utero vaginal prolapse

*******uv prolapse*******

History for a 60-Year-Old Woman with Second-Degree Uterovaginal Prolapse and Stress Incontinence 

 

1. Presenting Complaints

– Symptoms of Prolapse

– Vaginal bulge or a sensation of “something coming out.”

– Feeling of heaviness or dragging in the pelvis.

– Symptoms worsening with standing or straining and relieved by lying down.

 

– Symptoms of Stress Incontinence

– Involuntary urine leakage during coughing, sneezing, laughing, or physical activity.

– Frequency or urgency of urination (if present).

– Associated Symptoms

– Difficulty with voiding: incomplete emptying, weak stream, or double voiding.

– Recurrent urinary tract infections.

– Difficulty with bowel movements or constipation.

– Pelvic or lower back pain.

– Dyspareunia (painful intercourse) or vaginal dryness.

2. Duration and Progression

– Onset of symptoms: when they started and how they have progressed.

– Impact on daily activities and quality of life (e.g., work, social life, and intimacy).

 

 

3. Risk Factors

– Obstetric History

– Number of pregnancies, mode of delivery, history of prolonged labor, or instrumental deliveries,   Perineal tear/episiotomy

– Birth weight of babies (>4 kg increases risk).

 

– Gynecological History

– History of menopause and postmenopausal atrophy.

– Previous gynecological surgeries, such as hysterectomy or pelvic floor repair.

 

– Medical and Lifestyle History

– Chronic cough (COPD, asthma, smoking).

– Chronic constipation or straining.

– Obesity.

– Heavy lifting or strenuous physical work.

 

– Family History

– Any family history of pelvic organ prolapse or connective tissue disorders.

 

4. Treatment History

– Previous Interventions

– Use of vaginal pessaries and patient satisfaction with them.

– Any medications for bladder control (e.g., anticholinergics or beta-3 agonists).

– Previous physiotherapy or pelvic floor muscle training.

– Any prior surgeries for prolapse or incontinence.

 

5. Differential Diagnosis Considered

– Pelvic Masses:   Ovarian cysts, uterine fibroids.

– Bladder Disorders: Overactive bladder, urethral diverticulum.

– Other Incontinence Types: Mixed or urge incontinence.

– Rectal Prolapse or Intussusception.

 

6. Complications of Current Condition

– Vaginal ulcers or erosions due to prolonged prolapse- Local complications- Discharge, bleeding, ulcer

– Recurrent urinary tract infections.

– Hydronephrosis or renal dysfunction in severe cases of obstruction.

– Social embarrassment, depression, or anxiety.

– Sexual dysfunction- if sexually active

 

7. Patient Expectations

– Desire for definitive management or symptom relief.

– Preference for non-surgical versus surgical treatment.

– Concerns about post-operative recovery and risks.

– Goals related to quality of life, including mobility, independence, and sexual activity.

 

Examination

1. General Examination

– Vital Signs

– Measure blood pressure, pulse, respiratory rate, and temperature.

– Assess for hypertension or any other systemic conditions.

 

– General Appearance

– Body habitus (e.g., obesity, malnutrition).

– Mobility and functional status.

 

– Signs of Chronic Illnesses

– Pallor (anemia), cyanosis, jaundice, or lymphadenopathy.

– Signs of connective tissue disorders (e.g., hypermobility of joints).

 

– Skin Examination

– Look for skin changes such as bruising (possible anticoagulant use), trophic changes, or signs of chronic illnesses.

 

– Edema

– Check for pedal edema, which might indicate venous stasis or systemic disease.

 

2. Abdominal Examination

– Inspection 

– Look for scars from previous surgeries (e.g., cesarean section, hysterectomy, or pelvic surgeries).

– Assess for distension, visible masses, or hernias (e.g., incisional hernia).

 

– Palpation

– Palpate for tenderness or masses.

– Assess for an enlarged bladder (due to incomplete voiding) or other palpable abnormalities.

 

– Percussion

– Assess for bladder distension or ascites.

 

– Auscultation

– Listen for bowel sounds, especially if constipation or abdominal pain is reported.

 

3. Respiratory Examination

– Inspection

– Look for signs of chronic cough, barrel chest, or other indications of chronic obstructive pulmonary disease (COPD).

– Assess for use of accessory muscles of respiration.

 

– Palpation and Percussion

– Evaluate for resonance and chest wall tenderness.

 

– Auscultation

– Assess for wheezing, crackles, or decreased breath sounds that may indicate chronic bronchitis, emphysema, or other pulmonary conditions.

 

Note: Chronic cough can exacerbate prolapse symptoms and should be addressed as part of management.

 

4. Central Nervous System Examination

– Mental Status

– Assess orientation, memory, and cognition, especially if incontinence has affected mental well-being.

 

– Motor Examination

– Assess lower limb strength and mobility, as pelvic floor dysfunction may coexist with neurologic issues.

 

– Reflexes

– Check for bulbocavernosus and anal reflexes to assess sacral nerve integrity.

 

– Sensation

– Evaluate perineal sensation to rule out any nerve compression or neuropathy.

 

– Gait Assessment

– Observe for any gait abnormalities that may contribute to pelvic floor dysfunction.

 

5. Bimanual Pelvic Examination

 

Consent, ask to empty the bladder, light, gloves, sims and Cuscos self retaining  bivalved speculum, prepare sponge forceps.

– Preparation

– Ensure patient comfort and privacy.

Positioning the Patient

– Use a lithotomy position or alternative position if mobility is limited.

– External Genitalia Inspection

– Look for vaginal atrophy, irritation, ulcers, or signs of infection.

 

– Assessment of Prolapse

– Ask the patient to bear down (Valsalva maneuver) to observe the degree of prolapse.

– Grade the prolapse using the Baden-Walker or POP-Q system.

 

– Internal Palpation

– Assess vaginal tone and pelvic floor muscle strength (e.g., by asking the patient to contract the muscles)-

Oxford grading scale – no contraction – 0

Flicker —      1

Weak —–     2

Moderate —3

Good—-         4

Strong —-      5

– Palpate for uterine size, mobility, and any adnexal masses.

 

– Stress Test:

– Perform a cough stress test to confirm urinary leakage.

 

– Speculum Examination

– Evaluate the vaginal walls for any anterior or posterior wall defects (e.g., cystocele or rectocele).

– Check for ulcers or discharge.

Sim Position to assess enterocele /small rectocele

 

 

 

First degree

Cuscos speculum examination– Cervix- Healthy, Ulcers, oedema, bleeding, discharge.

Sims speculum– Check for cystocele if not previously seen, Ask to strain and comment on the decent, Enterocele, rectocele

VE– Reduce the prolapsed( lubricate well) and ask to cough. If incontinence- and do Boney’s test.  Do VE

 

Second degree(Beecham)

cervix is seen, anteriorly- cyctocele. Posterior- rectocele. Cervix- Healthy, Ulcers, oedema, bleeding, discharge.

Degree of prolapse. If 3rd degree- comment about the size.

Sims speculum– Check for cystocele if not previously seen, Enterocele, rectocele

VE– Reduce the prolapsed( lubricate well) and ask to cough. If incontinence- and do Boney’s test.  Do VE

PR– offer

 

 

POP Q system

 

 

Comparison of the Classification Systems

 

 

 

Management

 

Step 1: Counseling

 

– Explain the Condition

– Describe uterovaginal prolapse and stress incontinence, their causes, and progression.

– Reassure the patient that these are treatable conditions.

– Discuss Goals of Treatment

– Improve quality of life, relieve symptoms, and restore pelvic anatomy and function.

– Inform About Treatment Options

– Outline surgical and non-surgical options, including their benefits, risks, and success rates.

– Address Patient Expectations

– Clarify her priorities (e.g., symptom relief, avoidance of surgery, or sexual function).

 

 

Step 2: Lifestyle Modifications

– Weight Loss

– Encourage weight reduction to decrease pressure on the pelvic floor.

– Avoid Straining

– Treat chronic constipation with high-fiber diets, hydration, and laxatives if needed.

– Smoking Cessation

– Reduces chronic cough, which worsens prolapse and incontinence.

– Manage Chronic Cough or Comorbidities

– Treat COPD, asthma, or other conditions contributing to increased intra-abdominal pressure.

 

Step 3: Investigations

– Bladder Diary

– Record fluid intake, frequency of urination, episodes of incontinence, and triggers over 3–7 days.

– Urodynamic Studies 

– Assess bladder function and confirm stress incontinence.

– Rule out detrusor overactivity (urge incontinence) and mixed incontinence.

– Pelvic Ultrasound -TVS+ TAS

– Evaluate pelvic organ position, masses, and bladder post-void residual volume.

– Urine Analysis and Culture/UFR

– Rule out urinary tract infections.

– Blood Tests

– Check renal function (serum creatinine, electrolytes) if obstruction is suspected.

 

 

MANAGEMENT

Step 4: Non-Surgical Management 

 

– Pelvic Floor Muscle Training (PFMT)

– Regular Kegel exercises, guided by a physiotherapist.

– Success Rate: Improves symptoms in 50-70% of mild cases.

 

– Pessary Use

– Vaginal devices to support pelvic organs, especially for women avoiding surgery.

– Requires regular cleaning and follow-ups.

– Success Rate: Symptom improvement in 70-90% with proper fitting.

 

                    Types Of Pessaries-   Support pessary, Sapce occupying pessary

                                                           Support pessary- Ring , Smith, gehrung

Space occupying pessary- Gelhorn, Donut,Cube

  

How to measure pessary size

Line A: The vaginal length from posterior symphysis to apex or posterior fornix can be useful for sizing Ring, Donut and inflatable pessaries, or the length of a Gellhorn neck.

Line B: The vaginal width at the apex can be useful when considering the diameter of the Gellhorn, Dish, Shaatz.

Line C: The diameter of the introitus and vaginal shaft can help in measuring for the Cube.

 

 

– Lifestyle Adjustments (as above)

– Complement other treatments.

1. lifestyle modifications
2. limit fluid intake
3. ↓ alcohol/caffeine intake
4. stop smoking &
5. ↓ weight if BMI ≥30

 

 

Step 5: Medical Management 

 

– Vaginal Estrogen Therapy

– Indicated for postmenopausal women to improve vaginal tissue integrity.

– Success Rate:   Alleviates mild prolapse symptoms and improves continence in ~50%.

– Medications for Incontinence (if mixed incontinence) 

– Anticholinergics (e.g., oxybutynin) or beta-3 agonists (e.g., mirabegron).

– Success Rate: Effective in ~50-60% of patients with urgency components.

 

Step 6: Surgical Management 

   For Prolapse

1. Vaginal Hysterectomy with Pelvic Floor Repair

– Standard surgery for uterine prolapse.

– Success Rate: ~80-90% long-term success.

2. Sacrocolpopexy (with or without uterus sparing)

– Abdominal approach using mesh for suspension of the prolapsed uterus or vaginal cuff.

– Success Rate: >90% for symptom resolution.

-Route- open/laparoscopically

(POSTGRADUATE students must know about the steps of vaginal hysterectomy and how to handle the difficult cases)

3. Sacrospinous Ligament Fixation

– Vaginal approach to fixate the prolapsed vaginal apex or uterus.

– Success Rate: ~85%.

4. Colpocleisis (Vaginal Closure)

– For women who no longer desire vaginal intercourse.

– Success Rate: >95%, with minimal recurrence.

Types of Colpocleisis

1. LeFort Colpocleisis

Partial closure of the vaginal canal with preservation of lateral channels for drainage.

2. Complete Colpocleisis

Total closure of the vaginal canal without preserving any channels.

 

Preoperative Preparation

1. Patient Selection

– Severe pelvic organ prolapse (e.g., stage III or IV POP-Q system).

– No desire for vaginal intercourse.

– No significant risk of cervical or uterine pathology (if uterus is retained).

2. Preoperative Investigations

– Pap smear to rule out cervical pathology.

– Endometrial biopsy or ultrasound for uterine abnormalities if the uterus is retained.

– Urodynamic testing if urinary symptoms are present.

3. Consent

– Explain loss of vaginal function and sexual intercourse.

– Discuss possible complications: bleeding, infection, urinary retention.

 

For Stress Incontinence

 

1. Colposuspension (Burch Procedure)

– Lifts and supports the bladder neck and urethra.

– Success Rate: ~70-80%.

2. Mid-Urethral Sling Procedure

– Retropubic (TVT) or trans obturator (TOT) approach.

– Success Rate: ~80-90%.

-Although its use is controversial, transvaginal mesh should be reserved for complex cases at high risk of failure, such as multicompartment /recurrent prolapse(TOG2023)

-it should only  be used in the hands of trained and experienced surgeons.

3. Bulking Agents (Injection)

– Less invasive, short-term results.

– Success Rate:    ~40-60%.

Indications for bulking agents (injection synthetic material around urethra)

1. Wishing to avoid major surgery/mesh
2. Recurrent SUI after failed primary surgery
3. Willing to accept less cure rate in favor of less invasive procedure with less risk of voiding difficulty
4. Co-morbidities
5. Desire future pregnancy

 

Inform all these women that

• • Permanent material & may need repeat injections to have efficacy
  • Lesser efficacy than alternate surgical procedures
  • Poor durability  Limited evidence on long-term efficacy & side effects
  • NICE: give written information comprising agent name, manufacturer, injection date & surgeons details

 

Five agents currently available in UK

1. Polyacrylamide hydrogel (Bulkamid)
2. Polydimethlsiloxone
3. Carbon beads
4. Calcium hydroxyapatite
5. Cross linked vinyl dimethyl polydimethylsiloxane

 

Mechanism of action 

• Intramural bulking agents creat additional submucosal bulk by providing artificial mucosal cushion & help in coaptation (adaption of urethral muscles to remain closed at rest)
• The ideal bulking agent should be

1. easy to inject,
2. retain volume and durability,
3. be biocompatible with minimal inflammatory and fibrotic response.
4. no migration from the site of injection (normally meaning particles with a diameter of >80 μm suspended in a gel).

There is no ideal bulking agent

 

Step 7: Post-Operative Care and Follow-Up

– Early Recovery

-Antibiotics for 1 week

-Avoid constipation for 2weeks -lactulose for 1 week

-Avoid bathing in pools for 1 month

– Avoid heavy lifting and straining for 3months

– Resume light physical activity as tolerated.

-can have sexual intercourse after one month whenever she feels comfortable

– Long-Term Care

– Reinforce pelvic floor muscle exercises.

– Regular follow-ups for pessary care or to monitor for recurrence.

About the Author

admin

Administrator

Visit Website View All Posts