PROLAPSE. By Charlotte Robinson Women s Health Speciality Attachment
Introduction Case example Pelvic organ prolapse - Epidemiology - Aetiology - Anatomy - Types of prolapse/ severity - Examination/Investigation - Management Conclusion References
CASE EXAMPLE 84 year old female PC Dragging feeling down below HPC 3 year history, increased in severity, not painful - Feels worse after being on her feet for a while used to love walking around the shops, now I get everything delivered - Some slight stress incontinence - Finds defecating uncomfortable and difficult, often has to place a finger into the vagina to evacuate bowels fully - No vaginal/rectal bleeding, no abnormal discharge, not sexually active
PMH - Menopause at 53 - Regular smears, all normal. No history of STI - 2 vaginal deliveries, large babies, 3 rd degree tear with first son. - Constipation - Osteoarthritis - Type II DM - GORD
DH - Laxido, 2 sachets a day - Co-codamol 8/500mg PRN - Metformin 500mg TDS - Omeprazole 10mg OD - Multivitamins + Iron - NKDA
Surgical History Left knee replacement 2007 SH - Lives alone, husband died from heart attack 10 years ago - Family support nearby - Cleaner once a week. Otherwise active and independant around the house. - Cat called mittens. - Non drinker, Smokes 5 cigarettes a day since mid twenties (15 year pack history) FH - Both parents had diabetes, Father died of lung cancer in his 70 s, mother died of stroke in her 80 s, no other sig FH
ICE - Understanding is that things are coming down from up there, feels that this is the cause of her symptoms - Feels embarrassed and it is now affecting ADL and QoL, frustrated that it hinders her independence as she otherwise feels fit and well, worried about looking after mittens post-operatively - Hopes that surgery will make everything normal, wants to be able to do her Christmas shopping in person.
On Examination BMI 36 Obs, CN, Neuro, Cardio, Resp examinations all normal Abdo, SNT no palpable masses/hernias Gynaecological exam inspection, some atrophy, cervix appears at hymen when asked to cough BM poor vaginal tone, low sitting moveable cervix, no palpable masses, no pain/ cervical excitation, posterior bulging of vaginal wall Cusco s speculum, healthy looking cervix but extending into lower half of vagina Simm s speculum, significant bulging of posterior vaginal wall, slight bulging of anterior vaginal wall
PROLAPSE Definition: Occurs when weakness or damage in the supporting structures (ligaments and pelvic floor muscles) allows one or more of the pelvic organs to bulge/herniate (prolapse) into the vagina. INTERESTING FACT TIME! -Tale as old as time prolapse has been describes since Hippocrates The first successful vaginal hysterectomy for prolapse was self-performed in 1670 by a peasant woman named Faith Raworth. She was so debilitated by her uterine prolapse, that she tugged on her cervix and slashed off the prolapse with a sharp knife. She survived the haemorrhage, however continued to live the rest of her life debilitated by urinary incontinence. [1]
Epidemiology Thought to be extremely common, although difficult to ascertain as many women have mild symptoms, are asymptomatic or too embarrassed to seek medical help Over 50% of parous women thought to have some degree of prolapse [2,3] By the age of 80, 1 in 10 women will have had corrective surgery for prolapse [2,3]
Aetiology Pregnancy and vaginal delivery. (most common causes of weakening of the pelvic floor, particularly with large babies or difficult births) The more births, the more common Age. Prolapse is more common as you get older, particularly after the menopause Increased intra-abdominal pressure. Being overweight, constipation, chronic cough, prolonged heavy lifting Iatrogenic. Following a hysterectomy; vaginal vault prolapse may occur. Pelvic surgery may weaken support structures Congenital. Abnormal collagen metabolism; Ehlers-Danlos syndrome
Types of prolapse APICAL PROLAPSE - Uterine prolapse (when uterus and cervix falls into the vagina) - Vaginal vault prolapse (upper part of vagina falls into the vaginal canal posthysterectomy) ANTERIOR WALL PROLAPSE - Cystocele (bladder bulges into upper anterior wall of the vagina) - Urethrocele (urethra bulges into lower anterior wall of the vagina) POSTERIOR WALL PROLAPSE - Enterocele (bulge of the upper posterior wall of the vagina, containing small bowel) - Rectocele (rectum bulges into lower posterior wall of the vagina)
Normal anatomy recap : [image source] https://pfdoptions.com/what-is-pelvic-organ-prolapse/
Uterine Prolapse [image source] https://pfdoptions.com/what-is-pelvic-organ-prolapse/ GENERALISED SYMPTOMS Dragging sensation Heaviness in pelvis Feeling of lump coming down Dyspareunia Difficulty inserting tampons Discomfort (back/abdomen pain, not diagnostic) Loss of vaginal sensation Complete eversion, ulceration/discharge
Vaginal Vault Prolapse Similar to uterine prolapse, may be milder generalised symptoms Common after hysterectomy for previous prolapse [image source] https://pfdoptions.com/what-is-pelvic-organ-prolapse/
[image source] https://pfdoptions.com/what-is-pelvic-organ-prolapse/ Cystocele/ Urethrocele Urinary urgency and frequency Urinary incontinence Incomplete bladder emptying Urinary retention or decreased flow Nocturia May increase risk of UTI
Enterocele Often mild generalised symptoms or asymptomatic [image source] https://pfdoptions.com/what-is-pelvic-organ-prolapse/
Rectocele Constipation Difficulty defecating May digitally reduce in order to completely evacuate bowels Urgency [image source] https://pfdoptions.com/what-is-pelvic-organ-prolapse/
Severity Pelvic Organ Prolapse Quantification (POPQ) [2] Stage 0. No prolapse present Stage 1. Prolapse more than 1 cm above the hymen Stage 2. Prolapse within 1 cm proximally or distally to the hymen Stage 3. Prolapse greater than 1 cm below the hymen, but without complete vaginal eversion Stage 4. Complete vaginal eversion (complete procidentia) * All types can severely impact a woman's QoL, physical health, independence, intimate relationships, confidence and mental health.
Examination and Investigation Detailed history and examinations : - Abdominal examination, Bimanual examination, Cusco's speculum and Simm s speculum examination (allows you to view each vaginal wall separately), PR. USS to exclude pelvic masses if clinically suspected, +/- tumour markers Urodynamics if urinary incontinence ECG, CXR, FBC, U+E if appropriate to assess fitness for surgery Modified Oxford system for pelvic floor strength Assessment for QoL impact, vaginal symptoms e.g.;- ICIQ-VS questionnaire of
Management Nice guidelines coming out 2019 Conservative prevention is better than cure! - Pelvic floor excercises, pre and postnatal (best outcome with physiotherapist) - As relaxed and least traumatic birth as possible - Weight loss - Treat chronic cough and constipation - Biofeedback and vaginal cones Medication - Vaginal oestrogen creams may be beneficial for mild prolapse in postmenopausal women
Vaginal Pessary (want to have children, don t want/unsuitable for surgery) - Lots of different types, must be fitted by a trained health professional, short term and long term solutions (4-12 month) - Ring, most common or shelf, better for more severe prolapses. Little effect on posterior wall prolapse. [image source] https://www.mayoclinic.org/diseases-conditions/urinaryincontinence/multimedia/pessary-use/img-20006056
Surgery (If all else fails, recurrent prolapse, severe prolapse, urinary and faecal incontinence). SUBJECT TO CHANGE, PENDING GUIDENCE PROLAPSE VAGINAL PROCEDURE ABDOMINAL PROCEDURE Apical Anterior Posterior Vaginal hysterectomy Sacrospinous fixation Uterosacral ligament suspension Anterior colporrhaphy Transvaginal mesh repair Posterior colporrhaphy Enterocele repair Transvaginal mesh repair Perineal body reconstruction Sacrohysteroplexy Sacrocolpoplexy Paravaginal repair Sacrocolpopexy Sacrocolpopexy Colpocleisis - Lateral margins of the vaginal wall sutured, leaving a short ended vagina (last resort)
[image source] https://www.acog.org/patients/faqs/surgery-for-pelvic-organ-prolapse#the
[image source] https://www.acog.org/patients/faqs/surgery-for-pelvic-organ-prolapse#the
[image source] https://www.acog.org/patients/faqs/surgery-for-pelvic-organ-prolapse#the n.b., Recent concerns with some mesh repairs
CONCLUSION What type of prolapse is our patient suffering from? What risk factors did she have? How would you treat her? Any questions?
References 1. Pelvic Organ Prolapse: Background, History of the Procedure, Problem. (2017). Emedicine.medscape.com. Retrieved 27 November 2017, from https://emedicine.medscape.com/article/276259-overview#a8 2. Collins, S. (2012). Oxford handbook of obstetrics and gynaecology (3rd ed.). Oxford: Oxford University Press. 3. Royal College of Obstetricians and Gynaecologists. (2013). Pelvic Organ Prolapse. RCOG. Retrieved from https://www.rcog.org.uk/globalassets/documents/patients/patient-information-leaflets/gynaecology/pi-pelvicorgan-prolapse.pdf 4. Bottomley, C., & Rymer, J. (2008). 100 cases in obstetrics and gynaecology. London: Hodder Education. 5. Genitourinary Prolapse. Genital prolapse, information.. (2017). Patient.info. Retrieved 25 November 2017, from https://patient.info/doctor/genitourinary-prolapse-pro 6. Kumar, P., & Clark, M. (2005). Kumar & Clark's clinical medicine (6th ed.). Elsevier Saunders. 7. Surgery for Pelvic Organ Prolapse - ACOG. (2017). Acog.org. Retrieved 27 November 2017, from https://www.acog.org/patients/faqs/surgery-for-pelvic-organ-prolapse#the 8. Types of pessaries. (2017). Mayo Clinic. Retrieved 27 November 2017, from https://www.mayoclinic.org/diseases-conditions/urinary-incontinence/multimedia/pessary-use/img-20006056 9. What is Pelvic Organ Prolapse? PFD Options. (2017). Pfdoptions.com. Retrieved 27 November 2017, from https://pfdoptions.com/what-is-pelvic-organ-prolapse/
Further reading for the keen beans Article on recent vaginal mesh repair scandals http://www.bbc.co.uk/news/health-42110076 Nice guidline updates for mesh repair https://www.nice.org.uk/guidance/ipg267 Video of prolapse repair https://www.webmd.com/women/video/pelvicprolapse-repair