[6 min read] Managing pelvic organ prolapse in primary care

Pelvic organ prolapse (POP) occurs when the pelvic organs (i.e. the bladder, vagina, cervix, uterus and rectum) protrude downwards into the vaginal canal due to weakening of the pelvic floor and loss of anatomical support. POP is more common in older women, women who have had a vaginal delivery, and women who are overweight or obese.

It is essential for primary care practitioners to be able to support these patients in general practice.

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POP can be categorised as a cystocele (bladder prolapse), rectocele (rectal prolapse) and uterine prolapse, where the cervix and uterus protrude into the vaginal canal. Women may have a combination of types.

The most common presenting symptoms of POP include a sensation of something in the vagina, a palpable lump inside the vaginal canal or a visible protrusion. POP can also cause urinary and bowel symptoms such as difficulty urinating or defecating and incontinence. It can also significantly affect sex life and, in some cases, cause pelvic or back pain.

POP is diagnosed clinically based on symptomatology and examination findings. Physical examination should include a pelvic examination to determine the type and extent of the prolapse. In prolapse, a vaginal mass can be felt on examination – whether this is anterior, midline, or posterior can delineate the type of prolapse. The prolapse should be examined both at rest and with straining. POP can be staged using the pelvic organ prolapse quantification (POP Q) examination, based on the extent of the prolapse relative to the hymen, with stage 0 indicating no prolapse and stage IV indicating a total prolapse.

Management is patient centred and depends on the degree to which the prolapse affects the woman’s quality of life. Lifestyle changes should be encouraged and supported in all cases, such as weight loss and optimising bladder and bowel function. Patients should also be counselled to avoid straining, lifting and high-impact exercise. Topical oestrogen therapy may be appropriate for patients with concomitant evidence of vulvovaginal atrophy. Signposting to incontinence aids and optimising genital skin care is also important where incontinence is present. POP can have a significant effect on psychological well-being and sexual function, and it is important to support affected women to access counselling where indicated.

Further conservative management may involve referral for the fitting of a vaginal pessary, a silicone device which is inserted into the vagina to act as a support for the pelvic organs. Pessaries generally require initial fitting in a urogynaecology setting and replacement every 3–6 months.

Surgical management is indicated where conservative management has failed to provide adequate symptomatic relief, and around 1 in 8 women with POP will undergo surgery. The type of surgery offered depends on the type of prolapse, symptoms, desire for fertility and fitness for surgery. Surgical methods include sacrocolpopexy, uterosacral suspension and total hysterectomy.

In conclusion, pelvic organ prolapse is a common problem in women and can present to primary care in several ways. POP can be effectively managed conservatively or via surgical intervention using a patient-centred approach.

Dr Samantha Miller, MBChB

Read another article like this one: Managing urinary incontinence in primary care


References

  1. National Institute of Clinical Excellent (NICE)(2019). NICE Guideline [NG123] Urinary incontinence and pelvic organ prolapse in women: management. https://www.nice.org.uk/guidance/ng123
  2. Royal College of Obstetricians and Gynaecologists. Pelvic Organ Prolapse Patient Information Leaflet. https://www.rcog.org.uk/for-the-public/browse-all-patient-information-leaflets/pelvic-organ-prolapse-patient-information-leaflet/
  3. National Institute of Clinical Excellence (NICE): Patient decision aid on Surgery for vaginal vault prolapse patient decision: https://www.nice.org.uk/guidance/ng123/resources/surgery-for-vaginal-vault-prolapse-patient-decision-aid-pdf-6725286114
  4. NHS (2021). Pelvic Organ Prolapse. https://www.nhs.uk/conditions/pelvic-organ-prolapse/
  5. Clinical Knowledge Summary. Incontinence – urinary, in women. https://cks.nice.org.uk/topics/incontinence-urinary-in-women/
  6. BMJ Best Practice (2019). Uterine prolapse. https://bestpractice.bmj.com/topics/en-gb/659
  7. The State of Queensland (2019). What is pelvic organ prolapse and how common is it? https://www.health.qld.gov.au/news-events/news/what-is-pelvic-organ-prolapse-symptoms-treatment-childbirth-womens-health
  8. Continence Foundation of Australia (2022). continence.org.au
  9. BMJ Best Practice (2020). Urinary incontinence in women. https://bestpractice.bmj.com/topics/en-gb/169

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