In Clinical

Follow this topic

Bookmark

Record learning outcomes

Technician Vicky is in the consultation room with Corinne Palmer who has asked to speak to her in private.

“I don’t quite know how to say this, but… a bit of me seems to be falling out,” says Corinne, blushing.

“Do you mean down below?” asks Vicky.

“Yes,” replies Corinne. “I’m so embarrassed to have to say this, but yes, I can feel – and even see – something bulging out of my vagina.”

Vicky patiently and gently questions Corinne further, finding out that she’s up to date with her smear tests but that she is experiencing some leakage of urine when she sneezes or exercises, and has noticed a little bit of pain during sex. Corinne is clearly worried, as well as self-conscious, and eventually asks the question that has clearly been uppermost in her mind: “Is it cancer?”

Answer

From what Corinne is describing, it seems likely that she has a pelvic organ prolapse, in which one of the organs in the pelvis (the womb, bowel, bladder or top of the vagina) slip from their usual position and bulge into the vagina. The condition is not life-threatening but can cause a sensation of heaviness or dragging in the pelvic area, continence issues, bulging into and sometimes outside the vagina, and discomfort and numbness during sex. In some cases it is asymptomatic and is instead discovered during an internal examination, such as a cervical smear test.

Corinne needs to see her GP, requesting a female doctor (or chaperone if only male physicians are available), as she needs an internal pelvic examination. She may also be asked to provide a urine sample to exclude a urinary infection as she is complaining of stress incontinence. If the diagnosis of prolapse is confirmed, the type will be identified and the severity classified, with one regarded as relatively minor and four being quite severe. Both are important as they help determine which treatment is the most appropriate. Options include: topical oestrogen, pelvic floor muscle training, vaginal pessaries and various surgical procedures.

Lifestyle measures can also help, notably losing weight if body mass index (BMI) is higher than it should be, stopping smoking, tackling a chronic cough, getting any constipation under control, and avoiding heavy lifting and high-impact exercise such as trampolining. Pelvic floor exercises – sometimes referred to as kegels – can also help improve symptoms, particularly in terms of reducing urine leakage.

The bigger picture

The embarrassment many women feel about gynaecological matters means that many do not seek medical help for prolapse, which means it is difficult to put a figure on how many individuals experience it. However, according to the Royal College of Obstetricians and Gynaecologists, it seems to be extremely common, with around half of women over 50 having some symptoms and one in 10 having had surgery for it by the age of 80 years.

Prolapse occurs because the pelvic floor – ligaments and muscles that hold the lower abdominal organs in place – becomes weak. The most common reason for this is pregnancy and childbirth, particularly if the baby was large, or labour was prolonged or culminated in an instrumental delivery, but the menopause, being overweight, constipation, prolonged heavy lifting, persistent coughing and a hysterectomy can all contribute. 

Extend your learning

• Find out about the different types of prolapse by reading the relevant section of the Royal College of Obstetricians and Gynaecologists leaflet
• What is meant by an instrumental delivery?
• Remind yourself of the BMI scale
• If you haven’t come across them before, vaginal pessaries for prolapse can look eye watering. Read about the different types, when each is used and the risks they pose in a leaflet produced by the Brighton and Sussex University Hospitals NHS Trust
• Take a look at the video and leaflets on pelvic floor exercises published by the Chartered Society of Physiotherapy
• The use of mesh for vaginal wall prolapse has been in the news following safety concerns
• Find out what NICE has to say about the the use of mesh for vaginal wall prolapse.