1. Female Pelvic Organ Prolapse
Management in Primary Care
Dr Alice Clack – ST6 Hillingdon Hospital

2. Pelvic Organ Prolapse

3. Incidence Difficult to determine but common
~41% of women aged 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%

4. 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

5. Clinical Presentation
Common Symptoms associated with Pelvic Organ Prolapse

6. Sensory Lump Pain/discomfort in pelvis/vagina/buttocks/ lower back
Often vague ‘ache’ or ‘dragging’
Dyspareunia/
obstruction during intercourse
Excoriation/bleeding from protruding tissue

7. Urinary Hesitancy Poor Flow Incomplete emptying Recurrent UTI’s
Need to reduce prolapse or adopt specific postures to initiate/complete micturition

8. Gastro-intestinal Constipation Incomplete emptying Tenesmus Digitation
Incontinence
Flatus/Staining from residual stool

9. Incidental Finding

10. Physical and emotional impact and when should we ‘treat’?
Assessing Prolapse
Physical and emotional impact and when should we ‘treat’?

11. 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

12. 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?

13. 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

14. Types of Prolapse?

15. 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

16. 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

17. 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

18. Posterior Vaginal Wall Prolapse
Often associated with constipation and incomplete bowel opening (chicken and egg)
Often associated with ‘dragging’ sensation lower back

19. 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

20. 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

21. Management of Prolapse

22. 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

23. Treat Associated Symptoms
Constipation
Overactive bladder
Vulval irritation/atrophy
Back-pain/Pelvic pain

24. Optimise Pelvic Conditions
Pelvic floor exercises
Systemic/Topical HRT
Weight Loss
Do not reverse prolapse but can help prevent progression and improve associated symptoms

25. 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?

26. 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

27. 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

28. 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

29. 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

30. 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%)

31. Thank You