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.
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