Step-By-Step Approach to Managing Pelvic Organ Prolapse Information for Physicians

Surveillance médicale FP Watch

Step-by-step approach to managing pelvic organ prolapse Information for physicians

Risa Bordman MD CCFP FCFP Deanna Telner MD MEd CCFP Bethany Jackson MD CCFP D’Arcy Little MD CCFP

Definition of pelvic organ prolapse Step 4: Medical therapy Descent of pelvic organs into the vagina Use estrogen (oral or vaginal) for mild cystocele. • Anterior: cystocele (bladder most common), urethro- Consider a pessary. cele (urethra) • A pessary is a shaped device usually made of silicone • Middle: uterus, vault (after hysterectomy) and left in the vagina. • Posterior: rectocele (rectum), enterocele (small bowel, omentum) Tips on pessaries

Grades of uterine prolapse • There are 2 types: supportive for milder prolapses I Descent of the uterus to above the hymen and space-occupying for more serious prolapse. II Descent of the uterus to the hymen • Cost is $88 (Canadian) delivered to your office. III Descent of the uterus beyond the hymen • For women with atrophic changes, the vagina can IV Total prolapse be prepared with topical estrogen 2 to 3 times a week for a month before insertion. Step 1: Presentation and history • Aim for the largest pessary that fits comfortably. Prevalence: The prevalence of pelvic organ pro- • Examiner’s fingers should pass easily between the lapse among parous women is 50%. Most women are pessary and the vagina wall. asymptomatic. • After fitting the pessary in the office, have patients History: Physicians should ask about urinary frequency walk around and then try to urinate or defecate. and urgency, bulges or lumps in the vagina, pelvic pres- • Women can remove, wash with mild soap and sure or heaviness, incontinence of urine or stool, diffi- water, and replace the pessary weekly or monthly culty with defecation or constipation, dyspareunia, and (or it can be cleaned by a health care professional whether patients insert their fingers in the vagina to void every 3 to 6 months). or defecate. • There is no evidence or consensus on which pes- Risk factors: Childbirth, constipation, age, pelvic sur- sary is best, how often to clean it, or how often to gery, chronic cough, raised intra-abdominal pressure, visit a health professional. and obesity. • You can try to keep the vagina lubricated with estrogen or Trimo-San vaginal jelly. Step 2: Physical examination and investigations • Adverse effects include discharge, odour, pain, Physical examination: Bimanual, including speculum bleeding, failure to reduce prolapse, and expulsion. examination at rest and with straining. If prolapse is not • Long-term use carries a risk of vaginal erosion, so vagi- obvious, repeat with patient standing with 1 foot on a nal examinations should be done every 3 to 6 months. chair. To help with speculum examination, turn the regular • If forgotten, pessaries might become fixed in place. speculum 90º (watch the urethra) to see the anterior and To loosen fixed pessaries before removal, apply 2 g posterior walls or remove 1 blade from a double speculum of estrogen cream every second day for 2 weeks. and apply the single blade anteriorly and posteriorly. • Change a pessary after about 5 years or when it Investigations: Urine culture. If you are unsure of the wears out. diagnosis, use pelvic ultrasonography or cystography. Pessary companies Step 3: Treatment principles Most women are asymptomatic so no treatment is Milex (Cooper Surgical), 800 243-2974, needed. A trial of lifestyle modification might be www.coopersurgical.com beneficial: Kegel exercises, weight loss, smoking ces- Mentor, 800 668-6069, www.mentorcorp.com sation, treatment of constipation, electrical stimula- Superior, 800 268-7944, www.superiormedical.com tion, or biofeedback.

Vol 53: march • mars 2007 Canadian Family Physician • Le Médecin de famille canadien 485 FP Watch Surveillance médicale

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486 Canadian Family Physician • Le Médecin de famille canadien Vol 53: march • mars 2007 Surveillance médicale FP Watch

• Different pessaries are used for cystocele, stress incon- Complications include hemorrhage, hematoma, nerve tinence, uterine prolapse, rectocele, and combinations damage, voiding difficulties, recurrence of prolapse, of these (pessaries are not as good for vault prolapse dyspareunia, and mesh erosion. after hysterectomy). • Fit by trial and error with fitting rings, similar to dia- Bottom line phragm fitting. Women are often reluctant to discuss prolapse symp- • The most used pessary is the ring with support (treats toms. While there are no randomized controlled tri- grades I and II uterine prolapse and cystocele). als of treatment, pessaries are a good option for • Pessaries should be removed regularly for cleaning by those who wish to remain fertile or avoid surgery. patient or health care professional. • Patients should be seen every 3 to 6 months to check Resources for vaginal erosions. An Approach to Diagnosis and Management of Benign Uterine Conditions in Primary Care is available on-line Step 5: Further evaluations and surgical treatment with patient handouts and other useful resources at • Pelvic organ prolapse surgery has a success rate of www.benignuterineconditions.ca. Printed copies can be 65% to 90%; repeat operation rate is 30%. obtained from the Ontario College of Family Physicians • When more than 1 compartment is involved, patients on their website at www.ocfp.on.ca, by e-mail at need a combination of surgeries. [email protected], and by telephone at 416 867-8646. • Correcting cystocele can unmask stress incontinence (unkinking the urethra makes it easier to leak). You Dr Bordman is a family doctor at North York General could check for this before surgery by correcting the Hospital in Toronto, Ont, and an Assistant Professor in the prolapse with a pessary. Department of Family and Community Medicine at the • Some operations predispose patients to prolapse in University of Toronto. Dr Telner is a family physician at the another compartment. Toronto East General Hospital and an Assistant Professor in • Surgery can be via the abdomen (open or laparo- the Department of Family and Community Medicine at the scopic) or the vagina using fascia, mesh, tape, or University of Toronto. Dr Jackson completed a fellowship in sutures to suspend the organs. women’s health and is currently a family physician in Ottawa, • To conserve the uterus, sacrohysteropexy uses a Ont. Dr Little is a Lecturer in the Department of Family and Y-shaped graft to attach the uterus to the sacrum. Community Medicine at the University in Toronto. ✶ ✶ ✶