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 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:      August 2024                                Review Date: August 2026

Author                                      Dr S Burns

                                                 Dr M Schick

Contributors:                            Lisa Verity, Consultant Gynaecologist, RCHT

 

Version No.  4.1