female pelvic organ prolapse management in primary care dr alice clack – st6 hillingdon hospital
TRANSCRIPT
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Female Pelvic Organ Prolapse
Management in Primary Care
Dr Alice Clack – ST6 Hillingdon Hospital
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Pelvic Organ Prolapse
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Incidence
• Difficult to determine but common• ~41% of women aged 50-79 years show some
degree of prolapse• Most common reason for hysterectomy (13%)• Accounts for 20% of women on waiting lists
for major gynaecological surgery• Life-time risk of surgery for prolapse – 11%
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Risk Factors
• Main–Vaginal Delivery–Increasing Parity–Age–Obesity
• Other– Family History/race/connective tissue disorder– Constipation/chronic
cough/heavy lifting– Prolonged 2nd
stage/forceps delivery/macrosomia
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Clinical Presentation
Common Symptoms associated with Pelvic Organ Prolapse
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Sensory• Lump• Pain/discomfort in
pelvis/vagina/buttocks/ lower back – Often vague ‘ache’ or
‘dragging’• Dyspareunia/ obstruction during
intercourse• Excoriation/bleeding
from protruding tissue
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Urinary • Hesitancy• Poor Flow• Incomplete
emptying• Recurrent UTI’s • Need to reduce
prolapse or adopt specific postures to initiate/complete micturition
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Gastro-intestinal
• Constipation• Incomplete
emptying• Tenesmus• Digitation• Incontinence– Flatus/Staining from
residual stool
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Incidental Finding
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Assessing Prolapse
Physical and emotional impact and when should we ‘treat’?
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Quality of Life• Does it trouble the
patient and to what degree?– Or are they worried it is
dangerous/abnormal?
• What is the main symptom/problem for the patient?– Is treating the prolapse
the best way of treating that symptom
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Associated Symptoms
• Are there significant associated symptoms?
• How much trouble/harm are these causing– How likely are the
symptoms to be related to the prolapse?
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Confounding Symptoms• Unstable Bladder and bladder pain symptoms– Not generally secondary to prolapse
• Constipation/incomplete bowel emptying/incontinence– Often proceed prolapse
• Pelvic pain/back pain– Other causes more likely
• Vulval/vaginal discomfort– Prolapse incidental
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Types of Prolapse?
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Uterine Prolapse• Often associated with
ant. and post. wall prolapse (esp. ant.)
• Often associated with dragging pelvic and back discomfort and lump
• If severe often associated with voiding dysfunction
• May cause mechanical obstruction to intercourse
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Vaginal Vault Prolapse• Following Hysterectomy– 11.6% of hysterectomies
for prolapse– 1.8% of hysterectomies
performed for other reasons
• Again usually associated with at least anterior vaginal wall prolapse
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Anterior Vaginal Wall Prolapse
• Often associated with voiding dysfuction (obstructive pattern)
• Often associated with sensation of a lump and dragging
• Often associated with Uterine prolapse
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Posterior Vaginal Wall Prolapse
• Often associated with constipation and incomplete bowel opening (chicken and egg)
• Often associated with ‘dragging’ sensation lower back
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Degree of Prolapse?• POPQ??– Pre and post-op
assessment, communication between uro-gynaecologists and research
• Assessment in terms of stage – 1, 2, 3 adequate for communication between primary and secondary care– Hymen rather than introitus
is point of reference
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Prolapse Stages
• Stage 1: The most distal portion of the prolapse is >1cm above the level of the hymen
• Stage 2: The most distal portion of the prolapse is between 1cm above and 1cm below the hymen
• Stage 3: The most distal portion of the prolapse is >1cm below the hymen but complete eversion of the vaginal wall has not occurred
• Stage4: Complete eversion of the total length of the lower tract has occured
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Management of Prolapse
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Reassurance and Advise
• Low risk to patient• Reassurance is often all
patient wants• Open-door for future
intervention• Prevention of Progression– Weight loss– Constipation/chronic cough
avoidance– Pelvic floor excercises
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Treat Associated Symptoms
• Constipation• Overactive bladder• Vulval irritation/atrophy• Back-pain/Pelvic pain
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Optimise Pelvic Conditions
• Pelvic floor exercises• Systemic/Topical HRT• Weight Loss
– Do not reverse prolapse but can help prevent progression and improve associated symptoms
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Pessaries• Suitable for most
patients if willing to try• Important role in
management of high anaesthetic risk patients or if family incomplete
• Potential as trial of response to reducing prolapse– Symptoms resolved?– SI after prolapse
reduced?
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Ring Pessary• Measured from posterior
fornix to upper edge pubic symphisis
• Change 6 monthly and inspect vagina for ulcerations
• Easy to teach patients to remove and insert– Useful if menstruating or if
causing problems during intercourse
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Limitations of Pessaries • Often not acceptable to patients– Need to change regularly– Discomfort
• Sometimes not retained– Especially if previous vaginal hysterectomy– Can cause urinary retention/constipation if
displaced• Erosions• Vaginal Discharge (non infective)• Of limited help in reducing posterior wall
prolapse
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Referral to Secondary Care
• Significant prolapse or associated symptoms and:– requesting surgical
management– Failed conservative
management
• Multiple urinary symptoms with Prolapse
• Significant recurrent prolapse after surgery
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Surgical Procedures
• Anterior vaginal wall repair• Posterior vaginal wall repair• Vaginal hysterectomy• Vaginal Sacro-spinous fixation• Abdominal sacrocolpopexy (open or
laparoscopic)• Many and various mesh repairs
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Post-operative Complications• Early– Haematoma’s, infection– Urinary Retention– Vaginal Discharge (Non infective)– Early failure of repair
• Late– Recurrence (20-30%)– Mesh erosions– Progression of prolapse in other compartments– Dyspareunia (especially posterior)– Stress incontinence/unstable bladder (5%)
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Thank You