March 2008: Managing women with pelvic organ prolapse
How is prolapse diagnosed?
What are the treatment options available to GPs?
When should patients be referred?
How is prolapse diagnosed?
What are the treatment options available to GPs?
When should patients be referred?
Pelvic organ prolapse, or genital prolapse, is the descent of the pelvic organs into the vagina. It is often accompanied by urinary, bowel, sexual or local pelvic symptoms.
The incidence is difficult to determine, as many women do not seek medical advice. It has been estimated that around half of all parous women lose pelvic floor support, resulting in some degree of prolapse, and that only 10-20% of these women seek medical care.1
There is clearly a need to raise awareness of the symptoms of pelvic organ prolapse and the help that is available to patients; GPs could put up a poster in their surgery and ask women if they have a problem with prolapse.
In the UK, prolapse accounts for 20% of women on the waiting list for major gynaecological surgery.2 The incidence of prolapse requiring surgical correction in women who have had a hysterectomy is 3.6 per 1,000 person-years of risk; the cumulative risk is 1% at three years and 5% at 17 years post-hysterectomy.3
The risk of prolapse increases with age.4 Therefore, the incidence of prolapse will rise as life expectancy increases.
Prolapse is often asymptomatic and an incidental finding, and the results of clinical examination may not necessarily correlate with symptoms.5
Although prolapses can occur in the anterior, middle or posterior compartments of the pelvis, the pelvic floor should be considered as a single unit in the treatment of prolapse:
• Anterior compartment: prolapse of the urethra (urethrocele), bladder (cystocele) or both (cystourethrocele) into the vagina
• Middle compartment: uterine or vault descent and enterocele (herniation of the pouch of Douglas)
• Posterior compartment: prolapse of the rectum into the vagina (rectocele).
Enteroceles may contain part of the small bowel and omentum.
Cystoceles are the most common type of prolapse, followed by uterine descent and then rectoceles. Traditionally, uterine descent is graded as first degree (within the vagina), second degree (descent to the introitus) or third degree (descent outside the introitus).
A summary of the causes of prolapse is given in box 2, below.
Patients should be examined in a left lateral or standing position using a Sims speculum. This should be inserted along the posterior vaginal wall to assess the anterior wall and vault, and vice versa. Uterine descent can be assessed by traction with a single-toothed vulsellum. A cervix that protrudes outside the vagina may be ulcerated and hypertrophied.
A Sims speculum is essential to assess the degree of prolapse and determine which compartment is affected. If this is not available and the patient is suffering from symptoms of prolapse, she should be referred to a specialist. Referral is not usually urgent unless there is complete procidentia.
If the patient has urinary symptoms, a mid-stream urine specimen should be taken and sent for culture and sensitivity analysis before any investigations take place.
GPs should ask the patient about a history of rectal prolapse, bladder and bowel function and sexual activity.
Cystometry and uroflowmetry are recommended to evaluate potential stress incontinence, mixed symptoms of urinary incontinence and emptying phase dysfunction.
Prolapse may mask stress incontinence, so urodynamic studies should be undertaken before surgery. If these show stress incontinence, a continence procedure can be combined with pelvic floor reconstruction. However, some surgeons counsel women before the operation for prolapse and perform a continence procedure later.6
If the symptoms and signs of prolapse do not correlate, for example there is a sensation of prolapse but a prolapse is not discernable on examination, the patient should be referred for pelvic fluoroscopy with barium contrast in the vagina, bladder, small bowel and rectum.7
Conservative treatment should always be offered before a patient is referred.
It is also important to treat predisposing factors, such as obesity, COPD, constipation and pelvic masses.
Pelvic floor exercises
Pelvic floor exercises may limit the progression of mild prolapse and alleviate mild symptoms, such as low backache and pelvic pressure.8 However, they are not useful if the prolapse extends to, or beyond, the vaginal introitus.9 Pelvic floor exercises should be encouraged as soon as possible after childbirth.
Pessaries are used to treat and manage prolapse, although their use has decreased with advances in anaesthesia and surgical techniques. They are mainly indicated for:
• Patients who are unfit for, awaiting, or have declined surgery
• Women who may yet bear children
• Rarely, neonates with prolapse occurring in conjunction with neural tube defects.10
A variety of styles and sizes of pessary are available. There are two main types: support pessaries, which rest under the symphysis and sacrum and elevate the vagina, and space-occupying pessaries.11
The clinician should perform a bimanual examination and use a forefinger to estimate the size of the vagina. Sometimes, trial and error is the only way to determine the size of pessary required.
The pessary should be placed in the vagina and the woman encouraged to walk around. If she feels pain or discomfort, the pessary is likely to be too big and a smaller one should be tried.
The patient should be advised to return after one month for a check and asked to return earlier if she experiences pain or difficulty.
If there are no adverse symptoms, such as pain, discharge or bleeding, the pessary can be used for 9-12 months before being changed. If atrophy occurs, topical oestrogen cream should be applied twice a week and the pessary changed every two to three months.
Although uncommon, erosion or ulceration can occur with atrophic change in the vagina. If this happens, the pessary should be removed and oestrogen cream applied until the ulcer has healed. The pessary may then be replaced.
If the ulcer looks suspicious or does not heal, patients should be referred for biopsy. Patients with a decubitous ulcer and a complete procidentia may need hospitalisation and vaginal packing with oestrogen cream.
There is a lack of good data on the indications for different types of pessary, how often the pessaries should be changed and whether pessaries should be used concurrently with HRT or pelvic floor exercises.12
Some women, particularly older patients, may find it less embarrassing and stressful to visit their GP or practice nurse to change a pessary than to return to the specialist. No data have been published on the effect of pessaries on sexual function; however, a space-occupying pessary can be expected to hinder coitus.
If conservative treatment is ineffective or declined, the patient should be referred to a urogynaecologist. It is best to wait for at least 6-12 months after childbirth before considering any surgical intervention.
Surgery is indicated if:
• Pessary treatment fails
• The patient wants definitive treatment
• The prolapse is combined with urethral sphincter incompetence or faecal incontinence.
The lifetime risk of an operation for prolapse or incontinence by the age of 80 years has been reported to be 11%,4 but this is probably a gross underestimate of the true figure.
Surgery needs to be repeated in 11-29% of cases. The time interval between surgery and recurrence of prolapse reduces with each successive operation.4
The aims of surgical correction of prolapse are:
• Relief of symptoms
• Restoration of normal vaginal anatomy
• Preservation of sexual function, urinary continence and anal continence.
Injury after childbirth usually involves all pelvic floor and pelvic organ supports, although sometimes only one organ may prolapse. If more than one compartment is involved, a combination of procedures may be required.
Some operations, for example colposuspension for urinary incontinence, may predispose the patient to prolapse in another compartment.13
Operations are classified by compartment and approach (see table 1, attached). The patient's fitness and whether or not they are sexually active may influence the choice of procedure.
There is a lack of data on pregnancy outcomes and childbirth after prolapse surgery. If the prolapse remains corrected and the patient conceives, an elective caesarean section may be advisable. Generally, women should avoid heavy lifting after surgery and refrain from sexual intercourse for six to eight weeks.
Operations in the anterior compartment
Anterior repair (anterior colporrhaphy) is performed to rectify a cystourethrocele. Mesh may be placed in the anterior wall of the vagina for additional support if previous surgery was unsuccessful. Intraoperative complications are uncommon, although haemorrhage, haematoma and bladder injuries may occur. Difficulty in voiding and recurrence
of the prolapse are common postoperative problems.14
Paravaginal repair is an abdominal approach to correct a defect in the anterior compartment. A cure rate of more than 95% has been reported. This procedure can also be done laparoscopically or vaginally.
Operations in the middle compartment
Vaginal hysterectomy is the treatment of choice for uterine prolapse. It can be combined with an anterior or posterior repair, or both, if a cystocele or rectocele is present.
For women who wish to retain their uterus, sacrohysteropexy can be performed. It is also indicated if conservative treatment in a healthy, young, nulliparous woman fails, in women who wish to bear children, women who refuse hysterectomy and in women with a congenital anomaly (such as bladder exstrophy).
Vaginal vault prolapse
Sacrospinous fixation and iliococcygeal hitch do not require an abdominal incision, thereby reducing pain and shortening hospital stay.
Laparoscopic and abdominal sacrocolpopexy are alternative options. Laparoscopy results in shorter hospital stays. However, there are few prospective randomised studies and the role of laparoscopy needs to be defined.15 Abdominal sacrocolpopexy has a cure rate of 90%. Its main complications are intraoperative haemorrhage and a 3.3% risk of mesh erosion.16-18
Operations in the posterior compartment
Posterior repair (posterior colporrhaphy) is appropriate for correction of a rectocele and a deficient perineum. It involves the repair of a rectovaginal fascial defect and removal of excess vaginal skin, which must be done carefully as it can result in vaginal narrowing and dyspareunia. Other posterior compartment operations include perineoplasty and enterocele repair.
Pelvic floor clinics
In the past, gynaecologists were solely responsible for treating prolapse. However, the focus is now on treating the pelvis as a whole rather than as three different compartments. Consequently, patients with complex problems can be referred to a specialised pelvic floor clinic, run by surgeons experienced in urology, gynaecology and colorectal surgery, for a single examination and consultation. In an audit of such a clinic, 20% of patients required combined procedures and thus avoided the risk and recuperative time of two procedures.19
There is a lack of good data on the prevention and treatment of prolapse. In particular, more research is needed on the role of pelvic floor exercises and the pros and cons of the vaginal, abdominal and laparoscopic routes of surgery.Managing women with pelvic organ prolapse Useful information
Women's Health Concern provides factsheets on all common gynaecological conditions and a nurse-led telephone and email advice service for patients
tel: 0845 123 2319
Women's Health is a registered charity providing leaflets for patients on common gynaecological conditions www.womenshealthlondon.org.ukAuthors
Dr Natalia Price
specialist registrar in obstetrics and gynaecology
Mr Ian Currie
MB ChB FRCOG
consultant obstetrician and gynaecologist, Stoke Mandeville Hospital, Aylesbury