Female Pelvic Organ Prolapse

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 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%

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. 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