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MRCOG PART 2 SBAs and EMQs

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ESSAY 150 - PROLAPSE

Posted by Sarwat F.
Management of a 70 years old woman who presents with vault prolapse after hysterectomy will include history, examination, investigations and treatment either conservative or surgical.

In history she will be asked about the duration of symptoms, quality of life, use of HRT, any predisposing factor like chronic chough, constipation, use of certain medications like steroids and smoking. Occupational and social history will be asked. Reason for hysterectomy will also be asked. She will be asked about any associated urinary and bowel complaints like frequency of micturition, urgency and stress incontinence. She will be asked about past medical history of any chronic illnesses like diabetes mellitus, hypertension. Sexual history will be asked if she is sexually active or not.

Examination will be done including general physical examination. Abdominal examination will be done to check for any abdominal mass or ascites. Vaginal examination will be done to check any coexisting cystocele or rectoenterocele.

Various options for managing vault proplapse include conservative management and surgical procedures. Conservative management includes advice regarding weight reduction, stopping smoking, use of local estrogens to improve conditions of tissues, treating predisposing factors like cough constipation by giving anti tussives and laxatives. Pelvic floor exercises can also be advised but they are of limited value. Another measure is insertion of a vaginal pessary. Conservative measures are advised to women who are not medically fit or with minimal symptoms. Both ring and shelf pessaries can be used however a shelf pessary provides a better control. Side effects of pessary include expulsion, infection and ulceration.

However there are surgical options also which are more effective than pessary insertion. As she is healthy which means that she is medically fit, she can be offered surgical procedures. These include colporrhapy, colpectomy and colpocleisis, abdominal sacrocolpopexy, transvaginal sacrospinous colpopexy and abdominoperineal procedure,.

Of these colporrhaphy is not very successful and is associated with recurrence of symptoms and dysperunia although it is a quite simple procedure with quicker postoperative recovery.

Colpectomy and colpocleisis are preferred if woman is not sexually active. Colpocleisis (le fortes procedure) is preferable in older patients as it can be done under local anaesthesia. It involves high dissection of prolapsed tissue and placation of uterosacral ligaments with their attachment to vaginal vault for support. It has a risk of injury to bowel and ureters with 10 to 15 % risk of stress incontinence.

Both abdominal sacrocolpopexy and transvaginal sacrospinous colpopexy have success rate greater than 90 %. Abdominal sacrocolpopexy involve the use of a mesh to fix vagina to sacral promontory. It is associated with risks of anaesthetsia and surgical hazards of laparotomy, hemorrhage from presacral vessels . infection of mesh used, postoperatively stress incontinence may occur. Another abdominal procedure is sling operation in which both vaginal apices are attached to the rectus sheath but this changes the anatomy.

Vaginal rocedures are devoid of risks of laparotomy with reduced operating time. Another benefit is that concurrent repair of cystocele and rectocele can be undertaken. Vaginal procedures are associated with less postoperative pain and quicker recovery. However they are certain risks which include damage to pudendal nerves and vessels, sciatic nerve, infection and postoperatively chronic pelvic pain and failure.

For abdomino perineal procedure an abdominal and a vaginal surgeon are required. Levator muscle is sutured together in the midline between the rectum and vagina with 3 to 4 sutures and vaginal vault is sutured to the superior surface of the levator plate lateral to the rectum on right. Its success rate is also greater than 90%.

Certain laparoscopic procedures can be undertaken which include laparoscopic sacrocolpopexy, however long-term success rate are yet unknown.

Woman will be provided written information regarding various treatment options.

Posted by Nibedita R.
Management of this woman will depend on severity of symptoms, its effect on the quality of life, associated symptoms and impairment of sexual life.

A detail history including predisposing factors like chronic cough or constipation. Urinary frequency, urgency or incontinence may indicate associated cystocele. Bowel symptoms: Feeling of incomplete emptying, need for vaginal splinting to achieve complete evacuation and bowel incontinence may indicate associated rectocele. Difficulty in walking indicates a greater degree of prolapse. Type of hysterectomy performed and any concurrent repair operation should be asked. Previous vaginal operation may indicate scarred vagina and a difficult dissection involved.

Physical examination: including examination of chest (if chronic cough). Abdominal examination: to detect aggravating factor like mass or ascites. Vaginal examination: to assess the degree of prolapse and associated cystocele/rectocele. Mobility of paraurethral vagina, especially if incontinence surgery has to be done as part of her treatment.

Investigations performed will depend on associated symptoms. Chest-X ray if there is chronic cough. In the presence of urinary symptoms or presence of cystocele, MSU must be sent for microscopy culture and sensitivity. Urodynamic study is indicated in the presence of urinary incontinence.

Treatment will depend on degree of vault prolapse, associated symptoms, associated cystocele or rectocele and patients wishes for treatment.
Treatment of cough and constipation with antitussive and laxative will improve her symptoms. Associated urinary infection should be treated with appropriate antibiotics; this improves urinary symptoms and also reduces postoperative morbidity. Abdominal mass if detected has to be dealt with accordingly.

If degree of prolapse and/or symptoms are mild and the patient is not opting for surgical treatment, pessary can be offered. Ring pessary is easy to insert or remove and is less likely to produce vaginal ulceration. Shelf pessary may produce better control of symptoms if lax perineum.

Operative treatment is offered if symptoms are severe. Simple repair procedure involves excision of hernia sac at the vault and correction of cystocele or rectocele by anterior or posterior repair. Less surgical morbidity, although a poor success rate. Causes shortening and narrowing of vagina and dyspareunia in sexually active woman.
Sacrospinous ligament fixation is another vaginal operation. Technically difficult and requires surgical expertise. Can be done bilaterally, although fixation of vaginal vault to one sacrospinous ligament carries equal success rate (90%). Does not compromise size of vagina and associated cystocele and rectocele can be repaired concurrently. Risks involve deviation of vagina, haemorrhage from pudendal artery injury, pudendal nerve damage, stress incontinence and recurrence.
High dissection of enterocele and plication of uterosacral ligaments with their attachment to vaginal vault carries risk of injury to bowel and ureter with risk of stress incontinence.
Sacrocolpopexy is an abdominal procedure in which vault is anchored to the anterior longitudinal ligament of 1st sacral vertebra with non-absorbable mesh or fascial sling.
Success rate upto 90-95% and also increases functional length of vagina. Risks include bleeding from injury to presacral vessels, graft infection, erosion of vagina/ bowel, stress incontinence (10-30%) and backache. This operation can be performed laparoscopically, with the advantages of minimal access surgery. Associated with high failure rate and risks inherent to laparoscopy such as bladder and bowel injury.

Combined abdomino-perineal procedure with more anatomical repair has equal success rate (90%), but requires more time and two surgeons.

In Le-Forts colpocleisis operation, vagina is obliterated by purse-string suture. Simple operation and can be performed under LA. Drawback is recurrence and is only suitable if intercourse is not intended.

All the procedures, their advantages-disadvantages and success rate should be discussed with the patient to take an informed consent and should be supported with information leaflets.





Posted by narmin B.
In order to make a decision about the best method of the management in this patient, taking a history, examination and investigation are required.

A detailed history should be taken. Severity of prolapse and type of symptoms are important in planning the management. She may have urinary incontinence which needs investigation and treatment. Also symptoms like constipation, cough and weight gain can affect the severity of prolaspe and should be treated if present. Other habits like smoking can have adverse effect on her symptoms. Sexual activity is also should be asked as some of he surgical treatment is not appropriate in sexually active women. Also enquiry about availability of someone to look after her in the case of surgical treatment should be asked. Her wishes about surgical or non surgical treatment also must be noticed.

A general and gynaecological examination is required to assess general health and severity of prolapse and suitability for surgery. Blood pressure should be taken as hypertensive diseases is common in this age. Cardiac and respiratory auscultation may reveal an undiagnosed medical condition. Abdominal palpation is necessary for presence of any abdominal mass or ascites as this may predispose for prolapse. A genital examination is also necessary. Degree of prolapse should be assessed. Accessibility of the vagina for vaginal operation should be noticed. Stress incontinence can be demonstrated during the examination. Bimanual examination must be performed to identify any pelvic mass.

Type of Investigations depends on the findings in the history and examination. If a medical condition was discovered during the examination appropriate investigations and consultation with other specialists should be arranged. In the presence of urinary incontinence MSU and blood glucose are required. Urodynamic studies is required if there are urinary incontinence and surgical treatment is considered. An ultrasound or CTscan may be required to assess any abdominal masse. If the plan is surgical treatment, blood tests such as blood group, FBC, U&Es LFT are necessary.

Management depends on the severity of symptoms and patient?s wishes and availability of the expertise for performing the surgery.

Non-surgical management is suitable she has mild symptoms, refuse to have surgical treatment or the degree of prolapse is small. This starts with reduction of weight, stopping smoking, treatment of constipation and cough. These measures reduce the pressure on the pelvic floor and improve symptoms however is unlikely to cure the problem. Similarly pelvic floor exercise is unlikely to treat the vault prolase but is effective if there is associated urinary incontinence. Insertion of a ring or shelf pessary can be helpful in mild to moderate forms. But pessary needs to be changed regularly and can cause vaginal erosion. Hormone replacement therapy is not an effective treatment for prolapse but can cure the concurrent vaginal atrophy. In the case of non surgical management follow-up appointment should be arranged to monitor improvement of her symptoms.

Various types of surgical management can be discussed if other methods of treatment fail. Posterior repair is unlikely to improve vault prolapse but is helpful in treating associated rectocele. The operation has fewer complications and most surgeons are familiar with the technique. Colpocleisis approximates the anterior and posterior vaginal wall and closes vaginal canal and therefore is suitable if the woman is not sexually active. The success rate is about 50 %and has fewer complications. Sacrospinous colpopexy is suitable if there was good vaginal access. It fixes the vaginal vault to the sacrospinous ligament. Success rate is about 90% and common complications are back pain and detrusor instability. Sacro colpopexy is fixing the vaginal vault to the anterior surface of the sacral promontory, by using a mesh. Success rate is about 90% and complications are infection, back pain and detrusor instability. This woman should be counselled thoroughly about different methods and leaflets should be provided.
In the case of surgical management follow-up appointment is necessary to ensure the cure and to deal with complications.

Posted by Sonali G.
Incidence of vault prolapse after VH for prolapse is 12% and other indications is 2%
Management depends on associated symptoms, associated clinical findings and her wishes.
History of chronic cough or constipation is enquired which may be the constant factor aggravating the condition. Associated symptoms of urinary incontinence, urgency or other urinary symptoms are asked. History of incomplete defecation or dyschasia can suggest associated rectocele. Indications of vaginal hysterectomy and her previous notes are reviewed to look for any intraoperative or post operative complications that may affect the treatment decision.
.Per abdomen examination is done to rule out any masses. Speculum examination is performed to look for any associated cystocole, rectocele and also to assess the degree of vault prolapse. If she is complaining of incontinence, mobility of paraurethral vagina is also assessed. Internal examination is done to feel for any masses.
Investigations mainly is directed by symptoms and clinical findings. If she is complaining of urinary incontinence MSU is done to rule out UTI and then urodynamic studies are done because surgery may unmask any detrusor instability and if stress incontinence is present it needs to be treated too. Pelvic scan is done to exclude any pelvic masses. FBC U&E, LFT are done as baseline for preoperative assessment.
Treatment depends on her wishes and expertise and resources available. Conservative treatment in the form of physiotherapy and HRT will not be helpful. Ring pessary may not be helpful due to lax vaginal support. Instead shelf pessary might be helpful.

Surgical treatment can be in the form of abdominal or vaginal surgery. Vaginal sacrospinous fixation can be done bilaterally but unilateral can suffice with success rate of 80-90%. But it is associated with complications of pudendal nerve injury, vessels injury, sciatic nerve injury, dysparunea and chronic pelvic pain. If there is associated cystocele or rectocle it can be corrected at the same time.
Simple repair (post colporrhaphy) causes narrowing of vagina and may cause dysparunea.
McCall culdoplasty (uterosacral vault suspension) in presence of entererocele has 80% success rate but it carries the risk of injury to bowel and ureters and also risk of stress incontinence.
Colpocleisis is an option but it closes the vagina & so intercourse is not possible also there is high risk of recurrence.

Abdominal procedure in the form of sacrocolpopexy has a high success rate (93-98%) which involves funnelling of sling between anterior longitudinal ligament of s1 vertebrae to vaginal vault. Cystocele and rectocele can be corrected at the same time but there is the risk of injury to presacral vessels, urinary incontinence or infection of the graft. Laparoscopic sacrocolpopexy can be done but training is important. Combined abdominal perineal repair gives more anatomical repair but needs two surgeons.
New techniques like intravaginal sling plasty is a day care procedure but it needs further evaluation.
If she has a prolapse and stress incontinence, colposuspension should also be considered.
Associated symptoms of cough and constipation should be treated and advise to stop smoking and weight reduction is given along with any form of treatment..
Posted by Iman B.
Vaginal vault prolapse may occur in as much as 18% of patients following hysterectomy. It is due to relaxation of uterosacral and Mackenrodts ligaments, and usually associated with other pelvic wall defects as enterocele, rectocele, or cystocele.
In addition, many patients may also have somevoiding difficulties, as urge or stress incontinence, or retention of urine.
A history taken from the patient should include asking questions whether patient has constipation, or difficult defecation, requiring splinting, symptoms of urge or stress incontinence. History of previous pelivic surgeries, or endometriosis is also important as it will help in deciding the type and route of the operation, since vaginal approach is far more difficult if there are adhesions, and immobility of the uterus.

It is very important to note whther ot not the patient is sexually active as certain procedures may shorten the vaginal vault leading to dyspareunia.
The patient should undergo a urodynamic study with the prolapse reduced to diagnose any underlying voiding problem, sometimes the ureters will become kinked especially with moderate and severe prolapse and this will necessitate either an IVP or renal ultrasound scan to identify any deleterious effect on the kidneys. It at times becomes necessary to insert a ureteral stent prior to any surgical management of the prolapse.
An abdomino pelvic scan will identify any intrabdominal mases which may have precipitated the prolapse in the first place.
A complete urine analysis should be done to identify infection as a cause of urge incontinence if present.
A pessary may be used, to hold up the vaginal vault, and used indefinitely, it will require the use of hormone replacement therapy to prevent ulceration of the vagina by improveing its health, there is some degree of discomfort however, and the patient may find difficulty in inserting it, as well as it might not stay in its place due to a gaping vaginal introitus.
Many women if they are healthy may opt for surgical intervention.

Before any surgical operation the cystocele, rectocele, or enterocele must be diagnosed and an operation to correct the defects in the pelvic fascia performed. This will obviate the need to reoperate.
Taking HRT before the operation will improve the health of the vaginal tissues, and so improve the outcome of the procedure.
If the prolapse is mild then a simple iliofascial fixation may be done. In moderate cases of vault prolapsea sacrospinous fixation either unilaterally or bilaterally may be performed, the unilateral has a good satifaction rate, is easier to perform and will require a shortening slightly of the contralateral part of the vaginal to prevent occurrence of de novo rectocele from occurring. Bilateral sacrospinous fixation will require more invasive maneuvers, and will require the mobilisation of the rectum, it gives similar results, to the unilateral but requires more expertise.
Sacrospinous fixation requires great care to avoid the pudendal nerves and vessels, pain in the perineal region and buttocks is one side effect which usually resolves after a fw months.
If sacrospinous fixation or any other previous prolapse surgery fails then patient may be offered an abdominal colposuspension. It is also very useful if the patient wishes to maintain sexual function. Abdominal colpopexy has twice the success rate of sacrospinous fixation. A non absorbable Y saped mesh strengthens the hold on the uterosacral ligaments. One of its main complication is heavy bleeding, another problem is necrosis or infection of the mesh which will require reoperation and replaced.

If the patient is not sexually active then total colpoceisis may be performed, this very simple operation will have a decreased morbidity though it will mean no longer being able to try to visualise and screen when necessary to exclude for example vault cancer.
Posted by SWATI M.
Management depends upon the severity of symptoms,associated symptoms and if any medical disorder.
History regarding duration of her complaints,vaginal discomfort,effects on quality of life is taken into account.Precipitating factors such as chronic cough , constipation,prolong steroid use is enquired.Urinary symptoms such as frequency ,incontinence,urgency and bowel symptoms such as incontinence,sensation of incompete emptying is enquired as it may be associated .Sexual history should be taken into account as it influences treatment Examination including blood pressure (at this age hypertension is likely), chest examination if chronic cough,abdominal examination for any abdominal mass (may be precipitating cause).For assessing degree of prolapse she may need to be examined in supine and then standing position if prolapse is not evident.Examine with full bladder to demonstrate stress incontinence if history is suggestive.Look for any associated cystocele,enterocele,rectocele.
Investigations include chest X-ray if chronic cough,MSU if urinary symptoms and urodynamic studies for incontinence.FBC,blood sugar,ECG done for anaesthetic fitness if surgery is planned along with arrangements for anaesthetist review.
Treatment of precipitating factors such as chronic cough or constipation should be done. Conservative measures such as weight reduction,pelvic floor exercises or pessaries may be adviced but have limited benefit.These methods are adviced if woman is not medically fit for surgical procedure and have mild symptoms.
Surgical options include coaptation of uterosacral ligaments and reattaching vaginal vault to it by vaginal route.It is a simple,relatively less painful and quick recovery than abdominal procedures but technically difficult to identify uterosacral ligaments , involves risk of ureteric damage and can cause dyspareunia
Transvaginal sacrospinous fixation involves fixation of vaginal vault to sacrospinous ligament.Success rates are 90% with unilateral fixation .But it has risk of injury to pudendal vessels causing haemorrhageand pudendal nerve.Also increased risk of developing cystocele and stress incontinence and likely to have dyspareunia.
Another option is abdominal sacrocolpopexy during which vault is attached by mesh to anterior longitudinal ligament over sacral vertebrae 1&2.It has lower recurrence and dyspareunia than vaginal sacrospinous fixation and success rates are 90-95%.Stress incontinence may occur in 30%,risk of damage to venous plexuses and pelvic nerves.Mesh erosion or infection can occur and bowel adhesions or obstruction can occur if careful peritonisation not done.This procedure can be performed laparoscopically with advantages of minimal access surgery but involves inherent risk of visceral ,vascular injury ,need surgical expertise and long term results are not yet available.
In Le-fort?s colpocleisis vagina is obliterated.It is a simple procedure ,can be done under local anaesthesia but suitable only if intercourse is not intended.
Woman needs to be conselled about available options,provided with written information and her wishes are taken into consideration regarding her management.