female pelvic organ prolapse management in primary care dr alice clack – st6 hillingdon hospital

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