Gynaecological Prolapses

Essentials

• Symptomatic prolapses should be treated primarily surgically, provived that the patient is fit for the operation.
• In mild conditions symptoms may be alleviated with conservative treatment.
• It is important to inform the patient about the benign nature of the condition.

Definition

• Protruding changes that distend into the parturition canal and out of it, can be called gynaecological hernias. The bottom of the abdominal cavity gives way through the pelvic floor (parturition canal or vagina) and urogenital organs are pushed out of place. These changes may occur in
  • the front wall of vagina (cystocele)
  • the back wall of vagina (rectocele) or
  • in the middle part of vagina (uterus or posthysterectomy vaginal vault prolapse or enterocele)
• Often a patient has a combination of the aforementioned prolapses. A gynaecological prolapse may be associated with rectal prolapse Haemorrhoids.

Grades of severity

• Several systems for grading the severity of a prolapse have been developed.
• It is most recommended to describe the position of the prolapse relative to the vaginal orifice: e.g. vaginal part of the cervix 2 cm inside the vagina gets score -2 and vaginal part of the cervix 1 cm coming outside the vagina gets score +1. The grade of the prolapse is defined separately for the anterior and posterior wall as well as middle part of the vagina.

Frequency

• It is estimated that every fifth gynaecological operation involves some kind of repair of gynaecological protrusions through the pelvic floor. In some studies the prevalence of uterine prolapse has been found to be about 15%, but the share of persons with symptoms is considerably lower.

Aetiology

• Ageing predisposes a person to descensus and prolapses. Most cases involve postmenopausal women.
• The decrease in oestrogen secretion in the menopause makes the connective tissue, the mucosa, and the muscles of the pelvis weaker, and their ability to support the genital organs decreases.
• Full-term pregnancy regardless of the birth method increases the risk of developing prolapses.
• The connective tissue can be permanently damaged in a difficult childbirth (forceps, vacuum, or a very fast delivery).
• Also multiparity may overdistend the pelvic floor, as well as heavy work, chronic cough, constipation, ascites and large tumours in the pelvis.
• About 5% of prolapses are caused by congenital weakness of the connective tissue, which sometimes causes a uterus prolapse, even in quite young women who have not given birth.
• Factors elevating the intra-abdominal pressure, such as overweight, chronic lung diseases and physically very demanding work, predispose to a prolapse.

Symptoms

• In the early stage there is a feeling of protrusion and burden in the lower part of the abdomen, which grows worse towards the evening and disappears when the patient lies down.
• The patient often seeks for treatment when a distension is felt or can be noticed protruding out of the vagina. At this stage the patient usually also has other symptoms. The most typical symptom is difficulty emptying the bladder. Additionally, the patient may have difficulties in sexual intercourse and in emptying the bowel.

Diagnostics

• Evaluate the type and severity of the prolapse both at rest and on exertion in gynaecological examination position. The urinary bladder and the rectum should be empty.
• Inspection reveals the low perineum and a clear protrusion can be seen reaching down to the introitus or coming out of it.
• During the examination with speculum the disappearance of the anterior fornix can be noticed as the first sign indicating a defect/weakness in the anterior wall.
• After removal of the speculum the anterior wall is supported with an elevator and the disappearance of the posterior fornix can be seen, which indicates an incipient enterocele or a distending rectocele lower down.
• In rectovaginal palpation the defect between the posterior vaginal wall and rectum causing the rectocele can be felt.
• The severity of prolapse of the uterus in particular can be confirmed when the patient strains.
• The differential diagnosis excludes prolapse-like distensions such as divertuculum of the urethra, congenital cysts of the Gartner's duct, metastases of malignant tumours or a rare intestinal hernia pushing into the area.

Treatment

First aid

• The prolapse is repositioned in order to prevent complications (e.g. urinary retention) and is kept inside vagina (with a ring or cube pessary).
• The bladder is emptied by catheterization. If urinary retention is prolonged suprapubic cystostomy or long term catheterization may be performed.
• If the patient uses a prolapse ring or cube pessary, she must also at least twice a week use vaginal creme or vaginal suppositories containing oestrogen.
• If the patient's symptoms are alleviated and no adverse effects are encountered, conservative treatment may be continued instead of surgery.