QuestionSBA
QuestionChoice
Women with stress urinary incontinence should be referred for a trial of at least three months of supervised pelvic floor muscle training (PFMT).
49942
a
Refer the woman for pelvic floor muscle training (PFMT)
QuestionChoice
Duloxetine can be used as a second-line option for women with stress urinary incontinence where conservative management options have failed.
49945
d
Trial of duloxetine
QuestionChoice
Where a woman does not have symptoms of urinary tract infection (UTI) and urinalysis is negative for either leucocytes or nitrites, a urine samples should not be sent for culture as she is unlikely to have a UTI.
49944
c
Send a urine sample for culture
QuestionChoice
Antibiotics should not be prescribed for leukocytes on urinalysis in the absence of symptoms of urinary tract infection (e.g. dysuria, frequency or urgency).
49943
b
Prescribe a three-day course of oral trimethoprim
QuestionChoice
Referral for surgical management may be considered where conservative options have failed.
49946
e
Refer to urogynaecology for consideration of colposuspension
QuestionComment
but the urinalysis came back positive for leucocytes?
24077
QuestionComment
Leukocytes in the absence of nitrates do not usually indicate UTI

24860
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Hypertension Migraine
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Will
QuestionComment
Got the q right but is a pessary not more appropriate, pelvic training isn't going to necessarily reverse a prolapse is it even if there is an element of stress incontinence?
27812
QuestionComment
you start with conservative measures first for prolapse so would try pelvic floor exercises, then can go medical (with pessaries), then surgical 
28002
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CEM
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Relapse CT
Concept
Chapter
# Summary
  
 
Vaginal prolapse refers to the displacement of pelvic structures from their normal position towards or through the vaginal opening. Key signs and symptoms include pelvic discomfort, a sensation of pressure or 'heaviness', and visible protrusion of tissue from the vagina. Investigations primarily involve pelvic examination and potentially imaging studies. Management strategies range from conservative measures such as pelvic floor exercises, to pessary use, and surgical intervention.
  
 
# Definition
  
 
Vaginal prolapse is characterised by the descent of one or more pelvic structures from their normal anatomical position, moving towards or through the vaginal opening. 
  
 
# Epidemiology
  
 
Vaginal prolapse is a common condition, particularly in postmenopausal women and those who have undergone childbirth. The prevalence increases with age and parity, with an estimated 50% of women having some degree of prolapse, though only a fraction of these will experience symptoms.
  
 
# Aetiology
  
 
Risk factors for developing vaginal prolapse include:
  
 
  - Vaginal childbirth, particularly with traumatic or complicated deliveries
  - Increasing age
  - Menopause
  - Hysterectomy
  - Obesity
  - Chronic cough
  - Heavy lifting
  - Connective tissue disorders
  

# Classification
  
 
Pelvic organ prolapse can involve different structures, defined according to the organ which has prolapsed into the vagina and their position:
  
 
**Anterior vaginal wall:**
 
  - Cystocele: bladder (may lead to stress incontinence)
  - Urethrocele: urethra
  - Cystourethrocele: both bladder and urethra
  
 
**Posterior vaginal wall:**

  - Enterocele: small intestine
  - Rectocele: rectum
  
 
**Apical vaginal wall:**

  - Uterine prolapse: uterus
  - Vaginal vault prolapse: roof of the vagina (common after hysterectomy)



# Signs and Symptoms
  
Symptoms of genital prolapse can vary depending on the type and severity but may include:
 
  - Pelvic discomfort or a sensation of 'heaviness'
  - Visible protrusion of tissue from the vagina
  - Urinary symptoms such as incontinence, recurrent urinary tract infections or difficulties voiding
  - Defecatory symptoms, including constipation or incomplete bowel emptying
  - Sexual dysfunction, including dyspareunia 
  

# Differential Diagnosis
  
 
Differential diagnoses for genital prolapse may include:
  
 
  - **Gynaecological malignancy:** associated with abnormal vaginal bleeding, weight loss, and pelvic pain
  - **Cervicitis:** characterised by vaginal discharge, bleeding, and pelvic pain
  - **Urethral diverticulum:** presents with dysuria, recurrent UTIs, and a palpable anterior vaginal mass
  
 
# Investigations
  
 
**Bedside:**

- Detailed pelvic examination, including speculum and bimanual exam. A Sim's speculum is preferred for examination of vaginal prolapse. 

No **blood tests** are indicated for vaginal prolapse. 

**Imaging:**

- MRI may be helpful for surgical planning.

**Invasive tests:**

- Urodynamic studies may be indicated if there are co-existing urinary symptoms.


 
# Management
  
 
Management strategies for genital prolapse include:

**Conservative:** 
 
  - Lifestyle modifications, including weight loss, smoking cessation, avoiding heavy lifting
  - Pelvic floor exercises 
  - Pessary use, which can provide symptomatic relief and may be particularly suitable for women who are not surgical candidates

**Surgical:** 

  - Surgical repair, which may involve native tissue repairs or the use of mesh. Surgical approach can be vaginal, abdominal, or laparoscopic/robotic.
 
  
Surgeries for **uterine prolapse** include: 
  
  - Vaginal sacrospinous hysteropexy (with sutures)
  - Manchester repair
  - Vaginal hysterectomy 

Surgeries for **vault prolapse** include: 
  
  - Sacrocolpopexy with mesh
  - Vaginal sacrospinous fixation with sutures 

Surgeries for **anterior prolapse** include: 
  
  - Anterior colporrhaphy

Surgeries for **posterior prolapse** include: 
  
  - Posterior colporrhaphy


# Complications

- Complications of surgery: Urinary incontinence (after anterior repair), faecal incontinence, dyspareunia (after posterior repair), recurrence of prolapse. 
- Vaginal erosion: Untreated prolapsed uterus may lead to ulceration and subsequent erosion of the vaginal wall. 


# NICE Guidelines

[Click here for NICE guidance on pelvic organ prolapse](https://www.nice.org.uk/guidance/ng123)

# References

[BMJ Best Practice](https://bestpractice.bmj.com/topics/en-gb/659/)

[RCOG Guidance](https://www.rcog.org.uk/for-the-public/browse-our-patient-information/pelvic-organ-prolapse/)
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Picture
A cervical prolapse.
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Uterine prolapse.jpeg
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1059
Genital prolapse
Topic
26
Gynaecology
10025
A 55-year-old woman attends her general practitioner with a 1-year history of a lump in her vagina. She also complains of leaking urine when she coughs or sneezes, which has been ongoing for the past eight months. On examination, her abdomen is soft and non-tender. On digital vaginal examination, a small cystocele is felt at the anterior vaginal wall. She can contract her pelvic floor muscles voluntarily. She has no dysuria or increased urinary frequency. Urinalysis is positive for leucocytes but otherwise negative.

What is the most appropriate next step?
a