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