Login

Prolapse

Background

Affects 50% of parous women over the age of 50y

30% of women need further surgery in a lifetime; try to manage conservatively as surgery is not necessarily curative

Aetiology

  • labour especially if associated with prolonged pushing; forceps delivery, large baby
  • age, menopause and lack of oestrogen
  • chronic  cough or constipation
  • heavy lifting in occupation or hobbies

Presenting symptoms

  • Bulge
  • Dragging
  • Back ache
  • Pressure
  • Urinary symptoms
  • Bowel symptoms
  • Sexual problems

Primary Care Assessment

Examine the patient in supine position to exclude pelvic masses, then assess the prolapse using a Simms speculum in left lateral position, ask for a small cough/straining. Examine anterior and posterior vaginal walls

  • Consider standing the patient if she has symptoms but the prolapse is not obvious when lying down examination positions
  • Consider pelvic USS if pelvic mass found/suspected
  • Establish the grade of uterine prolapse:
    • Grade 1= bulge halfway to the hymen
    • Grade 2= bulge is to the hymen
    • Grade 3= bulge halfway past the hymen
    • Grade 4= maximum possible descent
  • If obstructed defecation, exclude rectal mass
  • Grades 3 and 4 are more likely to be associated with obstructive symptoms such as incomplete bladder or bowel emptying, and renal obstruction (consider renal USS and UE)

 Management

  • If no symptoms, no invasive treatment is necessary - advise on pelvic floor exercises
  • Ask the patient which is the main symptom? bladder, bowel or prolapse?
  • Include assessment of patient wishes/expectations
  • Treat constipation
  • Reduce risk factors eg, smoking, copd, constipation, obesity

 

Urinary incontinence-refer to continence service

Bowel symptoms          treat constipation and refer conservative bowel management

Prolapse symptoms      Pelvic floor for at least 12 weeks/refer pelvic floor nurses

Offer pessary

                                    Vaginal oestrogen

                                    Bowel and bladder team referral

 Referral

If above fails or not suitable due to severity refer to either uro gynaecology or complex uro gynaecology if urinary symptoms with previous incontinence surgery or previous surgery

 

Date Reviewed                          26/08/2019

Date of Next Review                  26/08/2020

Author                                      Dr Anna Harrold

 

Version No.  4.1