AKT · Obstetrics & gynaecology/Menopause & vulvallow yield

Vaginal prolapse

Pelvic floor support failure

Overview

Descent of the pelvic organs (bladder=cystocele, rectum=rectocele, uterus, vault) through weakened pelvic floor support. Driven by childbirth, age, oestrogen deficiency and raised intra-abdominal pressure.

Recognise

Sensation of "something coming down"/bulge, worse on standing/straining
Urinary (cystocele) or bowel (rectocele) symptoms; dragging discomfort
Quantified by POP-Q on examination

Red flags

Procidentia (complete uterine prolapse) with ulceration; urinary retention

Differentials & how to tell them apart

Vaginal/cervical cyst or tumourdiscrete mass rather than organ descent

Urethral diverticulumanterior, dysuria, post-void dribble

Investigations

Clinical examination (Sims speculum, POP-Q staging). Assess pelvic floor and continence.

Management

Pelvic floor muscle training (mild); pessary or surgery if symptomatic

1Lifestyle (weight, constipation, heavy lifting) + pelvic floor muscle training for mild symptomatic prolapse; topical oestrogen for atrophy.
2Vaginal pessary (ring/shelf) for conservative management.
3Surgical repair (e.g. anterior/posterior repair, hysteropexy, sacrocolpopexy) if conservative fails.

Pelvic floor muscle training — first-line for mild prolapse

Vaginal pessary — ring/shelf — conservative support

Surgery — definitive (repair/hysteropexy)

Key points

Pessaries are a good option for women unfit for or declining surgery. Treat associated atrophy with vaginal oestrogen.

Monitor & prognosis

Symptoms, pessary changes (every few months), continence.

Good symptomatic control; may recur.

Source: NICE NG123