Neobook — clinical reference

Prolapse is descent of the uterus (uterine prolapse) &/or vaginal walls (cystocoele, rectocoele, enterocoele, vault prolapse) through a deficient pelvic floor.

Symptoms: never operate without knowing if there are urinary or bowel symptoms & without knowing if the patient is sexually active.

Points on history taking

Patients present with a feeling of something coming down or out of the vagina, & backache
Severity of the symptoms & how much this upsets the patient’s lifestyle
With cystocoele or rectocoele there may be a feeling of incomplete emptying – a desire to micturate or defecate shortly after doing so.
Digitation – with rectocoele downward pressure with fingers on the vaginal floor assists defecation
General gynaecological & medical history, including promoting factors such as cough or constipation

Physical examination

General examination
Chest - check for evidence of chronic lung disease. Coughing worsens prolapse
Abdomen - note obesity or abdominal mass, which may promote prolapse
Pelvic examination:
- Look for procidentia and a ‘decubitus ulcer’ on the prolapsed cervix (it is the cervix roughened by underwear & looks like cancer – biopsy if necessary
- Ask the patient to bear down
- Use a Cusco speculum to assess laxity & atrophy of tissues
- Inspect the cervix & take a Pap smear if indicated
- With the patient in a left lateral position use a Sims’ speculum. Ask an assistant to hold the right leg up a little. Use the Sims’ speculum to hold back the anterior vaginal wall. Ask the patient to bear down & see if the posterior wall descends. Hold back the posterior vaginal wall & see if the anterior wall descends

Assessment of prolapse

Anterior vaginal wall descent suggests cytocoele
Posterior vaginal wall descent is suggestive of rectocoele or enterocoele
A finger in the rectum will fill a rectocoele, but not an enterocoele
Prolapse long after a hysterectomy may be vault prolapse
With uterine prolapse, there is some degree of cytocoele or rectocoele
Cystocoele and rectocoele may exist separately or together, with or without uterine prolapse

Grading of uterovaginal prolapse

Ideally, the POP-Q (pelvic organ prolapse quantification) system should be applied to express the degree & location of prolapse. It is complex. In simple terms the reference point is the hymen
Cystocoele and rectocoele are often graded mild, moderate or severe
Uterine prolapse may be graded in degrees
- 1^st degree: Cervix descends but higher than 1cm above the hymen
- 2^nd degree: between 1cm above & 1cm below the hymen
- 3^rd degree: beyond 1cm below the hymen but total vaginal length (TVL) -2cm
- 4^th degree: total eversion, ‘procidentia’

Management

Where possible, start with conservative before operative

Conservative management

Remove promoting factors – obesity, chronic cough, constipation
Try pelvic floor (Kegel’s) exercises in younger, mildly affected patients, & in postpartum patients
Use pessaries in patients who decline surgery or are not fit for surgery
Pessaries with oestrogen (Premarin) cream may restore normal anatomy & allow the vagina to heal and strengthen before surgery

Insertion of ring pessaries

Show & explain the pessary to the patient
Estimate the pessary diameter by opening the index and middle fingers in the lateral fornices and removing them while still open
Cover the pessary with KY jelly or oestrogen cream
Insert at 45% to the horizontal axis of the vagina – the posterior rim goes higher up. Avoid pressure on the urethra with insertion
Leave the pessary to rest between the posterior fornix & retropubis
Change the pessary every 3 to 6 months:
Ask about bleeding, pain, discharge, urinary or bowel symptoms
After removing a pessary, inspect the vagina for erosions
Replace or reinsert the pessary
Other pessary designs – Hodge, cube are perfectly acceptable

Surgery

Operations for prolapse: include anterior colporrhaphy for cystocoele & posterior colpoperineorrhaphy for rectocoele, each alone, together or combined with vaginal hysterectomy. Abdominal or laparoscopic sacrocolpopexy & vaginal sacrospinous fixation are used to for vault prolapse. Urinary stress incontinence procedures, e.g tape (preferable), sling, or Kelly-Kennedy plication may be added. The choice of operation depends on each patient’s unique needs & symptoms, & all have their complications.

Modern tapes may correct mild prolapse as well as stress incontinence. However, such tapes may contribute to other forms of prolapse, e.g. enterocoele. A complication of tapes & meshes is erosion into the vagina & bladder. Larger meshes erode in up to 10% cases & more & are currently under discussion.