History
An 83-year-old woman complains of a dragging sensation in the lower abdomen and lower back pain when standing or walking. It has been present for some years but she can now only stand for a short time before feeling uncomfortable. It is not noticeable at night. She has had four vaginal deliveries. She had her menopause at 52 years and took hormone-replacement therapy for several years for vasomotor symptoms. She has not had any postmenopausal bleeding and has not had a smear for several years. She is generally constipated and sometimes finds she can only defecate by placing her fin- gers into the vagina and compressing a ‘bulge’ she can feel. She has mild frequency and gets up twice most nights to pass urine. There is no dysuria or haematuria. Occasionally she does not get to the toilet in time and leaks a small amount of urine, but this does not worry her unduly.
Medically she is very well and does not take any medications regularly. She lives alone and does her own shopping and housework.
Examination
On examination she appears well. Blood pressure and heart rate are normal. She is of average build. The abdomen is soft and non-tender. There is a loss of vulval anatomy con-sistent with atrophic changes. On examination in the supine position there is a mild pro- lapse. On standing, the cervix is felt at the level of the introitus. There is a large posterior wall prolapse and a minimal anterior wall prolapse.
Questions
• What is the diagnosis for her discomfort and pain?
• How would you manage this patient?
Medicine
The diagnosis is of second-degree uterovaginal prolapse with rectocoele. Prolapse is trad-itionally categorized according to the level of descent of the cervix in relation to the introitus:
• first degree: descent within the vagina
• second degree: descent to the introitus
• third degree: descent of the cervix outside the vagina
• procidentia: complete eversion of the vagina outside the introitus.
More complex grading systems are used by some specialists that involve specific measure-ments using the hymen as a reference point. Common presenting symptoms are of ‘something coming down’, a ‘lump’ or a dragging sensation. Symptoms are always worse on standing or walking because of the effect of gravity. Prolapse is more common in women who are parous, have had long or traumatic deliveries, have a chronic cough or constipation. However it may occur in any woman, even if she is nulliparous, as it relates to collagen strength.
Management
Initial management involves treating the constipation with dietary manipulation and laxatives. This may relieve some of the symptoms and is also important to prevent recur-rence if surgery is to be performed. Pelvic floor exercises are helpful for mild prolapse and to preserve the integrity of repairn postoperatively, though in this case they are unlikely to make any significant difference to the presenting symptoms. If surgery is not wanted then she can try a ring pessary to hold up the prolapse, which can work extremely well and only needs replacing every 6 months. Although she is 83 this woman has no medical problems and should be offered definitive prolapse surgery which for her involves vaginal hysterectomy and posterior vaginal wall repair (colporrhaphy). As there is no abdominal incision involved, recovery is quick and she would expect to be in hospital for around 3 days.
KEY POINTS
• Prolapse incidence increases with age, parity, constipation and chronic cough.
• Conservative management with a ring pessary, or surgical prolapse repair may be appropriate.
• Relief of exacerbating factors is important to prevent symptoms worsening or to maintain the integrity of the repair.
need an explanation for this answer? contact us directly to get an explanation for this answer