Female Pelvic Organ Prolapse
Management in Primary Care
Dr Alice Clack – ST6 Hillingdon Hospital
Pelvic Organ Prolapse
Incidence
• Difficult to determine but common
• ~41% of women aged 50-79 years show some
degree of prolapse
• Most common reason for hysterectomy (13%)
• Accounts for 20% of women on waiting lists
for major gynaecological surgery
• Life-time risk of surgery for prolapse – 11%
Risk Factors
• Main
–Vaginal Delivery
–Increasing Parity
–Age
–Obesity
• Other
– Family History/race/
connective tissue disorder
– Constipation/chronic
cough/heavy lifting
– Prolonged 2nd
stage/forceps
delivery/macrosomia
Clinical Presentation
Common Symptoms associated with
Pelvic Organ Prolapse
Sensory
• Lump
• Pain/discomfort in
pelvis/vagina/buttocks/
lower back
– Often vague ‘ache’ or
‘dragging’
• Dyspareunia/
obstruction during
intercourse
• Excoriation/bleeding
from protruding tissue
Urinary
• Hesitancy
• Poor Flow
• Incomplete
emptying
• Recurrent UTI’s
• Need to reduce
prolapse or adopt
specific postures to
initiate/complete
micturition
Gastro-intestinal
• Constipation
• Incomplete
emptying
• Tenesmus
• Digitation
• Incontinence
– Flatus/Staining from
residual stool
Incidental Finding
Assessing Prolapse
Physical and emotional impact and
when should we ‘treat’?
Quality of Life
• Does it trouble the
patient and to what
degree?
– Or are they worried it is
dangerous/abnormal?
• What is the main
symptom/problem
for the patient?
– Is treating the prolapse
the best way of treating
that symptom
Associated Symptoms
• Are there significant
associated
symptoms?
• How much
trouble/harm are
these causing
– How likely are the
symptoms to be related
to the prolapse?
Confounding Symptoms
• Unstable Bladder and bladder pain symptoms
– Not generally secondary to prolapse
• Constipation/incomplete bowel
emptying/incontinence
– Often proceed prolapse
• Pelvic pain/back pain
– Other causes more likely
• Vulval/vaginal discomfort
– Prolapse incidental
Types of Prolapse?
Uterine Prolapse
• Often associated with
ant. and post. wall
prolapse (esp. ant.)
• Often associated with
dragging pelvic and
back discomfort and
lump
• If severe often
associated with
voiding dysfunction
• May cause mechanical
obstruction to
intercourse
Vaginal Vault Prolapse
• Following Hysterectomy
– 11.6% of hysterectomies
for prolapse
– 1.8% of hysterectomies
performed for other
reasons
• Again usually associated
with at least anterior
vaginal wall prolapse
Anterior Vaginal Wall Prolapse
• Often associated with
voiding dysfuction
(obstructive pattern)
• Often associated with
sensation of a lump and
dragging
• Often associated with
Uterine prolapse
Posterior Vaginal Wall Prolapse
• Often associated with
constipation and
incomplete bowel
opening (chicken and
egg)
• Often associated with
‘dragging’ sensation
lower back
Degree of Prolapse?
• POPQ??
– Pre and post-op
assessment,
communication between
uro-gynaecologists and
research
• Assessment in terms of
stage – 1, 2, 3 adequate
for communication
between primary and
secondary care
– Hymen rather than introitus
is point of reference
Prolapse Stages
• Stage 1: The most distal portion of the prolapse is
>1cm above the level of the hymen
• Stage 2: The most distal portion of the prolapse is
between 1cm above and 1cm below the hymen
• Stage 3: The most distal portion of the prolapse is
>1cm below the hymen but complete eversion of the
vaginal wall has not occurred
• Stage4: Complete eversion of the total length of the
lower tract has occured
Management of Prolapse
Reassurance and Advise
• Low risk to patient
• Reassurance is often all
patient wants
• Open-door for future
intervention
• Prevention of Progression
– Weight loss
– Constipation/chronic cough
avoidance
– Pelvic floor excercises
Treat Associated Symptoms
•
•
•
•
Constipation
Overactive bladder
Vulval irritation/atrophy
Back-pain/Pelvic pain
Optimise Pelvic Conditions
• Pelvic floor exercises
• Systemic/Topical HRT
• Weight Loss
– Do not reverse prolapse but can help prevent
progression and improve associated symptoms
Pessaries
• Suitable for most
patients if willing to try
• Important role in
management of high
anaesthetic risk
patients or if family
incomplete
• Potential as trial of
response to reducing
prolapse
– Symptoms resolved?
– SI after prolapse
reduced?
Ring Pessary
• Measured from posterior
fornix to upper edge pubic
symphisis
• Change 6 monthly and
inspect vagina for
ulcerations
• Easy to teach patients to
remove and insert
– Useful if menstruating or if
causing problems during
intercourse
Limitations of Pessaries
• Often not acceptable to patients
– Need to change regularly
– Discomfort
• Sometimes not retained
– Especially if previous vaginal hysterectomy
– Can cause urinary retention/constipation if
displaced
• Erosions
• Vaginal Discharge (non infective)
• Of limited help in reducing posterior wall
prolapse
Referral to Secondary Care
• Significant prolapse or
associated symptoms
and:
– requesting surgical
management
– Failed conservative
management
• Multiple urinary
symptoms with Prolapse
• Significant recurrent
prolapse after surgery
Surgical Procedures
•
•
•
•
•
Anterior vaginal wall repair
Posterior vaginal wall repair
Vaginal hysterectomy
Vaginal Sacro-spinous fixation
Abdominal sacrocolpopexy (open or
laparoscopic)
• Many and various mesh repairs
Post-operative Complications
• Early
– Haematoma’s, infection
– Urinary Retention
– Vaginal Discharge (Non infective)
– Early failure of repair
• Late
– Recurrence (20-30%)
– Mesh erosions
– Progression of prolapse in other compartments
– Dyspareunia (especially posterior)
– Stress incontinence/unstable bladder (5%)
Thank You