The smart way to learn. The smart way to teach.

MRCOG PART 2 SBAs and EMQs

Course PAID
notes328
EMQ1470
SBA2072
Do you realy want to delete this discussion?
Forum >>

Essay 299 - Prolapse

Essay 299 - Prolapse Posted by PAUL A.
A healthy 87 year old woman attends the gynaecology clinic with a 6 months history of feeling a lump in her vagina. (a) Describe your clinical assessment [8 marks]. (b) She is found to have a vaginal vault prolapse. Discuss the available treatment options indicating the circumstances when they will be recommended [12 marks].
Posted by Ajith S.

A-I will get details history regarding her lump, associated other symptoms like constipation, per vaginal and per rectal bleeding, faecal and urinary incontinence, any pain, especially back pain, how significantly this lump disturbed her day to day life. I want to know that whether she is she is sexually active or not and whether she wish to retain her sexual function. I will inquire her regarding past gynaecological history, whether she had any gynaecological surgeries especially, hysterectomy and urogynaecological procedures, any malignancies, and any surgical procedures ex hip replacement. If she had any surgery in past, will trace and go through operative notes. I will inquire her general health whether she is fit for major surgery especially chronic diseases like CVD, COAD ect, If so drug history.
On examination I will check her general health status including how mobile she is, BP, PR, abdomen for any lumps especially full bladder. On vaginal examination, estrogens status, ulcers over the lump details of genital prolapsed, use-POPQ- pelvic organ prolapsed quantification system for objective assessment and check stress incontinence with full bladder for masked stress incontinence. I will check her mobility of hip joint .I will do basic investigations like FBC, EUC, LFT, and ECG.

B-I will discuss with her nonsurgical and surgical options. I will change her medications which will exacerbate vault prolapsed -chronic cough-ACE Inhibitors, constipation.
Nonsurgical pelvic floor exercise –uncertain prognosis unlike will resolve vault prolapsed, If she does not like surgery or unfit I will offer Vaginal Pesseries like ring/self need wear lifelong, high risk of Pesseries expulsion, need to change in regular time -6-8 months and if it forgets to change can get vaginal erosions ulceration ,fistula formations . It is difficult have sexual intercourse with Pesseries.
Surgical methods-is she not desired to retain sexual function and she is frail, unfit for major surgery I will discuss colpocleisis short operating time low surgical and anaesthetic morbidity. Sacro- spinous fixation low operative morbidity but has high failure rate but need reasonable length in vagina to reach sacro-sipnous ligament. Abdominal sacro- colpopexy can do under open or laporoscopically but depends on surgeon’s experience; this procedure has higher complication rate, wound infection, mesh rejections and bladder injury.Abdomino sacro colpopexy has better success rate compare with vaginal procedure but need longer operative time especially laparoscopic procedure. Currently there is no evidence to suggest one procedure over other procedure .I will not offer her lleo-coccygeus fixation as it is not currently recommended. I will give her written information regarding above procedures.
Posted by C P.
A healthy 87 year old woman attends the gynaecology clinic with a 6 months history of feeling a lump in her vagina. (a) Describe your clinical assessment [8 marks]. (b) She is found to have a vaginal vault prolapse. Discuss the available treatment options indicating the circumstances when they will be recommended [12 marks].
A.
Clinical assessment includes history of the illness, examination and investigations. In the history I would like to find out what discomfort the vaginal lump causes, does it associated with any urinary symptoms, bowel symptoms or any problems with sexual intercourse. Overall her quality of life and her social life should be assessed.
Further I would like to know any previous surgery either hysterectomy was performed, if so what was the indication, was it for any malignancy or for any benign condition. If she had undergone any vaginal procedure that should be recorded. In particular any surgery for prolapse or slings for Genuine stress incontinence.
Further I will examine her general condition, per abdominal examination to feel any abdominal mass or tenderness. Speculum examination to know how far her prolapse is decented and does it associated with any element of cystocele or rectocele.
At this point investigation depends upon her symptoms, If she has any urinary symptoms I will do MSU. If my examination revealed any pelvic pathology I will ask for pelvic ultra sound to exclude pelvic pathology.
Further I will explain to the patient what was the finding on the on examination. I prefer to draw a diagram and explain to her.
B.
The treatment can be either Surgical or non surgical. Non surgical methods are using vaginal pessaries. Ring pessary is not very suitable for vault prolapse. Shelf passary is the idial. It is a devise which will relieve the symptoms of prolapse. If it is placed, it has to bechanged every 4 to 6 months, because if left longer tissue can over grow on it, and it will be difficult to remove. This devise can be offered If she is not keen for surgery or surgery is going to be after some time.
Since she is healthy 87 year old, she can be offered to go for surgical intervention, there a couple of options available. Sacrocolpopexy which can be done either by laparotomy or my laparoscopy. The expertise for laparoscopy is very much limited. Abdominal sacrocolpopext has good success history. Associated complication with this procedure are bleeding, infection and mesh erosion. The operation involves of anchoring a polyprophylin sling to the vault, it can extended to anterior and posterior of the vault, and retro peritonealy it is fixed to the sacral promontory.
Sacro spinatos colpopexty is the other procedure. This is done by vaginal approach where the apex of the vault in anchored to the iliac spine on one side. This procedure too has long term history of good outcome. Compare with abdominal sacro colpopext is is quicker and recovery is fast. Pudental neurovascular damage is one of the complicaion of this procedure. Th other complications of this procedure are infection and mesh erosion. Possible dysperiunia.
Mesh – sling procedures (Anterior and posterior Avulta) are available. Once again expertise are limited. In this procedure operating time is much quicker and complications are much less. Short time out come ins good and long time success rate is not known. Complications include mesh erosion, and infection.
If the patient is not sexually active and not keen for any major surgeries she can be offered to have Le Forts operation. This can be done under local anaesthesia. Compare with other procedure which described above,it is simple and less complicated.
Patient need explanation of the different procedures and pros and con. She should be given information about the procedures Finally patient’s decision should be taken in to consideration.
Posted by Vinutha G.
the symptom is most likely to be related to prolapse
I would ask her about the amount of discomfort she feels whether she feels it all the time or only during valsalva (cough ,straining)
Iwill ask her about symptoms related to bowel and bladder function
with special reference to stress incontinence.
I will also ask her regarding any sexual problems associated with the lump
In addition other symptoms regarding her general health ,constipation ,chronic cough,her mobiliy needs to be ascertained .
Her past medical history regarding systemic diseases like diabete s,hypertension any other significant problems (for anaesthesia)
Surgical history menstrual history specially with reference to postmenopausal bleeding ,obstetric hostory will be obtained
drug history specially HRT
I will perform a
general examination keepinh in mind the possibility of other problems at this age
I will perform an abdominal examination to assss for any masses including a full bladder ,any scars of surgeries
Local examination will include the vulva vagina (atrophic), size of the vagina,the size shape of the lumpwhether anterior compartment or posterior or lateral ,POP Q assessment to quantify the prolapse,any evidence of stress ,the tone of the pelvic musles.
iApelvic exaam for the size shape of uterus and any associated masses will complete my exam
Inves towards a general assessment ,FBC ,MSU,LFT U&eE CHEST XRAY scan (if any abnormality)



b)Adiagnosis of a vault prolapse havin been reached ,Iwill inform the lady about the diagnosis and ascertain her needs
Since it is not lifethreatening .
I will counsel her regarding the options available to her
These include the pessary ---the shelf works better than the ring
I will counsel her about the fitting procedure about the need for follow up and change it if infection ,erosion occurs
Iwill also inform her about the surgical options available to her

The sacrospinous fixation of the vault done vaginally usually unilateral is aprocedure with fairly good outcome
Tje possibility if injury to the pudendal vessels ,the need for an adequate depth and width of vagina must be kept in mind

Abdominal procedure of colposacro pexy has the associated morbidity of an abdominal procedure ,injury to the sacral vessels may also occur
Alaparoscopic method is being advocated recently with comparable results
For a woman who is not interested in sexual function ,colpocleisis where the walls of vagina are opposed is a suitable alternative
The high dissection of the enterocele sac and repair does not confer much benefit .
Iwill give written infirmation about the above ,get an anaesthetist to check her and help her to make an informed decision to improve her quality of life


pelvic muscles.
Posted by Sophia Y.
(a) Describe your clinical assessment [8 marks].

I will ask how this lump has affected her quality of life and fill in a \"quality of life disease validated questionnaire\". I will ask her precipitating factors eg walking or voiding & relieving factors. I will ask if needs to use her finger to push it back to the vagina.
I will ask her if the prolapse is associated with urinary symptoms such as urinary frequency, difficulty voiding and incontinence. I will ask if she suffers from constipation. I will ask if she has past prolapse surgery & hysterectomy, how many children she has & modes of delivery. I will also ask if she is sexually active.

On examination I will record her body mass index & check her blood pressure. I will do an abdominal examination to exclude a pelvic mass. I will do a speculum examination to assess the size of prolapse using the \"pelvic organ prolapse quantification\", checking for cystocoele, rectocoele, uterine descent or vaginal vault prolapse. I will do a vaginal examination to check pelvic floor muscle tone and exclude any adnexal mass. In presence of palpable pelvic mass i will arrange a pelvic ultrasound for confirmation.

(b) She is found to have a vaginal vault prolapse. Discuss the available treatment options indicating the circumstances when they will be recommended [12 marks].

Treatment options are determined by how the prolapse has affected her physically & quality of life, degree of prolapse, patient\'s wish, whether she is sexually active, presence of co-existing pathology, surgeon\'s choice & skill. Pelvic floor exercise has no place for vaginal vault prolapse.
If she is asymptomatic she can reassured which might be sufficient to relieve her anxiety. However if she is symptomatic, not keen on surgery & sexually inactive, a shelf pessary may be sufficient. It is cheap & convenient. She should be counselled that it has to be replaced every 4 to 6 months. It can cause her discomfort, vaginal wall erosion & abrasion.
If anterior and/or posterior vaginal wall co-exist, sacrospinous fixation & vaginal repair will be option of choice. However she should be warned about dyspareunia and buttock pain after surgery. If she has co-existing pathology in pelvis eg adnexal mass which needs excision, abdominal sacrocolpopexy will be the treatment of choice. Both surgery are effective. However, it has higher mortality & morbidity than sacrospinous fixation. The operation time and hospital stay is shorter in sacrospinous fixation than sacrocolpopexy with quicker recovery time. However she may complain of dyspareunia postoperatively. She can also be offered laparoscopic sacrocolpopexy, uterosacral ligament suspension or sacrospinous fixation if the surgeons are competent to perform these surgery. The recovery time is shorter with less blood loss and adhesions formation than open procedure. However it requires more advanced training for surgeons, longer surgical time (which should improve over time) and a higher risk of injury to ureter in uterosacral ligament suspension . If she is sexually inactive, declines shelf pessary but wants surgery under local anaesthetics, colpocleisis is an effective surgery with low complications, which is usually reserved for frail patients. She should receive written information leaflets about all these choices.
Posted by Johnson  O.
A/
I would take detailed history and effect of symptom on quality of life. History of any provocative factors like chronic cough in chronic obstructive pulmonary disease. Chronic constipation, presence of blood in stool. Any history of abdominal pain or swelling. Associated urinary symptoms like urinary incontinence which should be taking into considertion during treatment. Vagina discharges. I would ask her if she is sexually active. Previous surgery including hysterectomy and any previous pelvic floor repair.
Her BMI would be noted. Blood pressure measurement. Abdominal palpation for any mass. Vagina examination would include, any area of excoriation, size of the prolapse, ulceration, prolapse easily reducible. I would check for anterior and posterior vaginal wall prolapse. Any associated enterocele. Bimanual palpation for any adnexial mass. Urinary incontinence on straning. Rectal examination would be performed.
B/
Treatment options would depend on the effect of the symptoms on quality of life, desire to maintain sexual activity, other major procedure to be performed, her wishes and expertise.
In a healthy woman, Abdominal Sacrocolpopexy would be most appropriate option, because it is the most effective procedure, less likely to fail. It also gives opportunity to perform other necessary abdominal surgery. It is appropriate in a woman who wants to preserve are sexual activity.
Laparascopy Scarocolpoplexy is equally effective like open surgery. Has advantage of quick recovery and less hospital stay, but it require equipments and expertise.
Vaginal Sacrospinous fixation if there are other pelvic floor repair. It require adequate vagina wall. It can be done where the woman can\'t withstand long operation time. There may be shortening and narrowing of introitus, which would not be appropriate if sexually active.
Total mesh reconstruction are newer procedure. It can be performed in unit where there is expertise. Colpocliesis is another procedure, by obliterating vaginal opening where sexul activity is not desire.
If the woman declined surgery, pessaries can be used. Shelf pessary more effective than ring pessary after hysterectomy. This would need to be changed every 6months. There is risk of erosion, infection and not desirable if sexually active.
Information leaflet should be provided to enable woman make well informed decision.

Posted by H H.
A sensitive approach is adopted to this lady of 87 years.Will ask of the effect of the lump on her quality of life and if affecting her walking and daily activities.Will ask if lump is reducable when she lies on her back.Will ask of urinary problems like voiding problems,frequency,urgency and dysuria and burnining denoting urinary tract infection.Will ask if had previous retention of urine that required urinary cathetrisation.Will ask of problems at defecation ,constipation and if she had to reduce the mass by hand to defecate.Will ask sensitively regarding her sexual life ,if sexually active and problems.Will ask if had previous repair of prolapse , hysterectomy,previous treatment of the condition and her satisfaction with the treatment.Will ask of any vaginal discharge, colour and smell. Bloody discharge taken seriously. Will ask of special habits like smoking frequency .
On examination will check BP ,body mass index ,check chest for wheezes if smoker(she is healthy), abdominal examination for abdominal mass and palpate for a full bladder, do local examination to see nature of lump ,wether it is visible outside vulva or still in vagina, wether it is a cyst,a mass, tumour, prolapse(uterine or vaginal,cystocele,rectocele,enterocele or vault prolapse).Check if mass prolapsed contain the uterus.Would do rectal examination to differentiate between rectocele and enterocele.


B- Treatment will depend on the degree of vault prolapse, patient fitness for surgery,patient wishes and experience of the surgeon.
As patient is healthy ,then surgery can be the 1st line treatment option unless the patient decline surgery,in such case she can be fitted with a shelf pessary if she is not sexually active. If she is sexually active she can be offered a suitable sized ring pessary.She told about care of pessary ,time to change(3-6months) and need to be examined before application of another one.
Surgery in the form of plication of uterosacral ligaments offer a weak support for vault prolapse with risk of early recurrence , however the course of the ligament from the sacrum to back of cervix form the basis for recent sling operations, but this need surgical expertise.
Fixation of vaginal vault to ischial spine , sacrospinous fixation,offers a strong support to the vaginal vault and can be done unilaterally or bilaterally, but there is risk of bleeding or injury to the pudendal nerve.It has the advantage being a vaginal operation in women who decline an abdominal approach and in expert hands it can be an easy procedure with early post operative recovery for the patient.It can be coupled with the use of mesh to support the base of urinary bladder and another to reduce a rectocele.
The gold standard is sacro colpopexy which is an abdominal operation using a mesh to attach vaginal vault to the sacrum.It has a high success rate . Risks include,bleeding,infection, bowel injury and mesh erosion.It can be used if surgical experience present and patient acceptability of an abdominal approach.
In patients who are not sexually active and who are surgical risk ,Le Fort ‘s operation can be done which is a colpocleisis . The coapted walls of vagina will offer support to the prolapse.
Posted by shipra K.
a)Initial assessment of the patient includes a detailed history, examination an investigations as discussed below:
History should include besides the duration of symptoms,if the patient had undergone any surgery,if yes then for what indication,vault prolapse commoner after vaginal hysterectomy than abdominal.If there is any urinary complain of hesitancy,urgency,difficulty in voiding,stress incontinence,patient needs to reduce the lump to void.If patient sexually active then any coital difficulty.If there is any associated bowel compain like constipation ,she needs to strain at stools leading to increase chances of recurrence of prolapse.If the patient has chronic cough .If there is any distention of abdomen an associated ovarian cyst or ascites would lead to prolapse.Detailed past medical history of patient,at 87 years patient could be suffering from range of medical disorders which could render her unfit or high risk for surgery
Examination includes noting the General condition including vitals ,chest and cardiovascular examination(Patient whether fit for surgery or not).Abdominal examination to see for abdominal scars , ascites,palpable lump.Per speculum examination in left lateral examination would reveal lump in vagina.descent noted according to the POPQ classification. A full bladder examination should be done to see for urinary incontinence. Per vaginum examination would reveal any lump.
Investigations include Hemoglobin ,TLC,DLC, Urine examination routine microscopy,LFT,RFT,Blood sugar,Chest X ray,ECG,urodynamic studies with video cystometry.
b) Patient can be offered conservative treatment pessary -shelf pessary could offered in sexually inactive women and who is unfit for surgery.Pelvic floor exercises donot have much role.Medical problems like cough , constipation need to treated.
These patients need specialist treatment at tertiary level hospitals.
.First and the foremost criteria to decide on the surgical therapy which needs to offered will depend on the expertise of the surgeon in the particular surgery.
Surgical treatment includes abdominal sacrocolpopexy with success rate of 93% ,which could be offered to woman who would require a laparotomy any ways ie for any abdominal mass,also if the woman is sexually active since the length and axis of the vagina is maintained .Laparoscopic sacrocolpopexy needs to be to done by a surgeon with great expertise in laparoscopic surgeries,operating time required is much more than erquired for abdominal approach and increased chances of ureteric injuries. A vaginal approach is better if there is an anterior and posterior vaginal wall defect also then sacrospinous ligament fixation can be offered which has a success rate of 98%.There is lesser hospital stay,less blood loss associated with this but may cause increase in dyspareunia as vaginal axis is displaced.Also this requires that there should be good amount total vaginal length and vault diameter to reach the ischial spines.
If there is any contraindication to anaesthesia posterior intravaginal slingoplasty which has a success rate of 91% can be done under local anaesthesia,less operating time,less blood loss and is especially good for somebody who has had previous corrective surgeries.
Colpocleisis can be offered to sexually inactive and those who are high risk for anaesthesia and have recurrent prolapse.
Vault suspension procedures are easier and can be offered but has a higher failure rate. Iliococygeus fixation should not be offered
Posted by Leen K.
LEEN
A healthy 87 year old woman attends the gynaecology clinic with a 6 months history of feeling a lump in her vagina. (a) Describe your clinical assessment [8 marks]. (b) She is found to have a vaginal vault prolapse. Discuss the available treatment options indicating the circumstances when they will be recommended [12 marks].

(a) I would first ask about the effect of her symptom on her quality of life, as well as asking about other associated symptoms such as bowel changes and urinary incontinence, frequency, urgency or dysuria. Other associated symptoms that should be asked about includes bleeding, discharge and pain (including dyspareunia). I would also ask about whether there is any exacerbating factors.

I would want to find out about her parity and previous gynaecological history, including previous hysterectomy or prolapse surgery in the past. I would also ask about whether she suffers from chronic cough or constipation, as these may make her symptoms of prolapse worse, even after treatment.

I would assess her body mass index - overweight patients are more at risk of prolapse and tend to have poorer rates of success for prolapse surgeries. I would also assess her prolapse whilst she is standing and lying down (using a sims speculum when appropriate) and straining down - and assessing her using an objective prolapse scoring system. I would also ask her about whether she is sexually active and whether she would like to retain her sexual function - as this would help in deciding/choosing the appropriate treatment for her.

(b) COnservative management does not improve her symptoms. Pelvic floor exercise is of undetermined value. Ring pessaries may not be entirely helpful in the case of vaginal vault prolapse, as they tend to fall out. Shelf pessaries may help relieve her symptoms but do not cure her prolapse. It will need to be changed every 4-6 months but has the advantage of avoiding or delaying surgery with all its operative risks.

Sacrocolpoplexy is an abdominal procedure and success rates are good. It is associated with operative risks of infections (including mesh infection), bleeding, damage to visceral organs and vessels. Laparoscopic sacrocolpoplexy is associated with lower morbidity but requires a surgeon skilled in laparoscopic surgery.

Vaginal sacrospinous fixation is associated with lower morbidity and risks compared to sacrocolpoplexy, but has a higher failure rate. It can also cause dyspareunia because the vagina may be tightened or shortened and its axis might be changed following this surgery.

Colpocleisis is quick to perform and the patient recovers quickly with low morbidity. However, it is only suitable for women who do not wish to retain she sexual function anymore.
Posted by SANCHU R.
A healthy 87 year old woman attends the gynaecology clinic with a 6 months history of feeling a lump in her vagina. (a) Describe your clinical assessment [8 marks]. (b) She is found to have a vaginal vault prolapse. Discuss the available treatment options indicating the circumstances when they will be recommended [12 marks].

Sanchu
Her History would be to ask for how her symptom affects her quality of life.
History of vaginal bleeding and discharge should be asked for which may indicate a decubitus ulcer or malignancy.
Urinary symptoms of urgency, frequency, nocturia, hesitancy, straining to void, poor stream and stress incontinence should be asked for.
Any problem with her bowels-constipation or difficulty in defecation should be enquired.
Other symptoms of chronic cough, need to lift weights eg handling her sick partner should be asked for.
Her Obstetric history may explain the etiology with high parity, big babies, instrumental deliveries predisposing to prolapse.
Surgical History -history of hysterectomy, surgery for prolapse should be obtained.

Her examination would include abdominal examination to exclude any mass. Pelvic examination to diagnose and assess the lump. It can be a cyst. But commonly, uterovaginal prolapse ,cystocoele, enterocoele and rectocoele. She must be examined in the L lateral position using the Sim\'s speculum and a POP-Q quantification noted. The presence of vaginal atrophy and decubitus ulcers noted. The pelvic floor should be assessed. Any stress incontinence should be objectively tested in a moderately full bladder.

B)Conservative management would be to reassure if it is mild and if she can cope with the symptoms.
She can also be given the option of vaginal pessary -in a vault prolapse in a 87 year old, a shelf pessary would be ideal. She must be explained that it has to be changed every 6 months and the complication of erosion. Estrogen cream can be prescribed twice a week with the pessary.
She can be given the option of Surgical management- Abdominal sacrocolpopexy (Open or Laparoscopic) or Vaginal Sacrospinous fixation. There should be adequate length of the vagina for a possible sacrospinous fixation and it is easier to do all vaginally if she also has a cystocoele or rectocoele. The procedure is shorter with a lesser hospital stay and a slightly less success rate (80%) compared to abdominal sacrocolpopexy(87%).It has the complications of increased bleeding and buttock pain.
Colpocleisis is offered if she is not sexually active and high risk for surgery- can be done under local anaesthesia.


Posted by Sahithi T.
A))
In initial clinical assessment, I will ask about any pressure symptoms she is having. I will enquire about impact on quality of life. Any symptoms of having urinary incontinence, chronic constipation or chronic cough should be enquired. Any episode of post menopausal bleeding or vaginal discharge is important to rule out possibility of malignancy. I will enquire about her obstetrical history, number and mode of deliveries, any history of previous surgeries. I will ask about any history of similar complaints in past.
On examination, I would like to inspect vaginal mucosa and speculum examination with adequate lubrication to visualise the lump. I will check for any prolapsed uterus if present, any evidence of rectocele, entrocele or anterior vaginal wall prolapse. I will make objective assessment using POPQ system. At the same time I will reduce the prolapse and check for stress incontinence by making patient cough. I will check for perineal muscle tone and any defects. I will do abdominal examination to check any palpable mass. I will check for general fitness of patient by enquiring about any other medical condition and investigating her for full blood count, blood sugar levels, liver and renal function tests, ECG. Abdo-pelvic scan if required to rule out any abdominal or pelvic pathology. Thus my initial assessment is aimed to make clearer picture of the diagnosis of that lump along with patient’s suitability for surgical options.

B)) )
vaginal vault prolapse can be treated conservatively by using ring pesseries or by surgical correction. Ring pessery of appropriate size should be used after patient counselling. It is changed every six months. As it is foreign body, it may cause inflammation, vaginal discharge, and increased risk of infection. Many patients with mild grade prolapse can be successfully treated with this. Ring pessary is indicated in patients with underlying medical condition where operative option is with increased risk to life. The underlying cause such as chronic constipation or chest condition should be treated before any operative treatment. Role of pelvic exercise is questionable with aged women. It may be helpful adjuvant to other treatments with younger women with prolapse.
Opertaive options are vaginal and abdominal surgeries. Anterior and posterior vaginal repair is usually inadequate. It may cause dyspareunia, shorting of vagina. Abdominal sacro-colpopexy is most effective surgery in management of vault proplase but it has operative risks including injury to bowel, ureter or pelvic blood vessels. Too tight repair can cause intestinal obstruction. It is indicated in women who wish to conserve their sexual function and also indicated in women where there is inadequate length of vagina where vaginal repair is impossible. Vaginal sacrospinous fixation of vault is indicated in patient who wishes to conserve their sexual function and has adequate vaginal length. It requires expertise and there is a risk to injury to pudendal vessels and nerves. Abdominal repair involving vault suspension to anterior abdominal wall is described in literature. It carries less morbidity as compared to sacral colposuspanion. But it changes the axis of vagina. It can be done only when there is good abdominal muscle tone. Colpocleisis is indicated in patients where conservation of sexual functions is not desired. It can be done in woman with poor general health and high operative risk with other type of surgeries. Mesh repairs are suggested to repair defects but there is inadequate evidence. Laproscopic colpopexy is equally effective to abdominal approach. It requires more expertise to operate by laproscopic route. Treatment options should be individualised and discussed with woman before recommending any particular option. The choice of woman is important.
Posted by GHADA AHMAD  M.
M GH
A healthy 87 year old woman attends the gynaecology clinic with a 6 months history of feeling a lump in her vagina. (a) Describe your clinical assessment [8 marks]. (b) She is found to have a vaginal vault prolapse. Discuss the available treatment options indicating the circumstances when they will be recommended [12 marks].

A
As the lump is 6 months ago, I will ask about the effect of lump on the quality of life. I will enquire regard to aggravating and relieving conditions of that protruded lump. As well as, I will ask about past obstetric history regarding operative vaginal deliveries and previous history of pelvic surgery like vaginal operations or abdominal hysterectomy. Chest problems to be elucidated like chronic cough and wheezes along with GIT symptoms like chronic constipation. The associated urinary or bowel symptoms with that lump to excluded.

Clinical examination include BMI, BP, Temp. Chest examination to rule out chronic obstructive pulmonary disease and asthma. Abdominal examination to find out hernias/ abdominal masses.
Pelvic examination to determine site, size, shape, origin, consistency of the mass is mandatory.

B.
The treatment options of vaginal vault prolapse will depend on the the general condition of the patient, sexual activity, severity of prolapse and the patient\'s wishes. the patient should informed that this is not a life threatening condition and if it does not affect the quality of life, and if she can cope with it no treatment. If she is unfit for surgery and unhappy with that lump , I will offer her ring pessary and explain how to use it and possible complication like infections and ulcers. If she is fit for surgery and sexually active I will offer her vaginal sling operation like sacrospinous fixation. Colpocliesis like Le Forte operation to be offered if she is not sexually active and the prolapse affect her life. Abdomial sacrocolpopexy is another option for correction of prolapse but it necessitate good general condition. I will document the patient wishes in notes and take an informed consent regard to the option she want. I will provide her with written information leaflet. I will discuss the type of anaesthesia and analgesia in liaise with the anaesthetist.
Posted by Akanksha G.
A healthy 87 year old woman attends the gynaecology clinic with a 6 months history of feeling a lump in her vagina. (a) Describe your clinical assessment [8 marks]. (b) She is found to have a vaginal vault prolapse. Discuss the available treatment options indicating the circumstances when they will be recommended [12 marks].
a)my assessment would include details of the presenting complaint with its affection on the quality of life(QOL) using disease specific QOL questioonnaires.symtoms enquiry would include severity of prolapse and associated symtoms, particularly related bladder (urgency, incontinence (stress/urge), frequency and symptoms of UTI) and bowel(constipation). history of precipitating factors like chronic respiratory illness, constipation would be sought. sexual history of whether she is sexually active and the desire to retain sexual fuction helps in deciding the type of corrective surgery. history of comorbidities like any medical illness (diabetes, hypertension, ischemic heart disease, ) will hint towards her surgical fitness. history of any surgical illness will help plan her surgery better. examination will include examination of the systems (CVS and RS ) determine fitness for surgery. a abdominal examination to rule of any abdominal mass. local examination to determine the extent of prolapse, associated anterior and posterior vaginal wall prolapse the details of the findings would be documented according to the POPQ system which will be more objective assessment and also help help in comparing the results of the surgery. total vaginal lenght and vault bredth should be noted down since adequate vaginal length is required if sacrospinous vault suspension is contemplated. i would also assess for any occult urinary incontinence, in full bladder with replacement of the prolapse with a pessary or sponge forceps.
b)trearment options would depend on the desire to retain sexual function, surgical fitness of the lady,
conservative managemnt options include pelvic floor exercises and use of pessaries their usefulnesss is uncertain. pessaries can be offered to women who are unfit or decline surgery. pessary could be either ring pessary or shelf perssaries. shelf pessary is more commonly used and has to be changed every 6-8 months. sexual intercourse is impossible with shelf pessary and cannot be offerd sexually active women. risks with shelf pessary include erosion, fistula formation and infection. surgical treatment options are between, abdominal sacrocolpopexy and vaginal sacrospinous fixation. women who are sugically fit and desire to retain sexual function and do not have anterior or posterior vaginal wall prolapse are ideal candidates for the abdominal sacrocolpopexy. it carries less recurrence rate, less dysperunia, than sacrospinous fixation. hoeever the operative morbidity is more since its an open operation and if there are anterior and posterior vaginal wall prolapse the it has to be repaired by a second vaginal procedure. laparoscopic sacrocolpopexy can also be performed with equal success rates as open procedure with availability of the necessary skill. however one should be cautious while offering laparoscopic procedure since it requires long operating time. vaginal sacrospinous fixation is ideal for women who do not desire to retain sexual fuction and who on examination heve adequate vaginal length and vault breadth, and an associated anterior or posterior vaginal wall prolapse(all can be corrected at the same time). sacrospinous fixation causes narrowing of vaginal and hence not preferable in women to would desire to retain sexual function. women are unfit for surgery and would forgo sexual function can be counnselled for colpoceisis with either vaginectomy or curcumferential closure. uterosacral ligamnet fixation is also effective vaginal procedure but has th e risk of ureteric injury. total mesh reconstruction is a novel procedure and should not be offred outside research.
Posted by robina K.
I will asses her on the basis of her symptoms by obtaining history, signs by objective demonstration of prolapse and relevant investigations. I will ask her about the severity of symptoms affecting her quality of life by a disease specific validated questionaire. I will inquire about urinary and fecal incontinence , pain and ulceration which may indicate decubitus ulceration and severe prolapse. Though she is healthy I will still ask about any chronic illness like chest infection, chronic constipation and abdominal distention which indicates masses.I will review her previous operation notes for the type of hysterectomy as vaginal hysterectomy for uterovaginal prolapse is associated with increased risk of vault prolapse 11.8% and is likely to be more severe as compared to hysterectomy performed for other causes 1.6% . I will ask about any previous treatment .
I will examine her B.P , abdomen for mass arising from pelvis, do a vulval inspection for atrophy and ulceration .Degree of vault prolapse is assesed by pelvic organ prolapse quantification (POP-Q). It quantifies the exact prolapse of the apex of vault for more than 2 cm from the total vaginal length by taking plain of hymen as a fix point .Grading of prolapse is done by maximum tightning on coughing, maximum descent on traction or if women herself demonstrates it in a mirror.I will also asses any anterior or posterior compartment defects.Assesment of general health for anaesthetic fitness.If there are no urinary symptoms, no pelvic mass on abdominal examination and chest is clear bimanual pelvic examination is not indicated and no further investigations are offered.
(B) Available treatment options are Pelvic floor exercises for 3-4 months if the prolapse is mild but it is unlikely to be effective. long inpatient admission and Physiotherapists assistance is needed.
Vaginal pessary is an option in mild prolapse and in those women unfit for surgery.Ring or shelf pessary is advised if perineum is defecient .There risk of infection, ulceration and expulsion.It needs to be changed every 3-4 months.
Surgical options are Vault suspention procedures which can be done abdominally by a laparotomy or laparoscopically and through vaginal route.there is no evidence that one procedure is more effective than other .Sacrocolpopexy when vault is fixed to the sacral promontry through prolene mesh.High cure rate .I will offer this operation to the women if she is fit for anesthesia , expectant management fails or women opts fot it. If she has bladder or rectal prolapse can be repaired at the same time vaginally.Associated complications are risks of hemorrhage during surgery, anesthetic complications and post op rectal prolapse.Sacrocolpopexy can be performed laparoscopically if expertise are available.This procedure carries more complications than open one as risk of ureteric and bladder injury.
Sacrospinous ligament fixation .The angle of vault is fixed to the ileopectineal ligament usually unilateral.Causes vaginal distortion causing dysparunea in a sexually active women.It also increases risk of bladder prolapse however there is less risk of hemorrahge and ureteric injury.
Other procedures like vault suspension to the external oblique muscle apneurosis is an option to avoid risks associated with other ptocedures.
Vaginal procedures .I will offer these procedures if women is unfit for surgery, not sexually active ,adequate vaginal length and if women chooses this option.
Vaginal repair of anterior and posterior compartment defects along with reduction of enterocele is not going to affect her symptoms so not offered.
Vaginal sacrospinous ligament suspension under local or regional anesthesia is an option if there is adequate vaginal length .there is risk of ureteric injury..
Posterior intra vaginal sling procedures is another option in a frail women who is unfit for anesthesia and if expertise are available . as it can be performed under local anesthesia as a day case with quick recovery and short hospital stay.
Colpocleisis when there is deliberate closure of vagina with a purse string suture offered to frailwomen unfit for surgery.
Posted by Sameena M.
ASK PATIENT about the discomfort and pain caused by the prolapse,how is it effecting her quality of life(QoL questionnare can be used).Ask about any bowel or bladder symptoms present,any vaginal bleeding or discharge,any history of previous surgeries like hysterectomy,pelvic floor repair and bladder neck surgeries.ask about the obstetric history particularly about her parity and any difficult deliveries.ask about presence of any comorbidities and any medication she is on.ask about history of cough and constipation.ask if she is sexually active and will she like to preserve her sexual capacity.ask about history of HRT.
do a general physical examination ,assess her mobility and dextrility and check BMI.do an abdominal examination to look for any abominal /pelvic massess which can cause prolapse.check for health of vaginal and vulval skin,note atrophy,any ulcers or any bleeding or discharge.Do PS examination and look for state of vaginal skin .look for vaginal vault.
check for presence of vault prolapse,any cystocele,any rectocele,general tone of pelvic muscles.
use POP-Q score to grade vault prolapse and any cystocele or rectocele, if present.assess for vaginal lenghth and vaginal room at top(in case we go for sacrospinous fixation we will need enough room at the top of vagina).after reducing prolapse check for stress incontinence.if patient has urinary symptoms or demonstate stress incontinence after reducing prolapse request for urodynamics.
One of the treatment options is sacrocolpopexy .it is preffered option when patient has to undergo abdominal surgery for other reasons.patient needs to have general anaesthesia and inpatient hospital stay and a abdominal incision.it is assosiated with urinary track injuries,abdominal wall hernias.sacrocolpopexy can be done laproscopically but needs expertise and equipment and is assosiated with more urinary tract injuries and recurrence.it is not advisable.
sacprspinous fixation is advisable when patient needs other pelvic floor surgeries also.if patient needs any bladder neck surgery for urinary syptoms like TVT it can be done at the same time.it can be done under regional or general anaesthesia.hospital stay is shorter ,recovery is quicker .
it can cause buttocks pain to patient.patient needs to have good vaginal room for this surgery to be performed,which is sometimes difficult in old ladies.sexual functions are preserved.
colpoclesis can be offered in frial patients who cant tolerate other surgeries and who are not sexually active .it can be done under local anaesthesia.it is a simple procedure with no major morbidities.patient needs treatment of any vaginal infection or ulcers before this procedure.
Vaginal pessary can always be an option for a patient who does not want any surgery and is happy to have it changed every 4-6 months.it is an option for patients not fit for surgery.
pelvic floor exercises will not treat vault prolapse.
the options should be discussed with patient by a surgeeon who can offer her all these options.final decision depends on patients preferences.
Posted by Shalini  M.
Sha
a)It is essential to take a history of her symptoms progression-any associated urinary symptoms like stress incontinence or urgency as they need to be evaluated before deciding treatment for this lady.Also her papers should be reviewed for details of previous surgery-the indication and operative details like oophorectomy done or not.Also use of HRT and details of which drugs used n duration as they could need modification before treatment for prolapse.Also any history of anti-hypertensive drugs used like ACE-inhibitors which could cause chronic cough n prolapse.On examination her BMI should be assessed.Her general condition should be assessed like pulse,blood pressure and chest examination to rule out any chronic obstructive airway disease which could cause increased intra-abdominal pressure and prolapse.On abdominal examination,any mass should be looked for as that could cause prolapse.On local examination,any vulval or vaginal atrophy should be noted as they need correction with local estrogens.Also descent of lump should be noted and presence of cystocele or rectocele . enterocele should be noted.

b)Management of vault prolapse is surgical with surgeries like abdominal sacrocolpopexy,sacrospinous fixation and Le-fort\'s repair that could be planned depending on the wishes of the lady.However if the risk of surgery and anaesthesia is more then conservative measures like vaginal pessaries can be prescribed.
Abdominal colpopexy is the surgery with the best long term results and thus should be preferred in women who are young.Also the vaginal axis does not alter and thus less dyspareunia and preferred for women who are sexually active .However this surgery is a major one involving complications like wound infection,incisional hernia,hemorrhage,mesh erosion and bladder injury and thus not preferred in women who have co-existent morbidities and are elderly.sacrospinous fixation is a vaginally done procedure with less morbidity and thus suitable for the elderly as is a short procedure.Le fort\'s repair is obliteration of the vaginal canal in women who are elderly and not desirous of sexual function as it has minimal morbidity and least anaesthesia exposure.Vaginal pessaries like ring and shelf can be prescribed but use of shelf pessary preclude sexual intercourse and these are reserved for the elderly and frail women unsuitablr for anaesthesia.However complications like erosion,infection and calification could occur with the pessary and thus needs medical attention.
Posted by Manoj M.

M
(a) A history of lump in vagina may suggest a uterovainal prolapse but other history like of ulcer or bleeding should also be elicited to exclude alternative mass lesions that may suggest malignancy of uterovaginal region.
A history of quality of life affected with a validated questionnaire like King\'s health questionnaire.
A history of bladder dysfunction or incontinence with underlying pelvic organ prolapse should be elicited as may need additional investigations and or treatment.
A history of bowel symptoms like constipation may suggest underlying precipitating cause.
A past obstetric history e.g. difficult instrumental delivery, extended perineal tear may suggest contributory factors.
Past history of pelvic organ prolapse and treatment may suggest recurrance or new symptoms, A past history of hysterectomy may also help to decide the current treatment option.
Her desire to maintain sexual capacity should be obtained as this will help in her treatment options.
Her wishes and desire for treatment will form the mainstay of her treatment.
Her BP, BMI and her anaesthetic fitness for surgery should also be obtained, as she may need a surgical option for her treatment.
Abdominal examination to exclude pelvic mass lesion as cause of pelvic organ prolapse.
Speculum examination using sims speculum with standardised tools like pelvic organ prolapse quantification to assess the degree of pelvic organ prolapse.
Assess degreee of utero cervical descent may suggest need for vaginal hysterectomy along with pelvic organ prolapse repair and bimanual examination to exclude other mass lesions as cause of prolapse.

(b) Treatment options depends on quality of life affected, her choice and her fitness for surgery, expertise availability and include conservative options or surgical options.
If she is unfit for surgery or does not want surgical option then Do nothing with full explanation of her problem may be enough or alternatively a vaginal pessary more likely with shelf rather than ring pessary with vault prolapse. This will need a change every 6-8months. She should be explained the risks involved like calcium deposition, vaginal erosion and fistula And difficulty to maintain sexual intercourse with shelf pessary.
Abdominal sacrocoploplexy is an effective operation for vault prolapse which can help to maintain vaginal capacity for sexual function, but it is subjective to patients surgical fitness.
She should be explained complications involved like haemorrhage, blood transfusion, mesh rejection.
Laparoscopic sacrocolpoplexy is equally effective as abdominal but need expertise availability and risk of laparoscopic complications especially ureteric injury at sacrospinous ligament suspension.
Sacrospinous fixation is an alternative to sacrocolpoplexy but may reduce the functional capacity of vagina but associated with less morbidity with surgery compared with sacrocolpoplexy.
Sacrospinous fixation(SSF) also need adequate lenth of vagina to reach the sacrospinous ligament and can be done along with anterior and posterior vaginal wall repair.
SSF has also complicatons like need for blood transfusion, bladder injury, rectovaginal haematoma and vaginal pain.
Her choices should be considered and full written information details provided.
Posted by Nur Sakina K.
NSK
From A:
I’d enquire re severity of her symptoms and its impact on her QOL (quality of life). This can be assessed using validated QOL questionnaires such as The King’s Health questionnaire. Other associated symptoms such as bleeding, pain, presence of bowel and urinary symptoms are elicited. I’d specifically ask re urinary incontinence, frequency or voiding difficulties which suggests anterior vaginal wall prolapse (cystocele) and defecation difficulties and constipation suggesting posterior vaginal wall prolapse (rectocele). I’d ask whether previous gynaecological surgery, specifically hysterectomy had been done. If so, I’d review previous operative notes to assess whether preventive measures to reduce the risk of post hysterectomy vault prolapse had been performed such as Mc Call’s culdoplasty, prophylactic sacrospinous fixation (SSF) or suturing of the cardinal/uterosacral ligament complex to vaginal cuff with obliteration of the pouch of Douglas. Her sexual history to assess sexual activity and her desires to retain sexual function will affect my treatment options. I’d also ask her treatment desires, whether she is keen for surgery or conservative management.
Examination involves assessing location of the lump per vagina, the length and width of the vagina and palpating the uterosacral ligaments to assess the degree of vaginal vault descent. I’d document the site, severity and degree of prolapse involved. This can be objectively quantified using the POPQ system (pelvic organ prolapse quantification). I’d examine her in the left lateral position using a Simm’s speculum, then with her standing and straining to assess degree of prolapse and any associated urinary incontinence. If there is evidence of anterior vaginal wall prolapse, I’d reduce it using a sponge forceps/ pessary to exclude occult urinary incontinence. I’d palpate the pelvic floor muscles for any defects.

From B:
Treatment will depend on the severity of prolapse, her sexual function and desires for treatment. Conservative options such as vaginal pessaries (ring/ shelf) are useful if she is keen to avoid surgery. However shelf pessaries make sexual intercourse impossible and needs changing every 6-8 months. There is also the risk of pessary expulsion, vagina erosion, ulceration, fistulae formation and incarceration. Hence it is more suitable if she is not sexually active. Ring pessary are more likely to fail if she has a deficient perineum, thus shelf pessaries are more suitable. Local estrogen can be used with them to improve atrophic changes.
Surgical options include abdominal sacrocolpopexy (SCP), an effective operation with lower recurrence rate, vaginal length preservation and maintains a physiological vaginal axis. Thus, useful if she were sexually active. However it is associated with greater morbidities- bladder injury, incisional hernia, mesh rejection and wound infection. It can also be done laparoscopically although it requires higher laparoscopic skills, has a risk of ureteric injury and longer surgery time. Abdominal approach is appropriate if she requires a laparotomy for other reasons. Sacrospinous fixation (SSF) has a higher failure rate but lower morbidity compared to SCP such as less bleeding risk, shorter recovery time and hospital stay. However, it requires adequate vaginal length and width to reach the sacrospinous ligament. A vaginal procedure is appropriate in presence of vaginal wall prolapse, which can be repaired simultaneously. As deviation of vaginal axis occurs, it causes dyspareunia, vaginal shortening and narrowing especially when done with vaginal wall repairs. There is currently no evidence to recommend neither unilateral / bilateral fixation nor one procedure over the other. Uterosacral ligament suspension is effective, but carries a higher risk (upto 11%) of ureteric injury, bladder injury, UTI and bowel injury. It can be done either laparoscopically or vaginally. If she does not wish to retain sexual function, colpocleisis is an option. Advantages include a shorter surgery time, lower risk of morbidity, a high success rate and can be done under local anaesthetics.
Posted by Caithlin N.
a) The most likely diagnosis is pelvic organ prolapse, the differentials would be bartholins cyst and malignancy. I would ask her whether the lump is constantly present and if she can reduce it. If she has any vaginal or back pain associated with the lump. If she has noticed any bleeding or discharge. If she has any associated urinary symptoms such as frequency or incontinence. I would enquire about bowel symptoms such as constipation or faecal incontinence. If she has any history of a cough which may precipitate prolapse. I would enquire about her past obstetric history, number of pregnancies and birth weights. I would ask if any labour was long or difficul and whether she had any history of trauma to her anal sphincter. I would ask about any previous surgery such as hysterectomy. I would assess her body mass index.
I would examine her abdomen for any masses.
I would inspect the vulva for any lesions. I would ask her to cough to demonstrate stress incontinence. I would perform a speculum examination to visualise the vaginal lesion or prolapse. I would assess the degree of the cervical descent and look for cystocoele and rectocoele. I would document this using POP-Q. I would inspect the vaginal tissues for any evidence of atrophic vaginitis or ulceration. I would assess her pelvic masses.

b) I would explain my diagnosis to the patient and provide her with information leaflets. Treatment options should be disscussed with the patient and her wishes should be taken into account. Pelvic organ prolapse can either be treated conservatively or surgically.
Conservative options do not involve the risks associated with anaesthetic and can generally be accessed more rapidy. The are a good option for women who are unfit for surgery or who decline it for other reasons.
A ring pessary or shelf pessary(if her perineum is deficient )could be insered which allows symptomatic relief but is not curative. This can be inserted immediately in clinic but requires 6 monthly change. They may preclude sexual intercourse.
Formal training of pelvic floor exercises by a physiotherapist requires dedication and motivation and is not shown to be of benefit in vault prolapse. Though, it has no adverse effects and may also improve other symptoms of pelvic floor dysfunction.
Choice of operation depends on the knowledge and skill of the surgeon and unit protocols. If previous prolapse surgery has been performed the patient should be referred to a tertiary referral centre. The greatest information available is on sacrocolpopexy and sacrospinous fixation. Sacrocolopopexy can be performed either laparoscopically or by laparotomy. The operation is lengthy with a higher blood loss and slower return to normal activity than sacrospinous fixation. There are risks of haemorrhage, infection and damage to the bladder with both operations. Sacrocolpopexy is associated with recurrence of posterior wall prolapse and sacrospinous fixation with apical and anterior wall prolapse.
More recently sling procedures have been used, in which a synthetic mesh is inserted to support the tissues. There are associated risks of chronic inflammatory process and mesh rejection. If the vaginal tissue is atrophic there is the possibility of erosion. More research is required before these are routinely recommended.
Colpoclesis may be performed to close the vaginal and may be offered if the women does not wish to retain sexual function. It is considered a safe and effective procedure.
Posted by Dr Saritha M.
a)
Assessment involves detailed history about aggravating factors like cough and constipation, relieving factors like reducibility on lying down position is enquired. History of bladder disturbances like incomplete emptying, increased frequency, dysuria and bowel disturbance like incomplete emptying, delayed or difficult bowel opening is enquired. Effect on quality of life is assessed by disease specific validated QOL questionnaire. Sexual disturbance like dyspareunia and desire to retain sexual function is enquired. Previous history of surgeries for benign conditions like fibroid uterus, dysfunctional uterine bleeding or surgery for incontinence is enquired. Personal history of smoking is asked.
On examination, BMI is checked, chest auscultation for signs of chronic obstructive airway disease, Per abdomen any pelvic or abdomen mass is palpated. Genital examination for identifying degree of uterine descent and ant and post vaginal wall defects. Objective assessment is done by pelvic organ prolapse quantification with women in left lateral position at rest and at maximal valsalva manouver.Assess for occult stress incontinence after reducing prolapse and with full badder but evidence is not validated and the role of prophylactic surgery is not clear.
Investigation includes FBC, EKG, chest x-ray, Urine microscopy for evidence of infection, Ultrasound for post void residual urine and urodynamic studies, Intravenous urogram if ureteric obstruction is suspected.
b)
Conservative management includes pessary treatment, Ring or Shelf is commonly used. It is indicated in women who are not sexually active,physically frail women,unfit for surgery or it is declined. needs to be changed every 6-8 months to prevent vaginal wall ulceration.complication includes erosion and fistula formation on long term use. There is no evidence for role of pelvic floor exercises.
Surgical treatment are; Abdominal sacrocolpopexy indicated in sexually active women, undergoing laparotomy for other reasons. it has lower rate of recurrence and less dyspareunia. associated with long operating time, slower return to activity, high cost,complications like bladder injury, incisional hernia mesh rejection, wound infection. Sacrospinous fixation suitable for physically frail women because of morbidity associated with abdominal surgery.It requires adequate vaginal length and width.
It has got high recurrent vaginal prolapse and recurrent stress incontinence rate. complication includes blood transfusion, bladder injury vaginal pain and rectovaginal hematoma.There is no role to recommend uniateral or bilateral sacro spinous fixation, ileo coccygeous fixation is not recommended.Choice depends on circumstance and surgeon should be experienced in both procedures.
Uterosacral ligament fixation is effective but has got risk of ureteric injury. Anterior and posterior vaginal wall repair along with obliteration of enterocele sac is inadequate for vault prolapse and is associated with dyspareunia. Colpocleisis is effective procedure suitable for women who do not want to retain sexual function. It is done under local anesthesia, short operating time.
Laparoscopic colpopexy is effective as open colpopexy, has advantage of shorter hospital stay, quick recovery, less complication. It requires expertise and long operating time.
Sling procedure not used with out adequate cunselling.
women has to be provided with written information about the pros and cons about each procedure and women wish is considered in deciding the appropriate treatment.
Posted by Ron C.
RnRn

A.
Information on how the symptoms affect her quality of life (ie merely worried, significant discomfort, dyspareunia) may determine approach of treatment. Additional symptoms such as difficulties in passing stools or voiding, incomplete emptying, frequency or even stress or urge incontinence may affect management, as will presence of exacerbating factors (chronic cough in smoking, constipation). If there are sinister symptoms such as post-menopausal bleed or post-coital bleed this warrants further investigation and smear history is essential. Previous gynaecological (prolapse) surgery would affect choice for current surgical management and alters success and complication rates.
Examination includes blood pressure & pulse rate and height & weight for BMI. Abdominal palpation may reveal a pelvic mass. Vulval inspection to assess presence of prolapse and leaking on straining. Any abnormal skin lesions must be noted, as well as atrophic mucosa on subsequent vaginal assessment. Vaginal assessment with Sims speculum both left lateral and in supine position with the knees flexed and feet on the examination couch to assess degree of prolapse conform POP-Q score. Vaginal examination to confirm findings on speculum, assess pelvic floor muscle tone and presence of any pelvic masses. If present, uterus can be assessed for descent and size to see whether vaginal hysterectomy is possible.

B.
Vault prolapse is common after previous hysterectomy, especially if done for prolapse complaints. If patient is mainly worried and symptoms are mild, not compromising quality of life, reassurance with conservative management and general life style advices such as avoiding constipation, constipation and losing weight if obese may be all that is needed. Pelvic floor exercises won’t improve prolapse, but are useful as (additional) treatment for those who have associated complaints of stress incontinence. A (ring) pessary is useful in those not keen for surgery, though it interferes with intercourse and needs to be changed every 3-6 months. Medical management (anticholinergics) is only applicable as parallel treatment in those suffering urge-complaints simultaneously or after repositioning of prolapse with a pessary, though side effects like nausea & constipation may limit its usefulness. Those not keen for conservative management or ring pessary, or those in who this approach fails or who are not keen to try non-surgical management first can be counseled for surgery. Abdominal sacropexy and vaginal sacrospinous fixation have similar risks; bleed, infection, accidental damage to bowel or bladder. Abdominal sacropexia has more comorbidity with additional risk for erosion of mesh and requires longer surgery & recovery, but has less long term recurrence (13%). Sacrospinous fixation can additionally cause pain in the buttock, which is mostly transient though, and may cause more discomfort on intercourse. Recurrence can be as high as 25%. Nevertheless comorbidity is less with shorter operating time, and it may be an attractive approach if additional repair such as anterior or posteriol wall need to be done. An alternative abdominal approach is by means of using endogenous rectus sheath tissue to create a suspension. This procedure is relatively simple, but as there is paucity on long term data, counseling on its use is difficult. Finally colpocleisis is a procedure which due to its nature is only suitable for women who do not wish to remain sexually active. Hence this procedure is more suitable for frail women not fit to undergo major surgery, as it is a relatively simple procedure.
Posted by PAUL A.
A-I will get details history regarding her lump, associated other symptoms like constipation, per vaginal and per rectal bleeding, faecal (1) and urinary incontinence (1) , any pain, especially back pain, how significantly this lump disturbed her day to day life do not write lists . I want to know that whether she is she is sexually active or not and whether she wish to retain her sexual function (1) . I will inquire her regarding past gynaecological history, whether she had any gynaecological surgeries especially, hysterectomy (1) and urogynaecological procedures, any malignancies, and any surgical procedures ex hip replacement. If she had any surgery in past, will trace and go through operative notes. I will inquire her general health whether she is fit for major surgery especially chronic diseases like CVD, COAD ect, ?? no marks for this If so drug history.
On examination I will check her general health status including how mobile she is, BP, PR, abdomen for any lumps especially full bladder (1) . On vaginal examination, estrogens status, ulcers over the lump details of genital prolapsed, use-POPQ- pelvic organ prolapsed quantification system (1) for objective assessment and check stress incontinence with full bladder for masked stress incontinence (1) . I will check her mobility of hip joint why?? .I will do basic investigations like FBC, EUC ??, LFT, and ECG.

B-I will discuss with her nonsurgical and surgical options. I will change her medications which will exacerbate vault prolapsed - chronic cough-ACE Inhibitors healthy , constipation.
Nonsurgical pelvic floor exercise – uncertain prognosis unlike will resolve vault prolapsed ? meaning , If she does not like surgery or unfit I will offer Vaginal Pesseries (1) like ring/self need wear lifelong, high risk of Pesseries expulsion, need to change in regular time -6-8 months (1) and if it forgets to change can get vaginal erosions ulceration ,fistula formations . It is difficult have sexual intercourse with Pesseries.
Surgical methods- is she not desired to retain sexual function poor English and she is frail, unfit for major surgery I will discuss colpocleisis (1) short operating time low surgical and anaesthetic morbidity. Sacro- spinous fixation low operative morbidity (1) but has high er failure rate but need reasonable length in vagina to reach sacro-sipnous ligament. Abdominal sacro- colpopexy can do under open or laporoscopically (1) but depends on surgeon’s experience; this procedure has higher complication rate (1) , wound infection, mesh rejections ?? do you get rejection?? and bladder injury.Abdomino sacro colpopexy has better success rate (1) compare with vaginal procedure but need longer operative time especially laparoscopic procedure. Currently there is no evidence to suggest one procedure over other procedure .I will not offer her lleo-coccygeus fixation as it is not currently recommended. I will give her written information regarding above procedures.
Posted by PAUL A.
A healthy 87 year old woman attends the gynaecology clinic with a 6 months history of feeling a lump in her vagina. (a) Describe your clinical assessment [8 marks]. (b) She is found to have a vaginal vault prolapse. Discuss the available treatment options indicating the circumstances when they will be recommended [12 marks].
A.
Clinical assessment includes history of the illness, examination and investigations NO – clinical assessment = Hx & exam . In the history I would like to find out what discomfort the vaginal lump causes, does it associated with any urinary symptoms, bowel symptoms which urinary / bowel symptoms? or any problems with sexual intercourse. Overall her quality of life impact on her quality of life and her social life should be assessed.
Further I would like to know any previous surgery either hysterectomy (1) was performed, if so what was the indication, was it for any malignancy or for any benign condition. If she had undergone any vaginal procedure that should be recorded. In particular any surgery for prolapse or slings for Genuine obsolete terminology - urodynamic stress incontinence.
Further I will examine her general condition, per abdominal examination to feel any abdominal mass (1) or tenderness. Speculum examination to know how far her prolapse is decented and does it associated with any element of cystocele or rectocele use objective assessment tool like POP-Q. Your Hx needs to be more explicit – just urinary symptoms is not enough – you are particularly interested in incontinence or voiding problems .
At this point investigation depends upon her symptoms, If she has any urinary symptoms I will do MSU. If my examination revealed any pelvic pathology I will ask for pelvic ultra sound to exclude pelvic pathology.
Further I will explain to the patient what was the finding on the on examination. I prefer to draw a diagram and explain to her.
B.
The treatment can be either Surgical or non surgical. Non surgical methods are using vaginal pessaries. Ring pessary is not very suitable for vault prolapse. Shelf passary is the idial. It is a devise which will relieve the symptoms of prolapse. If it is placed, it has to bechanged every 4 to 6 months (1) , because if left longer tissue can over grow on it, and it will be difficult to remove. This devise can be offered If she is not keen for surgery or surgery is going to be after some time (1) .
Since she is healthy 87 year old, she can be offered to go for surgical intervention, there a couple of options available. Sacrocolpopexy which can be done either by laparotomy or my laparoscopy (1) . The expertise for laparoscopy is very much limited. Abdominal sacrocolpopext has good success history. Associated complication with this procedure are bleeding, infection and mesh erosion. The operation involves of anchoring a polyprophylin sling to the vault, it can extended to anterior and posterior of the vault, and retro peritonealy it is fixed to the sacral promontory (1) anterior longitudinal ligament, not to the bone .
Sacro spinatos colpopexty is the other procedure. This is done by vaginal approach (1) where the apex of the vault in anchored to the iliac spine on one side. This procedure too has long term history of good outcome. Compare with abdominal sacro colpopext is is quicker and recovery is fast (1) lower success rate . Pudental neurovascular damage is one of the complicaion of this procedure. Th other complications of this procedure are infection and mesh erosion. Possible dysperiunia.
Mesh – sling procedures (Anterior and posterior Avulta) not a recommended procedure are available. Once again expertise are limited. In this procedure operating time is much quicker and complications are much less. Short time out come ins good and long time success rate is not known. Complications include mesh erosion, and infection.
If the patient is not sexually active and not keen for any major surgeries she can be offered to have Le Forts operation (1) . This can be done under local anaesthesia. Compare with other procedure which described above,it is simple and less complicated.
Patient need explanation of the different procedures and pros and con. She should be given information about the procedures Finally patient’s decision should be taken in to consideration.
Posted by PAUL A.
the symptom is most likely to be related to prolapse
I would ask her about the amount of discomfort she feels whether she feels it all the time or only during valsalva (cough ,straining)
Iwill ask her about symptoms related to bowel and bladder function which specific symptoms?
with special reference to stress incontinence (1) .
I will also ask her regarding any sexual problems associated with the lump ? desire to maintain sexual function
In addition other symptoms regarding her general health ,constipation ,chronic cough,her mobiliy needs to be ascertained .
Her past medical history regarding systemic diseases like diabete s,hypertension any other significant problems (for anaesthesia) healthy 87 year old
Surgical history menstrual history specially with reference to postmenopausal bleeding ,obstetric hostory will be obtained ? previous hysterectomy / prolapse surgery
drug history specially HRT
I will perform a
general examination keepinh in mind the possibility of other problems at this age
I will perform an abdominal examination to assss for any masses (1) including a full bladder ,any scars of surgeries
Local examination will include the vulva vagina (atrophic), size of the vagina,the size shape of the lumpwhether anterior compartment or posterior or lateral ,POP Q (1) assessment to quantify the prolapse,any evidence of stress ? incontinence?? ,the tone of the pelvic musles.
iApelvic exaam for the size shape of uterus and any associated masses will complete my exam
Inves you were asked about clinical assessment towards a general assessment ,FBC ,MSU,LFT U&eE CHEST XRAY scan (if any abnormality)



b)Adiagnosis of a vault prolapse havin been reached ,Iwill inform the lady about the diagnosis and ascertain her needs
Since it is not lifethreatening .
I will counsel her regarding the options available to her
These include the pessary ---the shelf works better than the ring (1) in which circumstances will you use this??
I will counsel her about the fitting procedure about the need for follow up and change it if infection ,erosion occurs will you only change it IF infection / erosion occurs? (-1)
Iwill also inform her about the surgical options available to her

The sacrospinous fixation (1) of the vault done vaginally usually unilateral is aprocedure with fairly good outcome
Tje possibility if injury to the pudendal vessels ,the need for an adequate depth and width of vagina must be kept in mind

Abdominal procedure of colposacro pexy is this what it is called? has the associated morbidity of an abdominal procedure ,injury to the sacral vessels may also occur
Alaparoscopic method is being advocated recently with comparable results (1)
For a woman who is not interested in sexual function ,colpocleisis (1) where the walls of vagina are opposed is a suitable alternative
The high dissection of the enterocele sac and repair does not confer much benefit .
Iwill give written infirmation about the above ,get an anaesthetist to check her and help her to make an informed decision to improve her quality of life
Posted by PAUL A.
(a) Describe your clinical assessment [8 marks].

I will ask how this lump has affected her quality of life (1) and fill in a \"quality of life disease validated questionnaire\". I will ask her precipitating factors eg walking or voiding & relieving factors. I will ask if needs to use her finger to push it back to the vagina (1) .
I will ask her if the prolapse is associated with urinary symptoms such as urinary frequency, difficulty voiding and incontinence (1) . I will ask if she suffers from constipation ? incontinence . I will ask if she has past prolapse surgery & hysterectomy (1) , how many children she has & modes of delivery. I will also ask if she is sexually active wish to retain sexual function .

On examination I will record her body mass index & check her blood pressure. I will do an abdominal examination to exclude a pelvic mass (1) . I will do a speculum examination to assess the size of prolapse using the \"pelvic organ prolapse quantification (1) \", checking for cystocoele, rectocoele, uterine descent or vaginal vault prolapse. I will do a vaginal examination to check pelvic floor muscle tone and exclude any adnexal mass. In presence of palpable pelvic mass i will arrange a pelvic ultrasound for confirmation.

(b) She is found to have a vaginal vault prolapse. Discuss the available treatment options indicating the circumstances when they will be recommended [12 marks].

Treatment options are determined by how the prolapse has affected her physically & quality of life, degree of prolapse, patient\'s wish, whether she is sexually active, presence of co-existing pathology, surgeon\'s choice & skill. Pelvic floor exercise has no place for vaginal vault prolapse (1) .
If she is asymptomatic SHE PRESENTED WITH SYMPTOMS!! she can reassured which might be sufficient to relieve her anxiety. However if she is symptomatic, not keen on surgery & sexually inactive, a shelf pessary may be sufficient (1) . It is cheap & convenient. She should be counselled that it has to be replaced every 4 to 6 months (1) . It can cause her discomfort, vaginal wall erosion & abrasion.
If anterior and/or posterior vaginal wall (1) prolapse co-exist, sacrospinous fixation & vaginal repair (1) will be option of choice. However she should be warned about dyspareunia and buttock pain after surgery. If she has co-existing pathology in pelvis eg adnexal mass which needs excision, abdominal sacrocolpopexy do you need an abdominal mass / other pathology to be suitable for sacro-colpopexy?? will be the treatment of choice. Both surgery are effective. However, it has higher mortality & morbidity than sacrospinous fixation (1) . The operation time and hospital stay is shorter in sacrospinous fixation than sacrocolpopexy with quicker recovery time. However she may complain of dyspareunia postoperatively. She can also be offered laparoscopic sacrocolpopexy (1) , uterosacral ligament suspension or sacrospinous fixation ? mentioned already if the surgeons are competent to perform these surgery. The recovery time is shorter with less blood loss and adhesions formation than open procedure. However it requires more advanced training for surgeons, longer surgical time (which should improve over time) and a higher risk of injury to ureter in uterosacral ligament suspension . If she is sexually inactive, declines shelf pessary but wants surgery under local anaesthetics, colpocleisis (1) is an effective surgery with low complications, which is usually reserved for frail patients. She should receive written information leaflets about all these choices. Good answer
Posted by PAUL A.
A/
I would take detailed history and effect of symptom on quality of life (1) . History of any provocative factors like chronic cough in chronic obstructive pulmonary disease healthy . Chronic constipation, presence of blood in stool. Any history of abdominal pain or swelling. Associated urinary symptoms like urinary incontinence (1) which should be taking into considertion during treatment. Vagina discharges not a sentence . I would ask her if she is sexually active wish to retain sexual function . Previous surgery including hysterectomy and any previous pelvic floor repair (1) .
Her BMI would be noted. Blood pressure measurement. Abdominal palpation for any mass (1) . Vagina examination would include, any area of excoriation, size of the prolapse objective assessment using POP-Q , ulceration, prolapse easily reducible. I would check for anterior and posterior vaginal wall prolapse. Any associated enterocele. Bimanual palpation for any adnexial mass. Urinary incontinence on straning (1) . Rectal examination would be performed.
B/
Treatment options would depend on the effect of the symptoms on quality of life, desire to maintain sexual activity, other major procedure to be performed, her wishes and expertise.
In a healthy woman, Abdominal Sacrocolpopexy (1) would be most appropriate option, because it is the most effective procedure, less likely to fail. It also gives opportunity to perform other necessary abdominal surgery. It is appropriate in a woman who wants to preserve are sexual activity greater morbidity .
Laparascopy Scarocolpoplexy (1) is equally effective like open surgery. Has advantage of quick recovery and less hospital stay, but it require equipments and expertise.
Vaginal Sacrospinous fixation (1) if there are other pelvic floor repair (1) lower morbidity. It require adequate vagina wall. It can be done where the woman can\'t withstand long operation time. There may be shortening and narrowing of introitus, which would not be appropriate if sexually active.
Total mesh reconstruction are newer procedure. It can be performed in unit where there is expertise. Colpocliesis is another procedure, by obliterating vaginal opening where sexul activity is not desire (1) .
If the woman declined surgery, pessaries can be used (1) . Shelf pessary more effective than ring pessary after hysterectomy. This would need to be changed every 6months (1) . There is risk of erosion, infection and not desirable if sexually active.
Information leaflet should be provided to enable woman make well informed decision.
Posted by PAUL A.
A sensitive approach is adopted to this lady of 87 years.Will ask of the effect of the lump on her quality of life and if affecting her walking and daily activities (1) .Will ask if lump is reducable when she lies on her back.Will ask of urinary problems like voiding problems,frequency,urgency and dysuria and burnining denoting urinary tract infection (1) ? incontinence.Will ask if had previous retention of urine that required urinary cathetrisation.Will ask of problems at defecation ,constipation and if she had to reduce the mass by hand to defecate (1) .Will ask sensitively regarding her sexual life ,if sexually active wish to retain sexual function and problems.Will ask if had previous repair of prolapse , hysterectomy (1) ,previous treatment of the condition and her satisfaction with the treatment.Will ask of any vaginal discharge, colour and smell. Bloody discharge taken seriously. Will ask of special habits like smoking frequency .
On examination will check BP ,body mass index ,check chest for wheezes if smoker(she is healthy), abdominal examination for abdominal mass (1) and palpate for a full bladder, do local examination to see nature of lump ,wether it is visible outside vulva or still in vagina, wether it is a cyst,a mass, tumour, prolapse(uterine or vaginal,cystocele,rectocele,enterocele or vault prolapse) objective assessment using POP-Q .Check if mass prolapsed contain the uterus.Would do rectal examination to differentiate between rectocele and enterocele.


B- Treatment will depend on the degree of vault prolapse, patient fitness for surgery,patient wishes and experience of the surgeon.
As patient is healthy ,then surgery can be the 1st line treatment option unless the patient decline surgery,in such case she can be fitted with a shelf pessary (1) if she is not sexually active. If she is sexually active she can be offered a suitable sized ring pessary.She told about care of pessary ,time to change(3-6months) (1) and need to be examined before application of another one.
Surgery in the form of plication of uterosacral ligaments offer a weak support for vault prolapse with risk of early recurrence , however the course of the ligament from the sacrum to back of cervix form the basis for recent sling operations, but this need surgical expertise.
Fixation of vaginal vault to ischial spine , sacrospinous fixation (1) ,offers a strong support to the vaginal vault and can be done unilaterally or bilaterally, but there is risk of bleeding or injury to the pudendal nerve.It has the advantage being a vaginal operation in women who decline an abdominal approach and in expert hands it can be an easy procedure with early post operative recovery for the patient (1) lower morbidity.It can be coupled with the use of mesh to support the base of urinary bladder and another to reduce a rectocele (1) .
The gold standard is sacro colpopexy (1) which is an abdominal operation using a mesh to attach vaginal vault to the sacrum anterior longitudinal ligament .It has a high success rate . Risks include,bleeding,infection, bowel injury and mesh erosion greater morbidity (1) .It can be used if surgical experience present and patient acceptability of an abdominal approach.
In patients who are not sexually active and who are surgical risk ,Le Fort ‘s operation can be done which is a colpocleisis (1) . The coapted walls of vagina will offer support to the prolapse. good answer
Posted by PAUL A.
a) Initial assessment of the patient includes a detailed history, examination an investigations as discussed below: waste of time & space. Clinical assessment does not include investigations
History should include besides the duration of symptoms,if the patient had undergone any surgery,if yes then for what indication,vault prolapse commoner after vaginal hysterectomy (1) than abdominal is this because of the primary indication for vaginal hysterectomy??? .If there is any urinary complain of hesitancy,urgency,difficulty in voiding,stress incontinence (1) ,patient needs to reduce the lump to void.If patient sexually active then any coital difficulty wish to retain sexual function .If there is any associated bowel compain like constipation ,she needs to strain at stools leading to increase chances of recurrence of prolapse.If the patient has chronic cough .If there is any distention of abdomen an associated ovarian cyst or ascites how would you assess these? would lead to prolapse.Detailed past medical history of patient,at 87 years patient could be suffering from range of medical disorders which could render her unfit or high risk for surgery HEALTHY
Examination includes noting the General condition including vitals ,chest and cardiovascular examination(Patient whether fit for surgery or not).Abdominal examination to see for abdominal scars , ascites,palpable lump (1) .Per speculum examination in left lateral examination would reveal lump in vagina.descent noted according to the POPQ classification (1) . A full bladder examination should be done to see for urinary incontinence (1) . Per vaginum examination would reveal any lump.
Investigations include Hemoglobin , TLC,DLC what are these?? , Urine examination routine microscopy,LFT,RFT,Blood sugar,Chest X ray,ECG,urodynamic studies with video cystometry.
b) Patient can be offered conservative treatment pessary -shelf pessary (1) could offered in sexually inactive women and who is unfit for surgery.Pelvic floor exercises donot have much role.Medical problems like cough , constipation need to treated.
These patients need specialist treatment at tertiary level hospitals.
.First and the foremost criteria to decide on the surgical therapy which needs to offered will depend on the expertise of the surgeon in the particular surgery.
Surgical treatment includes abdominal sacrocolpopexy with success rate of 93% (1) ,which could be offered to woman who would require a laparotomy any ways ie for any abdominal mass will this not be offered if laparotomy was not required for other reasons?? ,also if the woman is sexually active since the length and axis of the vagina is maintained .Laparoscopic sacrocolpopexy (1) needs to be to done by a surgeon with great expertise in laparoscopic surgeries,operating time required is much more than erquired for abdominal approach and increased chances of ureteric injuries. A vaginal approach is better if there is an anterior and posterior vaginal wall defect (1) also then sacrospinous ligament fixation (1) can be offered which has a success rate of 98% ?? higher than for sacro-colpopexy??? .There is lesser hospital stay,less blood loss associated with this but may cause increase in dyspareunia as vaginal axis is displaced.Also this requires that there should be good amount total vaginal length and vault diameter to reach the ischial spines.
If there is any contraindication to anaesthesia posterior intravaginal slingoplasty which has a success rate of 91% can be done under local anaesthesia,less operating time,less blood loss and is especially good for somebody who has had previous corrective surgeries.
Colpocleisis (1) can be offered to sexually inactive and those who are high risk for anaesthesia and have recurrent prolapse.
Vault suspension procedures are easier and can be offered but has a higher failure rate. Iliococygeus fixation should not be offered
Posted by PAUL A.
LEEN
A healthy 87 year old woman attends the gynaecology clinic with a 6 months history of feeling a lump in her vagina. (a) Describe your clinical assessment [8 marks]. (b) She is found to have a vaginal vault prolapse. Discuss the available treatment options indicating the circumstances when they will be recommended [12 marks].

(a) I would first ask about the effect of her symptom on her quality of life (1) , as well as asking about other associated symptoms such as bowel changes and urinary incontinence (1) , frequency, urgency or dysuria. Other associated symptoms that should be asked about includes bleeding, discharge and pain (including dyspareunia). I would also ask about whether there is any exacerbating factors you need to be specific – general statements like exacerbating factors do not earn marks .

I would want to find out about her parity and previous gynaecological history, including previous hysterectomy or prolapse surgery (1) in the past. I would also ask about whether she suffers from chronic cough or constipation, as these may make her symptoms of prolapse worse, even after treatment.

I would assess her body mass index - overweight patients are more at risk of prolapse and tend to have poorer rates of success for prolapse surgeries. I would also assess her prolapse whilst she is standing and lying down (using a sims speculum when appropriate) and straining down - and assessing her using an objective prolapse scoring system (1) like which one? The examiner may not award the mark when other candidates actually state an example like POP-Q. I would also ask her about whether she is sexually active and whether she would like to retain her sexual function (1) is this Hx or examination??? - as this would help in deciding/choosing the appropriate treatment for her.

(b) COnservative management does not improve her symptoms. Pelvic floor exercise is of undetermined value (1) . Ring pessaries may not be entirely helpful in the case of vaginal vault prolapse, as they tend to fall out. Shelf pessaries may help relieve her symptoms (1) but do not cure her prolapse. It will need to be changed every 4-6 months (1) but has the advantage of avoiding or delaying surgery with all its operative risks.

Sacrocolpoplexy (1) is an abdominal procedure and success rates are good. It is associated with operative risks of infections (including mesh infection), bleeding, damage to visceral organs and vessels (1) . Laparoscopic sacrocolpoplexy (1) is associated with lower morbidity but requires a surgeon skilled in laparoscopic surgery.

Vaginal sacrospinous fixation is associated with lower morbidity (1) and risks compared to sacrocolpoplexy, but has a higher failure rate (1) . It can also cause dyspareunia because the vagina may be tightened or shortened and its axis might be changed following this surgery.

Colpocleisis is quick to perform and the patient recovers quickly with low morbidity. However, it is only suitable for women who do not wish to retain she sexual function anymore (1) good answer. However, your history should be more specific .
Posted by PAUL A.
A healthy 87 year old woman attends the gynaecology clinic with a 6 months history of feeling a lump in her vagina. (a) Describe your clinical assessment [8 marks]. (b) She is found to have a vaginal vault prolapse. Discuss the available treatment options indicating the circumstances when they will be recommended [12 marks].

Sanchu
Her History would be to ask for how her symptom affects her quality of life (1) .
History of vaginal bleeding and discharge should be asked for which may indicate a decubitus ulcer or malignancy.
Urinary symptoms of urgency, frequency, nocturia, hesitancy, straining to void, poor stream and stress incontinence should be asked for (1) .
Any problem with her bowels-constipation or difficulty in defecation (1) incontinence should be enquired.
Other symptoms of chronic cough, need to lift weights eg handling her sick partner should be asked for.
Her Obstetric history may explain the etiology with high parity, big babies, instrumental deliveries predisposing to prolapse.
Surgical History -history of hysterectomy, surgery for prolapse should be obtained (1) .

Her examination would include abdominal examination to exclude any mass (1) . Pelvic examination to diagnose and assess the lump. It can be a cyst. But commonly, uterovaginal prolapse ,cystocoele, enterocoele and rectocoele. She must be examined in the L lateral position using the Sim\'s speculum and a POP-Q (1) quantification noted. The presence of vaginal atrophy and decubitus ulcers noted. The pelvic floor should be assessed. Any stress incontinence (1) after reducing prolapse should be objectively tested in a moderately full bladder.

B)Conservative management would be to reassure if it is mild and if she can cope with the symptoms.
She can also be given the option of vaginal pessary -in a vault prolapse in a 87 year old, a shelf pessary (1) would be ideal. She must be explained that it has to be changed every 6 months (1) and the complication of erosion. Estrogen cream can be prescribed twice a week with the pessary.
She can be given the option of Surgical management- Abdominal sacrocolpopexy (1) (Open or Laparoscopic (1) ) or Vaginal Sacrospinous fixation. There should be adequate length of the vagina for a possible sacrospinous fixation and it is easier to do all vaginally if she also has a cystocoele or rectocoele (1) anterior or posterior wall prolapse . The procedure is shorter with a lesser hospital stay and a slightly less success rate (80%) compared to abdominal sacrocolpopexy (1) (87%).It has the complications of increased bleeding and buttock pain.
Colpocleisis is offered if she is not sexually active (1) and high risk for surgery- can be done under local anaesthesia. good answer but you need more details, especially in part (b)
Posted by PAUL A.
A))
In initial clinical assessment, I will ask about any pressure symptoms she is having. I will enquire about impact on quality of life (1) . Any symptoms of having urinary incontinence (1) , chronic constipation or chronic cough should be enquired. Any episode of post menopausal bleeding or vaginal discharge is important to rule out possibility of malignancy. I will enquire about her obstetrical history, number and mode of deliveries, any history of previous surgeries which particular operations? Hysterectomy / prolapse surgery . I will ask about any history of similar complaints in past.
On examination, I would like to inspect vaginal mucosa and speculum examination with adequate lubrication to visualise the lump. I will check for any prolapsed uterus if present, any evidence of rectocele, entrocele or anterior vaginal wall prolapse. I will make objective assessment using POPQ system (1) . At the same time I will reduce the prolapse and check for stress incontinence (1) by making patient cough. I will check for perineal muscle tone and any defects. I will do abdominal examination to check any palpable mass (1) ? before pelvic examination. I will check for general fitness of patient by enquiring about any other medical condition and investigating her for full blood count, blood sugar levels, liver and renal function tests, ECG. Abdo-pelvic scan if required to rule out any abdominal or pelvic pathology. Thus my initial assessment is aimed to make clearer picture of the diagnosis of that lump along with patient’s suitability for surgical options.

B)) )
vaginal vault prolapse can be treated conservatively by using ring pesseries or by surgical correction. Ring pessery of appropriate size should be used after patient counselling. It is changed every six months. As it is foreign body, it may cause inflammation, vaginal discharge, and increased risk of infection. Many patients with mild grade prolapse can be successfully treated with this. Ring pessary is indicated in patients with underlying medical condition where operative option is with increased risk to life (1) shelf pessery better . The underlying cause such as chronic constipation or chest condition should be treated before any operative treatment. Role of pelvic exercise is questionable with aged women (1) . It may be helpful adjuvant to other treatments with younger women with prolapse.
Opertaive options are vaginal and abdominal surgeries. Anterior and posterior vaginal repair is usually inadequate. It may cause dyspareunia, shorting of vagina. Abdominal sacro-colpopexy (1) is most effective surgery in management of vault proplase but it has operative risks including injury to bowel, ureter or pelvic blood vessels. Too tight repair can cause intestinal obstruction. It is indicated in women who wish to conserve their sexual function and also indicated in women where there is inadequate length of vagina where vaginal repair is impossible (1) . Vaginal sacrospinous fixation of vault (1) lower morbidity and better if anterior / posterior wall repair also needed is indicated in patient who wishes to conserve their sexual function and has adequate vaginal length. It requires expertise and there is a risk to injury to pudendal vessels and nerves. Abdominal repair involving vault suspension to anterior abdominal wall is described in literature. It carries less morbidity as compared to sacral colposuspanion. But it changes the axis of vagina. It can be done only when there is good abdominal muscle tone. Colpocleisis is indicated in patients where conservation of sexual functions is not desired (1) . It can be done in woman with poor general health and high operative risk with other type of surgeries. Mesh repairs are suggested to repair defects but there is inadequate evidence. Laproscopic colpopexy (1) is equally effective to abdominal approach. It requires more expertise to operate by laproscopic route. Treatment options should be individualised and discussed with woman before recommending any particular option. The choice of woman is important.
Posted by PAUL A.
M GH
A healthy 87 year old woman attends the gynaecology clinic with a 6 months history of feeling a lump in her vagina. (a) Describe your clinical assessment [8 marks]. (b) She is found to have a vaginal vault prolapse. Discuss the available treatment options indicating the circumstances when they will be recommended [12 marks].

A
As the lump is 6 months ago, I will ask about the effect of lump on the quality of life (1) . I will enquire regard to aggravating and relieving conditions ? like what? of that protruded lump. As well as, I will ask about past obstetric history regarding operative vaginal deliveries and previous history of pelvic surgery like vaginal operations or abdominal hysterectomy (1) . Chest problems to be elucidated like chronic cough and wheezes along with GIT symptoms like chronic constipation. The associated urinary or bowel symptoms like what? You need to be specific with that lump to excluded.

Clinical examination include BMI, BP, Temp. Chest examination to rule out chronic obstructive pulmonary disease and asthma HEALTHY . Abdominal examination to find out hernias/ abdominal masses (1) .
Pelvic examination to determine site, size, shape, origin, consistency of the mass is mandatory YOU HAVE NOT EXAMINED HER PROLAPSE??? .

B.
The treatment options of vaginal vault prolapse will depend on the the general condition of the patient, sexual activity, severity of prolapse and the patient\'s wishes. the patient should informed that this is not a life threatening condition and if it does not affect the quality of life, and if she can cope with it no treatment. If she is unfit for surgery and unhappy with that lump , I will offer her ring pessary and explain how to use it and possible complication like infections and ulcers (1) shelf pessery better. If she is fit for surgery and sexually active I will offer her vaginal sling operation like sacrospinous fixation (1) . Colpocliesis (1) like Le Forte operation to be offered if she is not sexually active and the prolapse affect her life. Abdomial sacrocolpopexy (1) is another option for correction of prolapse but it necessitate good general condition. I will document the patient wishes in notes and take an informed consent regard to the option she want. I will provide her with written information leaflet. I will discuss the type of anaesthesia and analgesia in liaise with the anaesthetist. You need a more detailed answer – see good answers above
Posted by PAUL A.
A healthy 87 year old woman attends the gynaecology clinic with a 6 months history of feeling a lump in her vagina. (a) Describe your clinical assessment [8 marks]. (b) She is found to have a vaginal vault prolapse. Discuss the available treatment options indicating the circumstances when they will be recommended [12 marks].
a)my assessment would include details of the presenting complaint with its affection effect on the quality of life(QOL) (1) using disease specific QOL questioonnaires.symtoms enquiry would include severity of prolapse and associated symtoms, particularly related bladder (urgency, incontinence (1) (stress/urge), frequency and symptoms of UTI) and bowel(constipation). history of precipitating factors like chronic respiratory illness, constipation would be sought. sexual history of whether she is sexually active and the desire to retain sexual fuction (1) helps in deciding the type of corrective surgery. history of comorbidities like any medical illness (diabetes, hypertension, ischemic heart disease, ) HEALTHY will hint towards her surgical fitness. history of any surgical illness will help plan her surgery better. examination will include examination of the systems (CVS and RS ) determine fitness for surgery previous hysterectomy / prolapse surgery . a abdominal examination to rule of any abdominal mass (1) . local examination to determine the extent of prolapse, associated anterior and posterior vaginal wall prolapse the details of the findings would be documented according to the POPQ system (1) which will be more objective assessment and also help help in comparing the results of the surgery. total vaginal lenght and vault bredth should be noted down since adequate vaginal length is required if sacrospinous vault suspension is contemplated. i would also assess for any occult urinary incontinence, in full bladder with replacement of the prolapse with a pessary or sponge forceps (1) .
b)trearment options would depend on the desire to retain sexual function, surgical fitness of the lady,
conservative managemnt options include pelvic floor exercises and use of pessaries their usefulnesss is uncertain (1) including pesseries??. pessaries can be offered to women who are unfit or decline surgery. pessary could be either ring pessary or shelf perssaries. shelf pessary is more commonly used (1) and has to be changed every 6-8 months (1) . sexual intercourse is impossible with shelf pessary and cannot be offerd sexually active women. risks with shelf pessary include erosion, fistula formation and infection. surgical treatment options are between, abdominal sacrocolpopexy (1) and vaginal sacrospinous fixation (1) . women who are sugically fit and desire to retain sexual function and do not have anterior or posterior vaginal wall prolapse are ideal candidates for the abdominal sacrocolpopexy. it carries less recurrence rate (1) , less dysperunia, than sacrospinous fixation. hoeever the operative morbidity is more since its an open operation (1) and if there are anterior and posterior vaginal wall prolapse the it has to be repaired by a second vaginal procedure. laparoscopic sacrocolpopexy (1) can also be performed with equal success rates as open procedure with availability of the necessary skill. however one should be cautious while offering laparoscopic procedure since it requires long operating time. vaginal sacrospinous fixation is ideal for women who do not desire to retain sexual fuction and who on examination heve adequate vaginal length and vault breadth, and an associated anterior or posterior vaginal wall prolapse (1) (all can be corrected at the same time). sacrospinous fixation causes narrowing of vaginal and hence not preferable in women to would desire to retain sexual function. women are unfit for surgery and would forgo sexual function can be counnselled for colpoceisis (1) with either vaginectomy or curcumferential closure. uterosacral ligamnet fixation is also effective vaginal procedure but has th e risk of ureteric injury. total mesh reconstruction is a novel procedure and should not be offred outside research.

Excellent answer
Posted by PAUL A.
I will asses her on the basis of her symptoms by obtaining history, signs by objective demonstration of prolapse and relevant investigations not necessary – clinical assessment does not include investigations . I will ask her about the severity of symptoms affecting her quality of life (1) by a disease specific validated questionaire. I will inquire about urinary and fecal incontinence (1) , pain and ulceration which may indicate decubitus ulceration and severe prolapse. Though she is healthy I will still ask about any chronic illness like chest infection, chronic constipation and abdominal distention which indicates masses.I will review her previous operation notes for the type of hysterectomy as vaginal hysterectomy for uterovaginal prolapse (1) is associated with increased risk of vault prolapse 11.8% and is likely to be more severe as compared to hysterectomy performed for other causes 1.6% . I will ask about any previous treatment .
I will examine her B.P , abdomen for mass (1) arising from pelvis, do a vulval inspection for atrophy and ulceration .Degree of vault prolapse is assesed by pelvic organ prolapse quantification (POP-Q) (1) . It quantifies the exact prolapse of the apex of vault for more than 2 cm from the total vaginal length by taking plain of hymen as a fix point .Grading of prolapse is done by maximum tightning on coughing, maximum descent on traction or if women herself demonstrates it in a mirror.I will also asses any anterior or posterior compartment defects.Assesment of general health for anaesthetic fitness.If there are no urinary symptoms, no pelvic mass on abdominal examination and chest is clear bimanual pelvic examination is not indicated and no further investigations are offered are all pelvic masses palpable abdominally???(-1) .
(B) Available treatment options are Pelvic floor exercises for 3-4 months if the prolapse is mild but it is unlikely to be effective (1) . long inpatient admission and Physiotherapists assistance is needed why is admission needed for pelvic floor exercises? .
Vaginal pessary is an option in mild prolapse and in those women unfit for surgery.Ring or shelf pessary (1) is advised if perineum is defecient .There risk of infection, ulceration and expulsion.It needs to be changed every 3-4 months (1) .
Surgical options are Vault suspention procedures which can be done abdominally by a laparotomy or laparoscopically and through vaginal route. there is no evidence that one procedure is more effective than other this is not correct – see RCOG guidelines .Sacrocolpopexy when vault is fixed to the sacral promontry (1) anterior longitudinal ligament through prolene mesh.High cure rate .I will offer this operation to the women if she is fit for anesthesia , expectant management fails or women opts fot it. If she has bladder or rectal prolapse can be repaired at the same time vaginally is this an advantage? She will require abdominal + vaginal surgery .Associated complications are risks of hemorrhage during surgery, anesthetic complications and post op rectal prolapse.Sacrocolpopexy can be performed laparoscopically (1) if expertise are available.This procedure carries more complications than open one as risk of ureteric and bladder injury.
Sacrospinous ligament fixation .The angle of vault is fixed to the ileopectineal ligament if this is true, why is it not called ileopectineal ligament fixation?? usually unilateral.Causes vaginal distortion causing dysparunea in a sexually active women.It also increases risk of bladder prolapse however there is less risk of hemorrahge and ureteric injury.
Other procedures like vault suspension to the external oblique muscle apneurosis is an option to avoid risks associated with other ptocedures.
Vaginal procedures ??? .I will offer these procedures if women is unfit for surgery, not sexually active ,adequate vaginal length (1) and if women chooses this option.
Vaginal repair of anterior and posterior compartment defects along with reduction of enterocele is not going to affect her symptoms so not offered.
Vaginal sacrospinous ligament suspension under local or regional anesthesia is an option if there is adequate vaginal length .there is risk of ureteric injury..
Posterior intra vaginal sling procedures is another option in a frail women who is unfit for anesthesia and if expertise are available . as it can be performed under local anesthesia as a day case with quick recovery and short hospital stay.
Colpocleisis when there is deliberate closure of vagina with a purse string suture offered to frailwomen unfit for surgery and do not wish to retain sexual function

See excellent answer above
.
Posted by PAUL A.
ASK PATIENT about the discomfort and pain caused by the prolapse,how is it effecting her quality of life(QoL questionnare can be used) (1) .Ask about any bowel or bladder symptoms present which specific symptoms? ,any vaginal bleeding or discharge,any history of previous surgeries like hysterectomy,pelvic floor repair and bladder neck surgeries (1) .ask about the obstetric history particularly about her parity and any difficult deliveries.ask about presence of any comorbidities and any medication she is on you will not get marks for such vague statements .ask about history of cough and constipation.ask if she is sexually active and will she like to preserve her sexual capacity (1) .ask about history of HRT why?? .
do a general physical examination again, no marks for general examination – you must be specific ,assess her mobility and dextrility and check BMI.do an abdominal examination to look for any abominal /pelvic masses (1) which can cause prolapse.check for health of vaginal and vulval skin,note atrophy,any ulcers or any bleeding or discharge.Do PS examination and look for state of vaginal skin .look for vaginal vault.
check for presence of vault prolapse,any cystocele,any rectocele,general tone of pelvic muscles.
use POP-Q score (1) to grade vault prolapse and any cystocele or rectocele, if present.assess for vaginal lenghth and vaginal room at top(in case we go for sacrospinous fixation we will need enough room at the top of vagina).after reducing prolapse check for stress incontinence (1) .if patient has urinary symptoms or demonstate stress incontinence after reducing prolapse request for urodynamics.
One of the treatment options is sacrocolpopexy (1) .it is preffered option when patient has to undergo abdominal surgery for other reasons.patient needs to have general anaesthesia and inpatient hospital stay and a abdominal incision.it is assosiated with urinary track injuries,abdominal wall hernias (1) greater morbidity .sacrocolpopexy can be done laproscopically (1) but needs expertise and equipment and is assosiated with more urinary tract injuries and recurrence.it is not advisable.
sacprspinous fixation is advisable when patient needs other pelvic floor surgeries (1) also.if patient needs any bladder neck surgery for urinary syptoms like TVT it can be done at the same time.it can be done under regional or general anaesthesia.hospital stay is shorter ,recovery is quicker (1) .
it can cause buttocks pain to patient.patient needs to have good vaginal room for this surgery to be performed,which is sometimes difficult in old ladies.sexual functions are preserved.
colpoclesis can be offered in frial patients who cant tolerate other surgeries and who are not sexually active (1) .it can be done under local anaesthesia.it is a simple procedure with no major morbidities.patient needs treatment of any vaginal infection or ulcers before this procedure.
Vaginal pessary can always be an option for a patient who does not want any surgery and is happy to have it changed every 4-6 months (1) which type of pessery?.it is an option for patients not fit for surgery.
pelvic floor exercises will not treat vault prolapse (1) .
the options should be discussed with patient by a surgeeon who can offer her all these options.final decision depends on patients preferences.
Posted by PAUL A.
Sha
a)It is essential to take a history of her symptoms progression-any associated urinary symptoms like stress incontinence (1) or urgency as they need to be evaluated before deciding treatment for this lady.Also her papers should be reviewed for details of previous surgery ? hysterectomy / prolapse surgery -the indication and operative details like oophorectomy done or not.Also use of HRT ? why?? and details of which drugs used n duration as they could need modification before treatment for prolapse.Also any history of anti-hypertensive drugs used like ACE-inhibitors healthy woman which could cause chronic cough n prolapse.On examination her BMI should be assessed.Her general condition should be assessed like pulse,blood pressure and chest examination to rule out any chronic obstructive airway disease which could cause increased intra-abdominal pressure and prolapse.On abdominal examination,any mass (1) should be looked for as that could cause prolapse.On local examination,any vulval or vaginal atrophy should be noted as they need correction with local estrogens.Also descent of lump should be noted and presence of cystocele or rectocele use objective assessment like POP-Q . enterocele should be noted.

b)Management of vault prolapse is surgical with surgeries like abdominal sacrocolpopexy,sacrospinous fixation and Le-fort\'s repair that could be planned depending on the wishes of the lady.However if the risk of surgery and anaesthesia is more then conservative measures like vaginal pessaries which type of pessery? can be prescribed.
Abdominal colpopexy is the surgery with the best long term results (1) and thus should be preferred in women who are young.Also the vaginal axis does not alter and thus less dyspareunia and preferred for women who are sexually active .However this surgery is a major one involving complications (1) like wound infection,incisional hernia,hemorrhage,mesh erosion and bladder injury and thus not preferred in women who have co-existent morbidities and are elderly.sacrospinous fixation (1) is a vaginally done procedure with less morbidity (1) and thus suitable for the elderly as is a short procedure.Le fort\'s repair is obliteration of the vaginal canal in women who are elderly and not desirous of sexual function (1) as it has minimal morbidity and least anaesthesia exposure.Vaginal pessaries like ring and shelf can be prescribed (1) why did you have to write about pesseries twice? Waste of time / space but use of shelf pessary preclude sexual intercourse and these are reserved for the elderly and frail women unsuitablr for anaesthesia.However complications like erosion,infection and calification could occur with the pessary and thus needs medical attention will you change the pessery?

See excellent answer above
.
Posted by PAUL A.
M
(a) A history of lump in vagina may suggest a uterovainal prolapse but other history like of ulcer or bleeding should also be elicited to exclude alternative mass lesions that may suggest malignancy of uterovaginal region.
A history of quality of life (1) affected with a validated questionnaire like King\'s health questionnaire.
A history of bladder dysfunction or incontinence (1) with underlying pelvic organ prolapse should be elicited as may need additional investigations and or treatment.
A history of bowel symptoms like constipation may suggest underlying precipitating cause.
A past obstetric history e.g. difficult instrumental delivery, extended perineal tear may suggest contributory factors.
Past history of pelvic organ prolapse and treatment may suggest recurrance or new symptoms, A past history of hysterectomy (1) may also help to decide the current treatment option.
Her desire to maintain sexual capacity (1) should be obtained as this will help in her treatment options.
Her wishes and desire for treatment will form the mainstay of her treatment.
Her BP, BMI and her anaesthetic fitness for surgery should also be obtained, as she may need a surgical option for her treatment.
Abdominal examination to exclude pelvic mass (1) lesion as cause of pelvic organ prolapse.
Speculum examination using sims speculum with standardised tools like pelvic organ prolapse quantification (1) to assess the degree of pelvic organ prolapse.
Assess degreee of utero cervical descent may suggest need for vaginal hysterectomy along with pelvic organ prolapse repair and bimanual examination to exclude other mass lesions as cause of prolapse.

(b) Treatment options depends on quality of life affected, her choice and her fitness for surgery, expertise availability and include conservative options or surgical options.
If she is unfit for surgery or does not want surgical option then Do nothing with full explanation of her problem may be enough or alternatively a vaginal pessary more likely with shelf (1) rather than ring pessary with vault prolapse. This will need a change every 6-8months (1) . She should be explained the risks involved like calcium deposition, vaginal erosion and fistula And difficulty to maintain sexual intercourse with shelf pessary.
Abdominal sacrocoploplexy (1) is an effective operation for vault prolapse which can help to maintain vaginal capacity for sexual function, but it is subjective to patients surgical fitness.
She should be explained complications involved like haemorrhage, blood transfusion, mesh rejection the mesh is not an organ – how does it get rejected? .
Laparoscopic sacrocolpoplexy (1) is equally effective as abdominal but need expertise availability and risk of laparoscopic complications especially ureteric injury at sacrospinous ligament suspension.
Sacrospinous fixation (1) is an alternative to sacrocolpoplexy but may reduce the functional capacity of vagina but associated with less morbidity (1) with surgery compared with sacrocolpoplexy.
Sacrospinous fixation(SSF) also need adequate lenth of vagina to reach the sacrospinous ligament and can be done along with anterior and posterior vaginal wall repair (1) .
SSF has also complicatons like need for blood transfusion, bladder injury, rectovaginal haematoma and vaginal pain.
Her choices should be considered and full written information details provided. ? colpocliesis

good answer
Posted by PAUL A.
NSK
From A:
I’d enquire re severity of her symptoms and its impact on her QOL (quality of life) (1) . This can be assessed using validated QOL questionnaires such as The King’s Health questionnaire. Other associated symptoms such as bleeding, pain, presence of bowel and urinary symptoms are elicited. I’d specifically ask re urinary incontinence (1) , frequency or voiding difficulties which suggests anterior vaginal wall prolapse (cystocele) and defecation difficulties and constipation suggesting posterior vaginal wall prolapse (rectocele). I’d ask whether previous gynaecological surgery, specifically hysterectomy had been done (1) . If so, I’d review previous operative notes to assess whether preventive measures to reduce the risk of post hysterectomy vault prolapse had been performed such as Mc Call’s culdoplasty, prophylactic sacrospinous fixation (SSF) or suturing of the cardinal/uterosacral ligament complex to vaginal cuff with obliteration of the pouch of Douglas. Her sexual history to assess sexual activity and her desires to retain sexual function (1) will affect my treatment options. I’d also ask her treatment desires, whether she is keen for surgery or conservative management.
Examination involves assessing location of the lump per vagina, the length and width of the vagina and palpating the uterosacral ligaments to assess the degree of vaginal vault descent. I’d document the site, severity and degree of prolapse involved. This can be objectively quantified using the POPQ system (1) (pelvic organ prolapse quantification). I’d examine her in the left lateral position using a Simm’s speculum, then with her standing and straining to assess degree of prolapse and any associated urinary incontinence. If there is evidence of anterior vaginal wall prolapse, I’d reduce it using a sponge forceps/ pessary to exclude occult urinary incontinence (1) . I’d palpate the pelvic floor muscles for any defects abdo / pelvic examination for mass – you will not miss this if you were systematic .

From B:
Treatment will depend on the severity of prolapse, her sexual function and desires for treatment. Conservative options such as vaginal pessaries (ring/ shelf) are useful if she is keen to avoid surgery (1) . However shelf pessaries make sexual intercourse impossible and needs changing every 6-8 months (1) . There is also the risk of pessary expulsion, vagina erosion, ulceration, fistulae formation and incarceration. Hence it is more suitable if she is not sexually active. Ring pessary are more likely to fail if she has a deficient perineum, thus shelf pessaries are more suitable. Local estrogen can be used with them to improve atrophic changes.
Surgical options include abdominal sacrocolpopexy (SCP) (1) , an effective operation with lower recurrence rate, vaginal length preservation and maintains a physiological vaginal axis. Thus, useful if she were sexually active. However it is associated with greater morbidities (1) - bladder injury, incisional hernia, mesh rejection and wound infection. It can also be done laparoscopically (1) although it requires higher laparoscopic skills, has a risk of ureteric injury and longer surgery time. Abdominal approach is appropriate if she requires a laparotomy for other reasons. Sacrospinous fixation (SSF) (1) has a higher failure rate but lower morbidity (1) compared to SCP such as less bleeding risk, shorter recovery time and hospital stay. However, it requires adequate vaginal length and width to reach the sacrospinous ligament. A vaginal procedure is appropriate in presence of vaginal wall prolapse (1) , which can be repaired simultaneously. As deviation of vaginal axis occurs, it causes dyspareunia, vaginal shortening and narrowing especially when done with vaginal wall repairs. There is currently no evidence to recommend neither unilateral / bilateral fixation nor one procedure over the other. Uterosacral ligament suspension is effective, but carries a higher risk (upto 11%) of ureteric injury, bladder injury, UTI and bowel injury. It can be done either laparoscopically or vaginally. If she does not wish to retain sexual function, colpocleisis is an option (1) . Advantages include a shorter surgery time, lower risk of morbidity, a high success rate and can be done under local anaesthetics.

Good answer
Posted by PAUL A.
a) The most likely diagnosis is pelvic organ prolapse, the differentials would be bartholins cyst and malignancy. I would ask her whether the lump is constantly present and if she can reduce it (1) . If she has any vaginal or back pain associated with the lump. If she has noticed any bleeding or discharge. If she has any associated urinary symptoms such as frequency or incontinence (1) . I would enquire about bowel symptoms such as constipation or faecal incontinence (1) . If she has any history of a cough which may precipitate prolapse. I would enquire about her past obstetric history, number of pregnancies and birth weights. I would ask if any labour was long or difficul and whether she had any history of trauma to her anal sphincter. I would ask about any previous surgery such as hysterectomy (1) . I would assess her body mass index.
I would examine her abdomen for any masses (1) .
I would inspect the vulva for any lesions. I would ask her to cough to demonstrate stress incontinence (1) with prolapse reduced . I would perform a speculum examination to visualise the vaginal lesion or prolapse. I would assess the degree of the cervical descent and look for cystocoele and rectocoele. I would document this using POP-Q (1) . I would inspect the vaginal tissues for any evidence of atrophic vaginitis or ulceration. I would assess her pelvic masses. effect on QoL

b) I would explain my diagnosis to the patient and provide her with information leaflets. Treatment options should be disscussed with the patient and her wishes should be taken into account. Pelvic organ prolapse can either be treated conservatively or surgically.
Conservative options do not involve the risks associated with anaesthetic and can generally be accessed more rapidy. The are a good option for women who are unfit for surgery or who decline it for other reasons.
A ring pessary or shelf pessary (1) (if her perineum is deficient )could be insered which allows symptomatic relief but is not curative. This can be inserted immediately in clinic but requires 6 monthly change (1) . They may preclude sexual intercourse.
Formal training of pelvic floor exercises by a physiotherapist requires dedication and motivation and is not shown to be of benefit in vault prolapse (1) . Though, it has no adverse effects and may also improve other symptoms of pelvic floor dysfunction.
Choice of operation depends on the knowledge and skill of the surgeon and unit protocols. If previous prolapse surgery has been performed the patient should be referred to a tertiary referral centre. The greatest information available is on sacrocolpopexy (1) and sacrospinous fixation. Sacrocolopopexy can be performed either laparoscopically (1) or by laparotomy. The operation is lengthy with a higher blood loss and slower return to normal activity than sacrospinous fixation (1) . There are risks of haemorrhage, infection and damage to the bladder with both operations. Sacrocolpopexy is associated with recurrence of posterior wall prolapse and sacrospinous fixation with apical and anterior wall prolapse.
More recently sling procedures have been used, in which a synthetic mesh is inserted to support the tissues. There are associated risks of chronic inflammatory process and mesh rejection. If the vaginal tissue is atrophic there is the possibility of erosion. More research is required before these are routinely recommended.
Colpoclesis may be performed to close the vaginal and may be offered if the women does not wish to retain sexual function (1) . It is considered a safe and effective procedure.

Good answer
Posted by PAUL A.
a)
Assessment involves detailed history about aggravating factors like cough and constipation, relieving factors like reducibility on lying down position (1) is enquired. History of bladder disturbances like incomplete emptying, increased frequency, dysuria and bowel disturbance like incomplete emptying, delayed or difficult bowel opening is enquired (1) incontinence . Effect on quality of life (1) is assessed by disease specific validated QOL questionnaire. Sexual disturbance like dyspareunia and desire to retain sexual function is enquired (1) . Previous history of surgeries for benign conditions like fibroid uterus, dysfunctional uterine bleeding or surgery for incontinence is enquired (1) ? prolapse surgery. Personal history of smoking is asked.
On examination, BMI is checked, chest auscultation for signs of chronic obstructive airway disease, Per abdomen any pelvic or abdomen mass (1) is palpated. Genital examination for identifying degree of uterine descent and ant and post vaginal wall defects. Objective assessment is done by pelvic organ prolapse quantification (1) with women in left lateral position at rest and at maximal valsalva manouver.Assess for occult stress incontinence after reducing prolapse (1) and with full badder but evidence is not validated and the role of prophylactic surgery is not clear.
Investigation includes FBC, EKG, chest x-ray, Urine microscopy for evidence of infection, Ultrasound for post void residual urine and urodynamic studies, Intravenous urogram if ureteric obstruction is suspected.
b)
Conservative management includes pessary treatment, Ring or Shelf is commonly used (1) . It is indicated in women who are not sexually active,physically frail women,unfit for surgery or it is declined. needs to be changed every 6-8 months (1) to prevent vaginal wall ulceration.complication includes erosion and fistula formation on long term use. There is no evidence for role of pelvic floor exercises.
Surgical treatment are; Abdominal sacrocolpopexy (1) ? laparoscopic indicated in sexually active women, undergoing laparotomy for other reasons still appropriate if laparotomy is not otherwise needed . it has lower rate of recurrence and less dyspareunia. associated with long operating time, slower return to activity, high cost,complications like bladder injury, incisional hernia mesh rejection, wound infection (1) . Sacrospinous fixation (1) suitable for physically frail women because of morbidity (1) lower morbidity associated with abdominal surgery.It requires adequate vaginal length and width.
It has got high recurrent vaginal prolapse (1) and recurrent stress incontinence rate. complication includes blood transfusion, bladder injury vaginal pain and rectovaginal hematoma.There is no role to recommend uniateral or bilateral sacro spinous fixation, ileo coccygeous fixation is not recommended.Choice depends on circumstance and surgeon should be experienced in both procedures.
Uterosacral ligament fixation is effective but has got risk of ureteric injury. Anterior and posterior vaginal wall repair along with obliteration of enterocele sac is inadequate for vault prolapse and is associated with dyspareunia. Colpocleisis is effective procedure suitable for women who do not want to retain sexual function (1) . It is done under local anesthesia, short operating time.
Laparoscopic colpopexy is effective as open colpopexy, has advantage of shorter hospital stay, quick recovery, less complication. It requires expertise and long operating time.
Sling procedure not used with out adequate cunselling.
women has to be provided with written information about the pros and cons about each procedure and women wish is considered in deciding the appropriate treatment.

EXCELLENT ANSWER
Posted by PAUL A.
RnRn

A.
Information on how the symptoms affect her quality of life (1) (ie merely worried, significant discomfort, dyspareunia) may determine approach of treatment. Additional symptoms such as difficulties in passing stools or voiding, incomplete emptying, frequency or even stress or urge incontinence (1) may affect management, as will presence of exacerbating factors (chronic cough in smoking, constipation). If there are sinister symptoms such as post-menopausal bleed or post-coital bleed this warrants further investigation and smear history is essential. Previous gynaecological (prolapse) surgery (1) hysterectomy would affect choice for current surgical management and alters success and complication rates.
Examination includes blood pressure & pulse rate and height & weight for BMI. Abdominal palpation may reveal a pelvic mass (1) . Vulval inspection to assess presence of prolapse and leaking on straining (1) after reducing prolapse. Any abnormal skin lesions must be noted, as well as atrophic mucosa on subsequent vaginal assessment. Vaginal assessment with Sims speculum both left lateral and in supine position with the knees flexed and feet on the examination couch to assess degree of prolapse conform POP-Q score. (1) Vaginal examination to confirm findings on speculum, assess pelvic floor muscle tone and presence of any pelvic masses. If present, uterus can be assessed for descent and size to see whether vaginal hysterectomy is possible.

B.
Vault prolapse is common after previous hysterectomy, especially if done for prolapse complaints. If patient is mainly worried and symptoms are mild, not compromising quality of life, reassurance with conservative management and general life style advices such as avoiding constipation, constipation and losing weight if obese may be all that is needed. Pelvic floor exercises won’t improve prolapse (1) , but are useful as (additional) treatment for those who have associated complaints of stress incontinence. A (ring) pessary is useful (1) shelf pessery – ring pessery will not normally interfere with intercoursein those not keen for surgery, though it interferes with intercourse and needs to be changed every 3-6 months. Medical management (anticholinergics) is only applicable as parallel treatment in those suffering urge-complaints simultaneously or after repositioning of prolapse with a pessary, though side effects like nausea & constipation may limit its usefulness no mention of urge incontinence in the question – is there an association between vault prolapse and urge incontinence??? . Those not keen for conservative management or ring pessary, or those in who this approach fails or who are not keen to try non-surgical management first can be counseled for surgery. Abdominal sacropexy and vaginal sacrospinous fixation (1) have similar risks NO – SUCCESS RATES AND RISKS ARE DIFFERENT. One is a vaginal operation and the other is abdominal – risks cannot be similar!!! ; bleed, infection, accidental damage to bowel or bladder. Abdominal sacropexia has more comorbidity how does this tie in with risks being similar?? with additional risk for erosion of mesh and requires longer surgery & recovery, but has less long term recurrence (13%) (1) . Sacrospinous fixation can additionally cause pain in the buttock, which is mostly transient though, and may cause more discomfort on intercourse. Recurrence can be as high as 25%. Nevertheless comorbidity is less with shorter operating time ??? , and it may be an attractive approach if additional repair such as anterior or posteriol wall need to be done (1) . An alternative abdominal approach is by means of using endogenous rectus sheath tissue to create a suspension. This procedure is relatively simple, but as there is paucity on long term data, counseling on its use is difficult. Finally colpocleisis (1) is a procedure which due to its nature is only suitable for women who do not wish to remain sexually active. Hence this procedure is more suitable for frail women not fit to undergo major surgery, as it is a relatively simple procedure.

you lost marks by being careless
Posted by A H.
a) My assessment of this patient will include a subjective assessment of her quality of life. I would ask about the effect of the prolapse on her ability to mobilise and perform normal daily activity. She would be asked about associated urinary incontinence, urgency, fequency or voiding difficulties as well as bowel symptoms including constipation, incontinence of faeces or flatus, and vaginal or anl digitation.
I will enquire about medical conditions like chronic cough and arthritis as well as diabetes, hypertension and cardiac disease.These will help to plan appropriate treatment and anaesthesia.
I would also like to know if she had a hysterectomy and whether this was for prolapse or another reason. She would be asked about previous continence surgery or pelvic floor repair. sexual activity and her desire to retain same will be explored.
Objective assessment of her quality of life (QoL) will be done using a validated QoL questionnaire.
Her cardiovascular and respiratory systems would be examined. A brief survey of her skeletal system will be done to assess degree of joint mobility. Her abdomen will be examined for masses or ascites.
A pelvic examination will be done to assess the presence or absence of the uterus and if present, its size position and mobility.
The pelvic floor will be examined toidentify defects.The integrity of the vaginal epitheleum,and the presence of anterior or posterior wall defeccts will be sought. Pelvic organ prolapse will be objectively assessed. Vault prolapse will be graded using the pelvic organ prolapse quantification.
She will be assessed for urinary incontinence with a full bladder following reduction of any anterior wall prolapse with a pessary

b)Managemet of vaginal vault prolapse can be conservative or surgical.
Conservative management involves the use of a shelf or ring pessary for reduction of the prolapse. This is suitable for a frail woman, one who is unfit for surgery or one who declines surgery.
It must be changed every 6 to 8 months in order to prevent incarceration, erosion of the vault , ulceration or fistula formation.
There is a risk of expulsion which is greater if there is pelvic floor weakness. The shelf pessary may be more useful than the ring but its main disadvantage is that the woman will not be able to have sexual intercourse. The lole of pelvic floor exercise for vault prolapse is not certain. Local estrogen therapy is not useful either except to improve the texture of the vaginal epithelial and aid healing if surgery is done.
Surgical procedures include abdominal sacrocolpopexy,( open or laparoscopic), or vaginal sacrospinous fixation. Sacrospinous fixation is associated with less post-operative morbidity than open sacrocolpopexy but has a higher failure rate. Although this is a healthy 87 year old the vaginal approach will result in earlier recovery and may be better suited. The complications include bladder injury, rectovaginal haematoma and bladder pain. It is necessary that the vagina be of adequate length and vault width so that the sacrospinous ligament can be reached. It causes shortening and acute retroversion of the vagina making intercourse uncomfortable. It is associated with an increased incidence of anterior vaginal wall prolapse.
The complications of open sacrocolpopexy include bladder injury, wound infection, incisional hernia and mesh rejection. Laparoscopic sacrocolpopexy is associated with less blood loss, shorter hospital stay, and shorter recovery time. However it is only available if there is an appropriately skilled surgeon. If an experienced skilled surgeon is available, the operation time may be much less and therefore this may be the operation of choice if this patient want to preserve sexual function.
Colpocleisis is a relatively short procedure with less complications and blood loss than the other two. However it is only appropriate if she does not wish to preserve sexual function
Ileo-coccygeus fixation is not recommended and vaginal uterosacral ligament fixation is associated with ureteric injury which can engender significant morbidity and will only be offered if the expertise is available and wil only be offered with caution.



Posted by mm S.
a) I will take history including the duration of her symptom and associated symptoms like abdominal pain and backache . presence of any vaginal discharge & its characteristic .i will enquire about her past obstetric history identifying risk factors like the number of vaginal deliveries and the need of operative delivery . gynecologic history of menopause and any past operations & the route for her hysterectomy and the reason and check any record of the operation .i will ask about urinary symptom like frequency , urgency and incontinence and any difficulty in defecation .In the examination I will check if there is any ulcerations and any vaginal infection and chech signs of estrogen deficiency and evaluate her prolapse using 9 point scale and the presence of any associated anterior or posterior cele . I will do rectal examination and check anal sphincter tone . investigation include FBC ,MSC,U&E,vaginal swabs,LIVER FUNCTION .
B) options include surgical and non surgical interventions . non surgical interventions like pessaries ,shelf pessary is ideal for vault prolapsed and ring pessary could be used in case any ulceration present . this could be used in short term awaiting surgery or healing of any ulcers or long term use according to her preference or if she is unfit for surgery . surgical interventions like vaginal sacropexy or abdominal sacropexy and in fragile patient vaginal lefort procedure under local anaesthesia .
Posted by Maayka ..
maayka

(a) A history would be elicited to determine if this lump noticed was reducible or not and if it is seen especially on standing or straining and if there is and associated problems encountered with sexual activity. An assessment of this problem on her quality of life will be noted as well as any other symptoms, particularly relating to urinary incontinence, frequency or urgency as she may have an underlying urological problem. If there is a problem with defaecation then it will suggest a posterior wall prolapse. The presence of any per vaginal bleeding may suggest an ulcer on the lump or another source of bleeding requiring further investigations. Her sexual function and desire to retain such will be of relevance with respect to treatment options. A surgical history of a previous hysterectomy will suggest the possibility of a vaginal vault prolapse. Any previous procedures for incontinence or anterior/posterior repairs will be noted.
General examination will take note of her general well being and mobility and then of her blood pressure, body mass index , as these will help decide treatment options. Abdominal examination should look for any palpable masses and a possible full bladder. Pelvic examination should be done with a full bladder to check for stress incontinence and, using the Sim’s speculum in the supine and modified left lateral position, to check the vaginal walls for prolapse. The vaginal walls will be inspected for ulcers, which should be treated before further options offered.

(b) Conservative options available are pessaries , either ring or shelf. The shelf pessary precludes sexual activity and requires changing every 6 months to avoid the risks of erosion, calcium deposition, fistula formation. It is to be used for the rest of the patient’s life if she declines surgery or is unfit. It can be used in the interim, while awaiting surgery. The ring pessary is not always a good option because the perineum is weakened and therefore unable to hold it in place. Pelvic floor exercises has no role for vaginal vault prolapse.
Surgical options are mainly the abdominal sacrocolpoplexy and the vaginal sacrospinous fixation(VSF). Both these allow sexual function to be maintained. The abdominal sacrocolpoplexy can be done especially if the patient is found to have another indication for the laparotomy route. It is generally done on fit patients because it has a higher perioperative morbidity and is done under general anaesthesia. It is not the first option if there is a co-existing anterior/posterior wall prolapse but the mesh can be extended to facilitate this repair. It involves a longer hospital stay and recovery period as opposed to the next option (VSF). VSF is a good option if there is co-existing wall prolapse and has the option of being done under local anaesthesia in frail patients. It is associated with less operative morbidity than abdominal sacrocolpoplexy and shorter hospital stay but greater occurrence of vaginal pain and dyspareunia.
These operations can also be done laparoscopically but an experienced surgeon should be performing it as there is an increased risk of injury to the ureters. This route has reduced operative morbidity.
Colpocleisis is an option which is available for women who do not wish to retain sexual function. It is a short procedure with reduced morbidity and can be done under local anaesthesia if required.
Posted by PAUL A.
a) My assessment of this patient will include a subjective assessment of her quality of life impact on. Are there more ‘objective’ tools you can use? . I would ask about the effect of the prolapse on her ability to mobilise and perform normal daily activity. She would be asked about associated urinary incontinence (1) , urgency, fequency or voiding difficulties as well as bowel symptoms including constipation, incontinence of faeces or flatus, and vaginal or anl digitation (1) .
I will enquire about medical conditions like chronic cough and arthritis as well as diabetes, hypertension and cardiac disease healthy – the examiner is telling you there will be no marks for this .These will help to plan appropriate treatment and anaesthesia.
I would also like to know if she had a hysterectomy (1) and whether this was for prolapse or another reason. She would be asked about previous continence surgery or pelvic floor repair. sexual activity and her desire to retain same will be explored (1) .
Objective assessment of her quality of life (QoL) will be done using a validated QoL questionnaire (1) .
Her cardiovascular and respiratory systems would be examined. A brief survey of her skeletal system will be done to assess degree of joint mobility. Her abdomen will be examined for masses (1) or ascites.
A pelvic examination will be done to assess the presence or absence of the uterus and if present, its size position and mobility.
The pelvic floor will be examined toidentify defects.The integrity of the vaginal epitheleum,and the presence of anterior or posterior wall defeccts will be sought. Pelvic organ prolapse will be objectively assessed how? . Vault prolapse will be graded using the pelvic organ prolapse quantification (1) you can get this across using fewer words .
She will be assessed for urinary incontinence with a full bladder following reduction of any anterior wall prolapse with a pessary (1)

b)Managemet of vaginal vault prolapse can be conservative or surgical.
Conservative management involves the use of a shelf or ring pessary (1) for reduction of the prolapse. This is suitable for a frail woman, one who is unfit for surgery or one who declines surgery.
It must be changed every 6 to 8 months (1) in order to prevent incarceration, erosion of the vault , ulceration or fistula formation.
There is a risk of expulsion which is greater if there is pelvic floor weakness. The shelf pessary may be more useful than the ring but its main disadvantage is that the woman will not be able to have sexual intercourse. The lole of pelvic floor exercise for vault prolapse is not certain (1) . Local estrogen therapy is not useful either except to improve the texture of the vaginal epithelial and aid healing if surgery is done.
Surgical procedures include abdominal sacrocolpopexy,( open or laparoscopic (1) ), or vaginal sacrospinous fixation. Sacrospinous fixation (1) is associated with less post-operative morbidity than open sacrocolpopexy but has a higher failure rate (1) . Although this is a healthy 87 year old the vaginal approach will result in earlier recovery and may be better suited. The complications include bladder injury, rectovaginal haematoma and bladder pain. It is necessary that the vagina be of adequate length and vault width so that the sacrospinous ligament can be reached. It causes shortening and acute retroversion of the vagina making intercourse uncomfortable. It is associated with an increased incidence of anterior vaginal wall prolapse.
The complications of open sacrocolpopexy include bladder injury, wound infection, incisional hernia (1) and mesh rejection. Laparoscopic sacrocolpopexy is associated with less blood loss, shorter hospital stay, and shorter recovery time. However it is only available if there is an appropriately skilled surgeon. If an experienced skilled surgeon is available, the operation time may be much less and therefore this may be the operation of choice if this patient want to preserve sexual function.
Colpocleisis (1) is a relatively short procedure with less complications and blood loss than the other two. However it is only appropriate if she does not wish to preserve sexual function
Ileo-coccygeus fixation is not recommended and vaginal uterosacral ligament fixation is associated with ureteric injury which can engender significant morbidity and will only be offered if the expertise is available and wil only be offered with caution. Very good answer
Posted by PAUL A.
a) I will take history including the duration of her symptom and associated symptoms like abdominal pain and backache . presence of any vaginal discharge & its characteristic .i will enquire about her past obstetric history identifying risk factors like the number of vaginal deliveries and the need of operative delivery . gynecologic history of menopause and any past operations & the route for her hysterectomy part (a) did not state she had a hysterectomy and the reason and check any record of the operation .i will ask about urinary symptom like frequency , urgency and incontinence (1) and any difficulty in defecation .In the examination I will check if there is any ulcerations and any vaginal infection and chech signs of estrogen deficiency and evaluate her prolapse using 9 point scale which 9 point scale? and the presence of any associated anterior or posterior cele . I will do rectal examination and check anal sphincter tone . investigation include FBC ,MSC,U&E,vaginal swabs,LIVER FUNCTION clinical assessment does not include investigations .
B) options include surgical and non surgical interventions . non surgical interventions like pessaries ,shelf pessary (1) is ideal for vault prolapsed and ring pessary could be used in case any ulceration present . this could be used in short term awaiting surgery or healing of any ulcers or long term use according to her preference or if she is unfit for surgery . surgical interventions like vaginal sacropexy is there such an operation?? or abdominal sacropexy and in fragile patient vaginal lefort (1) procedure under local anaesthesia . You have to earn 10 marks – where did you expect the examiner to award these marks? You should have read the topic before attempting the question. See good answers above
Posted by PAUL A.
maayka

(a) A history would be elicited to determine if this lump noticed was reducible or not and if it is seen especially on standing or straining (1) and if there is and associated problems encountered with sexual activity. An assessment of the effect of this problem on her quality of life (1) will be noted as well as any other symptoms, particularly relating to urinary incontinence (1) , frequency or urgency as she may have an underlying urological problem. If there is a problem with defaecation what type of problem? then it will suggest a posterior wall prolapse. The presence of any per vaginal bleeding may suggest an ulcer on the lump or another source of bleeding requiring further investigations. Her sexual function and desire to retain such (1) will be of relevance with respect to treatment options. A surgical history of a previous hysterectomy will suggest the possibility of a vaginal vault prolapse. Any previous procedures for incontinence or anterior/posterior repairs will be noted (1) .
General examination will take note of her general well being and mobility and then of her blood pressure, body mass index , as these will help decide treatment options. Abdominal examination should look for any palpable masses (1) and a possible full bladder. Pelvic examination should be done with a full bladder to check for stress incontinence (1) and, using the Sim’s speculum in the supine and modified left lateral position, to check the vaginal walls for prolapse. The vaginal walls will be inspected for ulcers, which should be treated before further options offered use POP-Q to assess prolapse .

(b) Conservative options available are pessaries , either ring or shelf (1) . The shelf pessary precludes sexual activity and requires changing every 6 months (1) to avoid the risks of erosion, calcium deposition, fistula formation. It is to be used for the rest of the patient’s life if she declines surgery or is unfit. It can be used in the interim, while awaiting surgery. The ring pessary is not always a good option because the perineum is weakened and therefore unable to hold it in place. Pelvic floor exercises has no role for vaginal vault prolapse.
Surgical options are mainly the abdominal sacrocolpoplexy (1) and the vaginal sacrospinous fixation(VSF). Both these allow sexual function to be maintained intercourse may be painful with vaginal procedure . The abdominal sacrocolpoplexy can be done especially if the patient is found to have another indication for the laparotomy route. It is generally done on fit patients because it has a higher perioperative morbidity (1) and is done under general anaesthesia. It is not the first option if there is a co-existing anterior/posterior wall prolapse but the mesh can be extended to facilitate this repair. It involves a longer hospital stay and recovery period as opposed to the next option (VSF). VSF is a good option if there is co-existing wall prolapse (1) and has the option of being done under local anaesthesia in frail patients. It is associated with less operative morbidity (1) than abdominal sacrocolpoplexy and shorter hospital stay but greater occurrence of vaginal pain and dyspareunia.
These operations can also be done laparoscopically (1) but an experienced surgeon should be performing it as there is an increased risk of injury to the ureters. This route has reduced operative morbidity.
Colpocleisis is an option which is available for women who do not wish to retain sexual function (1) . It is a short procedure with reduced morbidity and can be done under local anaesthesia if required. Very good answer
Posted by PAUL A.
A good answer should include the following

(a)
History
• Clarify nature of symptoms – worse with standing / straining; relieved by lying down (1 mark)
• Effects on quality of life (1 mark)
• Urinary symptoms – incontinence, incomplete voiding, voiding difficulties (1 mark)
• Bowel symptoms – incontinence, difficulty emptying rectum (1 mark)
• Sexual history and desire to retain sexual function (1 mark)
• Previous gynaecological history especially hysterectomy / prolapse surgery (1 mark)

Examination
• BMI. Abdominal – abdominal mass (1 mark)
• Speculum examination: objective assessment of prolapse using POPQ (1 mark)
• Assess for stress incontinence after reducing prolapse with full bladder (1 mark)
• Pelvic examination – pelvic mass (1 mark)

(b)
Treatment options

Non-surgical options
• Pelvic floor exercises – no evidence for efficacy. May be used in women who want to avoid surgery but maintain sexual function. Unlikely to be effective (1 mark)
• Pesseries – ring / shelf: ring pessery likely to be expelled in women with deficient perineum. Sexual intercourse not possible with shelf pessery. (1 mark)
• Should be reserved for women who are unfit / decline surgery or while awaiting surgery. Need to be changed every 6-9 months (1 mark)

Surgical options

• Abdominal sacro-colpopexy – effective operation.. Major abdominal surgery suitable for a relatively healthy woman (1 mark)
• May require additional vaginal procedure if woman also has anterior / posterior vaginal wall prolapse (1 mark)
• Sacro-spinous fixation – suspends vault from sacro-spinous ligament. Associated with higher failure rate compared to sacro-spinous fixation (1 mark)
• However, vaginal procedure with lower morbidity therefore suitable for women who are unfit for laparotomy (1 mark)
• Allows simultaneous vaginal wall repair and therefore more appropriate in women with anterior / posterior wall prolapse (1 mark)
• Laparoscopic sacro-colpopexy may be undertaken if expertise is available (1 mark)
• Colpocleisis may be used in frail women who do not wish to retain sexual function (1 mark)

Ref: The management of post-hysterectomy vaginal vault prolapse. RCOG green-top guideline # 46. Oct 2007. http://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT46PosthysterectomyVaginalProlapse2007.pdf
adasd Posted by PAUL A.

adas