Pelvic Organ Prolapse

Background

• Abnormal descent/herniation of one or more of the pelvic organs as a result of failure of ligamentous and fascial supports, resulting in the protrusion of the organ beyond its normal anatomical confines
• Can occur
  • Anteriorly (urethrocele, cystocele, cystourethrocele)
  • Middle/Apically (uterine, vaginal vault (post-hysterectomy), enterocele)
  • Posteriorly (rectocele)
• Can also be classed by severity
  • Stage 0- no prolapse
  • Stage 1- more than 1cm above the hymen
  • Stage 2- within 1cm of the hymen
  • Stage 3- more than 1cm below the hymen but less than 2cm away from the introitus
  • Stage 4- protrusion out of the introitus
    • Alternatively
  • 1st degree- prolapse contained within the vagina
  • 2nd degree- prolapse through the introitus
  • 3rd degree- entire uterus outside the introitus
• Common: mild prolapse can be found in up to 50% of parous women (many asymptomatic)

Risk factors

• Multiparity and vaginal child birth
• Age
• High BMI
• Others include family history, intrapartum complications e.g. macrosomia, prolonged labour, assisted labour; young pregnancy; constipation;

Presentation

• General sensation of pressure, fullness, heaviness (‘something coming down’)
  • Bulge/protrusion may be felt/seen
  • Difficulty with tampons
  • Spotting
• It is important to ask about urinary symptoms e.g. frequency, incontinence, urgency, incomplete emptying; weak flow;
  • Rarely, some need to manually reduce the prolapse prior to urination.  More commonly, some women need to change positions to empty the bladder
• Ask also about sexual difficulty including dyspareunia; loss of sensations
• Ask about any bowel symptoms e.g. constipation, urgency, incontinence, incomplete evacuation/straining, change of position etc
• On examination
  • Ideally examine standing and lying (flat and left lateral)
  • Use a Sims speculum (if available) to look at the walls of the vagina and/or a bivalve to look at the cervix/uterus
  • Ask the patient to strain/cough to exacerbate any findings
  • Ulceration may be seen on the prolapsing part

Investigations

• Usually a clinical diagnosis but some investigations may be warranted e.g.
  • in the case of urinary sx (e.g. urinalysis, residual volume scan, urodynamics etc)
  • bowel symptoms may warrant anal manometry/USS

Management

1. Watchful waiting, with observation for development of any new symptoms/complications
   1. for stage 1 or asymptomatic patients
2. Conservative management
   1. Lifestyle
      1. e.g. weight loss, treat constipation, reduce heavy lifting
   2. Physiotherapy (pelvic floor)
      1. Useful for stage 1/2 symptomatic patients
   3. Local oestrogen creams may be trialled in conjunction with physiotherapy, particularly in post-menopausal women
3. Pessaries
   1. Considered effective in most women if tolerated and suitably fitting
      1. (many different sizes/shapes)- ring pessary often very effective although accurate fitting is recommended
      2. Usually replaced every 3-6 months
4. Surgery
   1. NB The evidence for classical prolapse surgeries e.g. tapes/colposuspension/fixation, is lacking and these are becoming less routine
   2. Only considered if there is failure of management with pessary; prolapse is symptomatic i.e. incontinence, difficulty with voiding/defecating etc; and where patient preference is a strong factor

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