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

Physical and emotional impact and when should we ‘treat’? 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