Rethinking Activity After Pelvic Prolapse Surgery

For years, patients recovering from pelvic prolapse surgery have received variable and conservative post-operative activity restrictions, but the guidance has begun to change. These days, experts at Cleveland Clinic and elsewhere are rethinking their approach.

“Traditionally, there's been quite a variety in terms of what gynecologic surgeons tell patients regarding physical activity after surgery,” says Deepanjana Das, MD, a Cleveland Clinic specialist in urogynecology and reconstructive pelvic surgery. “A lot of those older restrictions, such as not lifting more than 10 pounds for six weeks after surgery, don't have any evidence behind them. They are just anecdotal recommendations being reiterated without question.”

Those who advocate for loosening restrictions point to an improved patient experience.

“We know there are benefits to being physically active,” says Dr. Das. “Being able to go back to your usual activities sooner and have the improved quality of life that the surgeries will allow are important benefits, as is the potential for a quicker return to work. Taking time off work can mean financial constraints for many.”

Despite a gradual shift to more liberal guidelines over the last five to 10 years, a recent survey shows that most gynecologic surgeons continue to recommend limiting activity after surgery. For example, 60% restrict lifting for at least six weeks after minimally invasive laparoscopic hysterectomy. Yet data show that lifting a 13-pound load from the floor does not increase intra-abdominal pressure any more than rising from a standard-height chair.

In one study, complications were rare among patients who resumed physical activity following procedures such as minimally invasive sacrocolpopexy, vaginal suspension procedures and vaginal closure procedures, often accompanied by hysterectomy and concomitant incontinence procedures.

Current research has driven similar acceptance of earlier post-surgery resumption of physical activity across disciplines, including orthopedics and general surgery notes Dr. Das.

She points to studies by Mueller and O’Shea that compared outcomes in patients who received some form of post-surgical restrictions in regard to activity and lifting with those who were given more liberal activity recommendations such as “just do what's comfortable.” These studies found no differences in terms of patient satisfaction or substantive anatomic outcomes after surgery.

“It's very reassuring to know that liberal activity is safe and that we may not need to give patients these restrictions,” says Dr. Das.

New guidance

In light of recent data around pelvic surgery, Dr. Das and colleagues at Cleveland Clinic’s Obstetrics & Gynecologic Institute reviewed the literature and changed some suggested activity limits.

“We say recovery is individualized and you're OK to resume activities like lifting, running or high-impact aerobic activities and sit-ups as soon as you feel strong enough,” she says.

The clinicians advise that patients may safely walk and climb stairs right after surgery.

Other postoperative guidelines include not putting anything in the vagina for six weeks unless otherwise instructed by their doctor; refraining from driving while taking narcotic pain medication and until the patient feels able to safely slam the brakes if needed; and not sitting or lying in bed for more than two hours at a time while awake to reduce the risk of blood clots.

While most patients are good candidates for liberalized physical activity, it’s important to know the individual patient, including their history and risk factors, Dr. Das says.

“Patients are assessed for urinary, bowel and prolapse-related symptoms before and after surgery,” she says. “We also ask about satisfaction after surgery to see if the patient had a good experience and how they felt their recovery went.”

Recovery advice can also depend on the patient's normal level of activity before surgery and their general level of fitness. Someone accustomed to rigorous workouts, such as high-intensity interval training, is different than someone who was more sedentary preoperatively.

Implementing these changes requires a consistent and unified approach to counseling surgical patients, says Dr. Das. “Our nursing team does a lot of preoperative counseling, so it’s important to get the whole team on board.”

This is especially important in the absence of unified large-scale guidelines, which are currently being developed by a taskforce, on which Dr. Das serves, for the American Urogynecologic Society.

Since the longest study outcomes available are just one year, much more research is needed, Dr. Das says. In the short-term, she adds, the patient-guided approach seems warranted.

“We want to make sure that people know that the outcomes are the same, and there's no benefit in restricting activity.”

Sources

Mueller MG, et al. Activity Restrictions After Gynecologic Surgery. Obstet Gynecol. 2024 Mar 1;143(3):378-382. doi: 10.1097/AOG.0000000000005501.

Mueller MG, et al. Activity Restriction Recommendations and Outcomes After Reconstructive Pelvic Surgery: A Randomized Controlled Trial. Obstet Gynecol. 2017 Apr;129(4):608-614. doi: 10.1097/AOG.0000000000001924.

Mueller MG, et al. Restricted Convalescence Following Urogynecologic Procedures: 1-Year Outcomes From a Randomized Controlled Study. Female Pelvic Med Reconstr Surg. 2021 Feb 1;27(2):e336-e341. doi: 10.1097/SPV.0000000000000922.

O'Shea M, Siddiqui NY, Truong T, Erkanli A, Barber MD. Standard Restrictions vs Expedited Activity After Pelvic Organ Prolapse Surgery: A Randomized Clinical Trial. JAMA Surg. 2023 Aug 1;158(8):797-805. doi: 10.1001/jamasurg.2023.1649.