Definition of pelvic organ prolapse
Descent of pelvic organs into the vagina
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Anterior: cystocele (bladder most common), urethrocele (urethra)
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Middle: uterus, vault (after hysterectomy)
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Posterior: rectocele (rectum), enterocele (small bowel, omentum)
Grades of uterine prolapse
I Descent of the uterus to above the hymen
II Descent of the uterus to the hymen
III Descent of the uterus beyond the hymen
IV Total prolapse
Step 1: Presentation and history
Prevalence
The prevalence of pelvic organ prolapse among parous women is 50%. Most women are asymptomatic.
History
Physicians should ask about urinary frequency and urgency, bulges or lumps in the vagina, pelvic pressure or heaviness, incontinence of urine or stool, difficulty with defecation or constipation, dyspareunia, and whether patients insert their fingers in the vagina to void or defecate.
Risk factors
Childbirth, constipation, age, pelvic surgery, chronic cough, raised intra-abdominal pressure, and obesity.
Step 2: Physical examination and investigations
Physical examination
Bimanual, including speculum examination at rest and with straining. If prolapse is not obvious, repeat with patient standing with 1 foot on a chair. To help with speculum examination, turn the regular speculum 90º (watch the urethra) to see the anterior and posterior walls or remove 1 blade from a double speculum and apply the single blade anteriorly and posteriorly.
Investigations
Urine culture. If you are unsure of the diagnosis, use pelvic ultrasonography or cystography.
Step 3: Treatment principles
Most women are asymptomatic so no treatment is needed. A trial of lifestyle modification might be beneficial: Kegel exercises, weight loss, smoking cessation, treatment of constipation, electrical stimulation, or biofeedback.
Step 4: Medical therapy
Use estrogen (oral or vaginal) for mild cystocele. Consider a pessary.
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A pessary is a shaped device usually made of silicone and left in the vagina.
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Different pessaries are used for cystocele, stress incontinence, uterine prolapse, rectocele, and combinations of these (pessaries are not as good for vault prolapse after hysterectomy).
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Fit by trial and error with fitting rings, similar to diaphragm fitting.
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The most used pessary is the ring with support (treats grades I and II uterine prolapse and cystocele).
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Pessaries should be removed regularly for cleaning by patient or health care professional.
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Patients should be seen every 3 to 6 months to check for vaginal erosions.
Step 5: Further evaluations and surgical treatment
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Pelvic organ prolapse surgery has a success rate of 65% to 90%; repeat operation rate is 30%.
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When more than 1 compartment is involved, patients need a combination of surgeries.
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Correcting cystocele can unmask stress incontinence (unkinking the urethra makes it easier to leak). You could check for this before surgery by correcting the prolapse with a pessary.
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Some operations predispose patients to prolapse in another compartment.
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Surgery can be via the abdomen (open or laparoscopic) or the vagina using fascia, mesh, tape, or sutures to suspend the organs.
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To conserve the uterus, sacrohysteropexy uses a Y-shaped graft to attach the uterus to the sacrum. Complications include hemorrhage, hematoma, nerve damage, voiding difficulties, recurrence of prolapse, dyspareunia, and mesh erosion.
Bottom line
Women are often reluctant to discuss prolapse symptoms. While there are no randomized controlled trials of treatment, pessaries are a good option for those who wish to remain fertile or avoid surgery.
Resources
An Approach to Diagnosis and Management of Benign Uterine Conditions in Primary Care is available on-line with patient handouts and other useful resources at www.benignuterineconditions.ca. Printed copies can be obtained from the Ontario College of Family Physicians on their website at www.ocfp.on.ca, by e-mail at cme_ocfp{at}cfpc.ca, and by telephone at 416 867–8646.
Tips on pessaries
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There are 2 types: supportive for milder prolapses and space-occupying for more serious prolapse.
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Cost is $88 (Canadian) delivered to your office.
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For women with atrophic changes, the vagina can be prepared with topical estrogen 2 to 3 times a week for a month before insertion.
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Aim for the largest pessary that fits comfortably.
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Examiner’s fingers should pass easily between the pessary and the vagina wall.
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After fitting the pessary in the office, have patients walk around and then try to urinate or defecate.
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Women can remove, wash with mild soap and water, and replace the pessary weekly or monthly (or it can be cleaned by a health care professional every 3 to 6 months).
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There is no evidence or consensus on which pessary is best, how often to clean it, or how often to visit a health professional.
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You can try to keep the vagina lubricated with estrogen or Trimo-San vaginal jelly.
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Adverse effects include discharge, odour, pain, bleeding, failure to reduce prolapse, and expulsion.
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Long-term use carries a risk of vaginal erosion, so vaginal examinations should be done every 3 to 6 months.
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If forgotten, pessaries might become fixed in place. To loosen fixed pessaries before removal, apply 2 g of estrogen cream every second day for 2 weeks.
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Change a pessary after about 5 years or when it wears out.
Pessary companies
Milex (Cooper Surgical), 800 243–2974, www.coopersurgical.com
Mentor, 800 668–6069, www.mentorcorp.com Superior, 800 268–7944, www.superiormedical.com
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