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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, 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 U&E)


Management

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


Urinary incontinence: See Urinary Incontinence Guidelines


Bowel symptoms:     Treat constipation

     Refer to Bowel and Bladder service for conservative bowel management before referral to Colorectal team.


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

           Offer pessary

                                    Vaginal oestrogen

                                    Refer Bowel and bladder team if mixed symptoms


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.

If bowel symptoms are main concern, refer to colorectal team after conservative bowel nurse input.




 

Date Reviewed                        December 2020

Date of Next Review                December 2021

Author                                                  Dr S Burns

Contributors:                            Lisa Verity, Consultant Gynaecologist, RCHT

 

Version No.  4.1