Urogynecology at the Crossroads
I had a lovely conversation with a woman and her husband last week. Ellen had undergone sacrospinous ligament fixation (SSLF) for uterine prolapse in 2023. Often referred to as “minimally invasive,” SSLF is a deep surgery through the back vaginal wall - all the way to the spine.
The SSL is attached to the outer edge of the sacrum and coccyx (tailbone) at one end, and the ischial spine at the other (black arrow). The all-important pudendal nerve, which feeds the perineum and controls sensations associated with urination and defecation, is sandwiched in-between the SSL and the sacrotuberous ligament (red arrow).
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SSLF is usually reserved for post-hysterectomy women, but in Ellen’s case her cervix was tethered to one of the SSLs. The surgery failed and her symptoms returned far worse, but she was very fortunate to have avoided life-altering pudendal nerve damage.
In normal anatomy the uterus is positioned directly behind the abdominal wall. The two round ligaments come off the front of the uterus, travel down the inguinal canal on either side of the lower abdominal wall, wrap under the pubic bones, and embed in the large labia surrounding the vagina.
When lumbar curvature is in place, with every in-breath the round ligaments pull the uterus down and forward into the lower belly. It is difficult to imagine a more diabolical surgery than tethering the uterus (or vaginal stump) to the back of the body.
Urogynecology is a subspecialty of gynecology that arose during the 1990s to take advantage of the enormous “pelvic floor disorders” market. At least as lucrative as orthopedics, urogynecology has brought nothing new to women’s health, but is recycling the same old, damaging, and ineffective operations developed by gynecology during the late 19th and 20th centuries.
Urogynecology clinics have become ubiquitous across the country. Osteopath Earle M. Pescatore from the AdventHealth Medical Group in Palm Beach, Florida tells us,
“For many women, finding the right care for urogynecology and reconstructive surgery can mean the difference between living with discomfort and returning to the activities that matter most to them.” (1)
In reality, the overwhelming majority of women who undergo “reconstructive” pelvic surgery live the rest of their lives with physical and sexual disability.
Another osteopath, David Williams from Urogynecology of East Alabama states,
“For some women, their condition can be managed with treatment plans involving physical therapy exercises tailored toward pelvic floor disorders, medication or medical devices. For others, minimally invasive surgical techniques provide effective, long-term solutions.” (2)
Urogynecology of East Alabama advertises that Williams performs “sling surgery, sacral colpopexy (sic) and hysterectomies.”
So-called “sling surgery” places a strip of polypropylene mesh between the urethra and front vaginal wall. Polypropylene is not inert in the body, but becomes brittle and sharp over time, acting like a hacksaw to erode through the extremely delicate tissues of the urethra, bladder, vagina, and bowel.
Sacrocolpopexy, the only other surgery besides SSLF performed in an attempt to suspend the post-hysterectomy vagina, is fraught with risk and failure. A deep and dangerous operation, sacrocolpopexy connects the vaginal stump to the anterior ligament of the spine by way of a strip of polypropylene mesh.
Hysterectomy removes the uterus, which with its broad bands of connective tissue separates the abdominal from pelvic cavities. The reason SSLF and sacrocolpopexy were developed in the first place was to treat so-called “vault prolapse,” where the untethered vagina turns inside-out, forming a football-size bulge that must be responded to surgically.
More gravely, the top of the surgically-closed vagina can open, resulting in vaginal evisceration, an emergency, life-threatening situation where the intestines spill out of the body.
Urogynecology is a dangerous and unnecessary medical practice. If a woman has not had pelvic surgery, including episiotomy (cutting the vaginal sphincter during childbirth), prolapse and incontinence are very easy to stabilize and reverse.
The more tissue that is surgically excised, the more difficult it is for the vagina to close down naturally against intraabdominal pressure. Every time we take a breath in, we are creating a tremendous amount of internal pressure. That pressure moves through the abdomen and pelvis in a very specific pathway.
Breathing naturally under the forces of gravity is what sculpts the female spine and pelvis, and places the pelvic organs as we run and cartwheel through life. Pelvic reconstructive surgery changes the flow of internal pressures, making prolapse and incontinence far more likely in the aftermath of these operations.
Urogynecology, as well as gynecology, urology, and women’s physical therapy, are not working with the true dynamics of the female body. As you can read about here, OBGYN students are no longer even taught anatomy! Simulation exercises, AI, and robotic surgeries have removed the reconstructive pelvic surgeon from a direct relationship with the surgical field, female anatomy, and ultimately responsibility for their profound, devastating, and irreversible surgical blunders.
https://www.adventhealth.com/news/urogynecologist-expands-womens-health-and-reconstructive-care-palm-coast
https://www.eastalabamahealth.org/news-and-media/urogynecologist-helps-women-regain-comfort-control-and-confidence