HEALTHCARE INNOVATIONS 25 MARCH 2018 Understanding pelvic organ prolapse

allow stools to pass; low back pain due to bowel prolapse

• Discomfort or a lack of sensation during sexual intercourse

• There may not be any symptoms at all, however, and the prolapse may only be revealed following a vaginal examination by a healthcare professional, such as during a smear test. It’s also worth noting that a small prolapse can often be normal.

HOW IS PROLAPSE DIAGNOSED? Your doctor will perform a vaginal examina- tion as well as a speculum (a plastic or metal instrument) examination to check which part of pelvic fl oor is prolapsing.

Half of women over 50 will have some symptoms of pelvic organ prolapse, and by the age of 80, more than one in 10 will have had surgery to treat a prolapse

desire to have an active sex life and whether you plan to have children in the future. Some women may choose to delay having surgery until their family is complete. In recent years, a number of new operations

have been developed where a mesh (support- ing material) is sewn into the vaginal walls. The risks and benefi ts of mesh are unclear, and it’s currently recommended that opera- tions using mesh for prolapse repair are only performed in the context of research. Current evidence doesn’t recommend the routine use of mesh to treat prolapse as the fi rst surgical intervention, due to higher complication rates when compared to non-mesh repairs. Your gynaecologist will advise you about

DOES THIS CONDITION ALWAYS REQUIRE TREATMENT? No. If you only have a mild prolapse or have no symptoms from your prolapse, you may choose to take a ‘wait and see’ approach. The following may ease your symptoms: • Lifestyle changes

managing a chronic

such as losing weight; cough by stopping

smoking; and avoiding constipation, heavy lifting or high-impact exercises

• Doing pelvic fl oor exercises — you may be referred to a physiotherapist who specialises in prolapse management

• Using vaginal oestrogen cream P

elvic organ prolapse isn’t uncommon, explains consultant gynaecologist and obstetrician Miss Avanti Patil. Patients

who come to my urogynaecology clinic, she explains, say things like: “I feel a lump or a bulge from down below, doctor. What could it be?” Well, it can be a sign of prolapse.

WHAT EXACTLY IS PELVIC ORGAN PROLAPSE (POP)? The ‘pelvic fl oor’ is a group of muscles that form a kind of hammock across your pelvic opening. Normally, these muscles and the ligaments surrounding them keep the pelvic organs in place. These organs include your bladder, uterus, vagina, small bowel and rectum. If these support structures are weakened

by overstretching, the pelvic organs can bulge into the vagina. This is what’s known as pelvic organ prolapse (POP).

HOW COMMON IS POP? It’s diffi cult to know exactly how many women are aff ected by prolapse, since many don’t consult their doctor about it. However, it does appear to be very common, especially in older women. Half of women over 50 will have some symptoms of POP, and by the age of 80, more than one in 10 will have had surgery to treat a prolapse.

WHY DOES POP HAPPEN? Any event that increases pressure within the abdomen can lead to POP, including: • Pregnancy / childbirth • Ageing, particularly after the menopause • Being overweight • Constipation, heavy lifting

persistent coughing and

• Following a hysterectomy, the top of the vagina (vault) can prolapse • Genetics may also play a role

WHAT ARE THE OPTIONS FOR TREATING POP? Your options for treatment will depend on the type of prolapse you have, how severe it is and your


which procedure is best for you — the pros and cons of each option, the risks and the re- covery plans — so you can decide whether you wish to go ahead with your operation. The key points to remember are that pro-

lapse isn’t life-threatening, although it may aff ect the quality of your life. Not everyone with prolapse needs surgery, but you may wish to consider surgery if other options have not adequately helped.

Meet the expert

circumstances. Treatment

options include physiotherapy, pessaries and surgery. Pessaries are plastic or silicone devices

which fi t into the vagina and help support the pelvic organs. They come in various shapes and sizes, but the most common type is a ring pessary. You may choose this option if you don’t wish to have surgery, are thinking about having children in the future or have a medi- cal condition that makes surgery more risky. Pessaries

should be changed or

Often, it’s a combination of these factors that results in a prolapse.

WHAT ARE THE DIFFERENT TYPES OF PROLAPSE? There are diff erent types of prolapse, de- pending on the organ that’s bulging into the vagina. • Cystocele — the bladder bulges into the front wall of the vagina

• Rectocele — the rectum bulges into the back wall of the vagina

• Uterine prolapse — the uterus hangs down into the vagina

• One in 10 women who have had a hyster- ectomy can have the top of vagina (vault) prolapse down

WHAT ARE THE SYMPTOMS OF POP? The type and severity of prolapse will deter- mine the symptoms. They can include: • The commonest symptom is the sensation of a lump or a bulge ‘coming down’ causing discomfort inside the vagina

• Frequent urination; incomplete emptying of the bladder; urinary leakage on coughing, sneezing or laughing; and frequent cystitis due to bladder prolapse

• Constipation or incomplete bowel empty- ing; needing to push back the prolapse to


cleaned and reinserted regularly. This can be done by your doctor, nurse or sometimes by yourself. It’s possible to have sex with some types of pessary although you and your part- ner may occasionally become aware of it. The aim of surgery is to relieve your symp-

toms while ensuring your bladder and bowel each function normally following the opera- tion. If you’re sexually active, every eff ort will be made to ensure that your sex life is as en- joyable as ever after the operation. Your decision to have surgery will depend

on the severity of your symptoms and the im- pact the prolapse has on your daily life. The type of surgery will depend on the type of prolapse, symptoms, your age, general health,

Miss Avanti Patil, MBBS, DFFP, FRCOG, is a consultant gynaecologist and obste- trician at Buckinghamshire Healthcare NHS Trust, Bucks. She has special inter- ests in urogynaecology (urinary incon- tinence, urodynamic and pelvic organ prolapse, vaginal reconstructive surgery) and postpartum perineal problems. Miss Patil is the lead clinician for the gynae- cology arm of the obstetrics and gynae- cology speciality, and keeps ‘patient-cen- tred satisfaction goals’ as a mainstay of her practice. Miss Patil has a wide range of expertise in general gynaecology pro- viding high-quality care to women with menstrual disorders, pelvic pain, endo- metriosis, contraception and the meno- pause. Miss Patil is also a specialist con- sultant for women with spinal injuries (for their gynaecology issues) at the National Spinal Injuries Centre, Bucks. She enjoys spending time with her daughter and has a passion for meditation.

Medical secretaries: Mrs Lindsay Gough and Mrs Gill Corbett T: 07702 499189 / 01296 337988 E: Private Hospitals: BMI The Chiltern Hospital, Great Missenden, Bucks BMI The Shelburne Hospital, High Wycombe, Bucks

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