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