HNY Policy and Pathway Repository - York

Weakness of the vaginal walls with/without significant descent of the cervix.

Presenting symptom usually a “lump down below”. Types include;

• Cystocele: anterior vaginal wall prolapse
• Rectocele: posterior vaginal wall prolapse
• Enterocele: prolapse of the vaginal vault (usually as a result of hysterectomy)
• Uterine Prolapse: graded 1 (minimal descent), 2 (cervix at introitus), 3(cervix beyond introitus) to 4 (cervix and uterus outside introitus; procidentia)

While prolapse is not considered a life-threatening condition, and some women can have a prolapse without having any symptoms at all, it may cause a great deal of discomfort and distress. Common symptoms can include:

• A feeling of dragging or heaviness in the pelvic area
• A bulge in the front or back wall of the vagina - sometimes, this bulging may extend outside the vagina
• Difficulties with continence - bladder or bowel, depending on the location of the prolapse
• Discomfort and lack of sensation during sex

• Exclude cancerous cause for “lump”
• New presentation of procidentia with poor urinary output- consider acute gynaecology admission

History: including associated bladder and bowel symptoms

• Examination: establish type of prolapse and any underlying atrophy. Note presence of urethral caruncle (or prolapse) is pathognomonic of estrogen deficiency
• Assess urinary symptoms - consider Bladder Diary and explain details of Bladder Training
• Treat underlying atrophy by any one of the treatment options below:
  • Vagifem pessary 10mcg daily for 2 weeks then twice weekly
  • Ovestin cream 1 applicatorful (500mcg) daily for 2 weeks then twice weekly- note this may damage rubber in condoms
  • Estring 7.5micrograms/24hours for 3 months and review
  • Cystocele/Uterine Prolapse present: consider fitting a ring pessary​​​​
• Lifestyle changes - reduce weight, address constipation, stop smoking
• Address uncontrolled chronic illness adding to increased abdominal pressure
• Pelvic Floor Exercise – Pelvic Floor Exercises for Women
• Women’s Health physio: all women with prolapse should be referred first for gynae physio prior to considering surgery, as outcomes are much better.

Investigations prior to referral

• Bladder diary
• Gynae physiotherapy – refer via MSK form

Information to include in referral letter

• Reason for referral
• Examination findings
• Treatment to date
  • Gynae physiotherapy completed
  • Atrophy treated
  • Bladder drill/urinary symptoms addressed
• Bladder diary completed and attached
• Past medical/surgical history
• Drug history
• BMI (must be below 35)
• Smoking cessation

Patient information leaflets/ PDAs

• Pelvic organ prolapse
• Surgery for stress incontinence
• Pelvic Floor Exercises for Women
• Bladder Training
• Bladder Diary / Urinary Input Output chart
• https://www.squeezyapp.com/

References

https://www.nice.org.uk/guidance/ng123

https://www.rcog.org.uk/en/about-us/nga/nga-news/nice-guideline-urinary-incontinencepelvic-organ-prolapse/