprapubic tube removal (7.2% vs 19.8%, P =.001) in patients given Macrobid 100 mg daily while catheterized postoperatively. However, prophylactic antibiotics did not decrease symptomatic UTI at the six- to eight-week postoperative visit (1.8% vs 5.4%, P =.10).³⁵ Van der Wall et al. found a decrease in UTIs in suprapubic and indwelling catheter patients receiving ciprofloxacin (20% vs 5%, RR 4.0).²⁸ A Cochrane review revealed weak evidence that antibiotic prophylaxis compared with giving antibiotics when clinically indicated reduced the rate of symptomatic urinary tract infection in female patients with abdominal surgery and a urethral catheter for 24 hours.³⁶ The use of prophylactic antibiotics must be balanced with the risks associated with their use and their potential to promote the development of resistant bacterial strains.

Removal

While drainage of the bladder via catheterization is often necessary after pelvic floor surgery, it should be removed expeditiously. The risk of infection is directly related to the duration of catheterization. In addition, catheterization is often viewed by patients as one of the more disruptive interventions of the postoperative period.