MRCOG/MOG PRACTICE QUESTION 2

QUESTION 2

A 58 year-old woman has had a TAHBSO 3 years earlier for uterine fibroids and now complains of ‘something coming down’ her vagina. Examination reveals a vault prolapse and a moderate cystocoele.

How would you manage her? (Key word here is MANAGE; which would include history, examination, investigation, treatment)

a)      History

Clarify nature of symptoms, worse with standing/ standing, relieved by lying down

Effects on quality of life

Urinary symptoms- any incontinence, incomplete voiding, voiding difficulties (symptoms likely to be related to prolapse)

Bowel symptoms- incontinence, difficulty emptying rectum (URINARY AND BOWEL symptoms comes hand in hand)

Sexual history and desire to retain sexual function

Previous gynecological history especially on the hysterectomy/ prolapse surgery

b)      Examination

BMI

Any abdominal mass

Speculum examination; using the objective assessment of prolapse with POP-Q

Access for SUI after reducing prolapse with full bladder

Pelvic examination (the Bimanual- to assess for pelvic mass)

c)      Investigations

Relevant blood investigations eg FBC, Renal Profile, pre-operative work up

d)     Treatment options

Non-surgical options

-Pelvic floor exercise – no evidence for efficacy, used in women whom wants to avoid surgery but maintain sexual function, unlikely to be effective

- Pessaries- ring/shelf (with the ring, likely to be expelled in women with deficient perineum/perineal body. With shelf pessary, sexual intercourse may not be possible). Should be reserved for women who are unfit/decline surgery or while awaiting surgery. Need to be changed every 6-9 months.

Surgical options

-          Abdominal sacro-colpopexy- effective, evidence proven, major surgery for a relatively healthy women but may require the additional vaginal procedure if woman has anterior/posterior vaginal wall prolapse

-          Sacrospinous ligament fixation – vaginal procedure with lower morbidity and suitable for women who are unfit for laparotomy. Failure rate higher than abdominal route. Allows simultaneous vaginal wall repair.

-          Laparoscopic sacro-colpopexy may be undertaken if expertise is available

-          Colpocleisis may be offered for frail women who do not wish to retain sexual function.

-          Mesh- controversial and probably should not be mentioned in an exam answer as the only evidence for it would be anterior repair.