Information
Pelvic organ prolapse is defined as the symptomatic descent of one or more of:
the anterior vaginal wall, the posterior vaginal wall, the cervix or uterus, or the apex of the vagina (vault or cuff scar after hysterectomy).
The vagina can be considered as having anterior, posterior and apical compartments.
Common symptoms:
• Vaginal heaviness and bulge
• Bladder and bowel difficulties (may include incomplete emptying, urgency, frequency)
• Discomfort that may be felt vaginally, abdominally and may include low back pain.
Some 20–40% of all women will experience prolapse symptoms that may be bothersome and affect their quality of life. Treatment for pelvic organ prolapse should start with non-surgical (conservative) management options that may include: pelvic floor muscle training, lifestyle advice, a vaginal pessary to support the prolapse; and if indicated, vaginal (topical) estrogen for post-menopausal women. Nonsurgical management options may be used in combination to maximise a reduction in symptoms.
Surgical treatment may also be offered with the aim of restoring the vaginal anatomy. If the prolapse symptoms are not very bothersome, a woman may choose neither management option, and instead, wait to see if her symptoms worsen or improve.
Vaginal pessaries are used intravaginally to try to restore the prolapsed organs to their normal position and relieve symptoms.
Please see Primary Care Management for advice on the management of vaginal prolapse and the fitting of a ring pessary.
If conservative measures are not satisfactory (see Primary Care Management), refer to Gynaecology routinely via Sci Gateway to consider alternative management.
Please note that NURSE-LED hospital pessary clinics are only for reviews and not for new referrals due to capacity issues – NEW PATIENTS SHOULD BE REFERRED TO GENERAL GYNAECOLOGY and will be seen within a GENERAL GYNAE clinic.
Management of vaginal prolapse
Advice for both symptomatic and asymptomatic cases:
- Good pelvic floor engagement – Advice +/- Referral to Women’s Health Physiotherapy via SCI Gateway. See Urogynaecology – RefHelp (nhslothian.scot) for more information.
- Constipation – Avoidance / Effective management
- Healthy weight – Weight loss if indicated +/- Referral to the Adult Weight Management Service. See Weight Management Service Adult – RefHelp (nhslothian.scot) for more information.
Further measures are only indicated if the prolapse is symptomatic:
• Typical prolapse symptoms : Feeling a bulge or a dragging sensation with discomfort
• Pain or dyspareunia – not usually caused by prolapse – consider topical estrogen if postmenopausal
• Urinary symptoms – may often co-exist but rarely directly caused by a prolapse
→ Please refer to advice regarding management of urinary symptoms (Urogynaecology – RefHelp (nhslothian.scot)
For management of prolapse symptoms, offer vaginal pessary (independent of age, sexual activity, degree of prolapse)
• In primary care, a ring pessary may be tried (compatible with sexual activity / suitable for self-management)
Fitting a vaginal ring pessary
The correct pessary is the smallest device that does not fall out and is comfortable. Patients should be unaware of their pessary and be able to void normally after a pessary has been fitted.
It is not uncommon to take a few attempts before establishing the correct size (trial and error).
The pessary is to be placed between posterior fornix and behind the pubic bone without compressing the urethra. There should be a little space between the pessary and the back of the pubic bone.
To decide the size of pessary, the following are relevant:
- Vaginal length (between posterior fornix and pubic bone)
- Vaginal width (especially width of the vault)
- Size of introitus / Perineal support
- Large introitus / poorly supported perineum limit the usefulness of ring pessaries
- Small introitus limits the size of pessary that can be inserted (especially when self-managed) – insertion should not cause significant discomfort
- Smaller introitus / good perineal support favour pessary retention – pessary does not need to fill the vagina to be retained
Vaginal pessaries require to be removed and replaced at regular intervals (every 6 months unless self-managed) – pessary neglect increases risks of complications
UK Clinical Guideline for best practice in the use of vaginal pessaries for pelvic organ prolapse:
https://www.thepogp.co.uk/_userfiles/pages/files/resources/uk_pessary_guideline_final_april21.pdf
