Pelvic Organ Prolapse
A 65-year-old woman, gravida 6, para 6, presented with a distressing vaginal bulge and urine retention. Her medical history includes hypertension, and coronary heart disease. Her previous surgeries included a vaginal hysterectomy at 45 years old and coronary artery bypass grafting five years earlier. On pelvic examination, she had significant anterior wall and apical prolapse, but only minor posterior wall prolapse. The findings of a quantitative pelvic organ prolapse evaluation are consistent with Stage III pelvic organ prolapse. She experiences no incontinence when the anterior prolapse is reduced in the office. She prefers to render her coital ability.
- Vaginal bulge and urine retention
- Hypertension, and coronary heart disease.
- Support pessary
- Suburethral sling procedure
- Anterior repair
Half of women over 50 will experience some symptoms of pelvic organ prolapse, and more than one in ten will have had surgery to correct the problem by the age of 80.
Extensive anterior wall prolapse can cause urethral kinking, while advanced posterior wall prolapse might compress the urethra directly, obstructing bladder outflow. Obstructive voiding, which leads to urine retention, affects up to 30% of patients with stage III-IV POP.
Observation is a great alternative for women who have few symptoms that do not impede their quality of life. For women with stage I–II vaginal prolapse, including PHVP, pelvic floor muscle training (PFMT) is an effective therapeutic option. For women with stage II–IV PHVP, vaginal pessaries offer an alternate therapy option. Pessary use before reconstructive surgery in women with urinary retention has been shown to resolve the urinary retention in 75% of patients. Women with symptomatic PHVP should be offered surgical treatment after receiving appropriate counseling (Given the patient’s age and medical comorbidities, a nonsurgical approach should be tried first).
Before Starting Pessary Treatment (NICE guidelines):
- Consider using topical estrogen to address vaginal atrophy, and explain that more than one pessary fitting may be required to obtain a suitable pessary.
- Discuss the impact of various types of pessaries on sexual intercourse.
- Describe any issues such as vaginal discharge, bleeding, difficulty removing the pessary, and pessary expulsion.
- To avoid serious pessary complications, explain that the pessary should be removed at least once every 6 months.
- McCall culdoplasty at the time of vaginal hysterectomy is effective in preventing subsequent PHVP.
- Suturing the cardinal and uterosacral ligaments to the vaginal cuff at the time of hysterectomy
- Sacrospinous fixation (SSF).
- Barber, M. D. (2016). Pelvic organ prolapse. Bmj, 354.
- Hagen, S., Kearney, R., Goodman, K., Melone, L., Elders, A., Manoukian, S., … & Bugge, C. (2020). Clinical and cost-effectiveness of vaginal pessary self-management compared to clinic-based care for pelvic organ prolapse: protocol for the TOPSY randomised controlled trial. Trials, 21(1), 1-13.
- National Institute for Health and Care Excellence. (2019). Urinary incontinence and pelvic organ prolapse in women: management (Published: 2 April 2019). Retrieved from https://www.nice.org.uk/guidance/ng123
- Pelvic Organ Prolapse Quantification (POP-Q) System. (2020, September 29). Physiopedia, . Retrieved 07:05, May 23, 2021 from https://www.physio-pedia.com/index.php?title=Pelvic_Organ_Prolapse_Quantification_(POP-Q)_System&oldid=252031.
- Royal College of Obstetricians and Gynaecologists. (2015). Post-Hysterectomy Vaginal Vault Prolapse (Green-top Guideline No. 46). Retrieved from https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-46.pdf