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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,  big babies
  • age, menopause and lack of estrogen
  • chronic  cough or constipation
  • heavy lifting in occupation or hobbies

Presenting symptoms

 

 

 

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 4are 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