Investigation of prolapse symptoms

EXAMINATION

General examination should include fitness for surgery. Abdominal examination should be performed to exclude an intra-abdominal mass. A bimanual pelvic examination or ultrasound should exclude a pelvic mass and delineate the size of the uterus and ovaries if present.

The patient should be examined in the horizontal position, conventionally in the left lateral position with a Sims speculum. If prolapse is not evident, even with a Valsalva manoeuvre, the patient should be examined in the upright position. It is important to reproduce the symptoms and signs with which the patient presents. If this is not possible a further examination may be required. Many women are only aware of their symptoms after a long period in the upright position. An early morning clinic appointment may preclude detection of the prolapse. Some clinicians examine women in the lithotomy position. This enables closer inspection of vaginal supports, particularly if looking for site-specific defects in the endopelvic fascia. A second retracting instrument will be required to do this to visualize the lateral sulci.

The POPQ examination (see p. 498) gives an objective record of the prolapse stage.

URODYNAMICS STUDIES

If there are no urinary symptoms urodynamic studies are not justified outside the research setting. If a woman has significant urinary symptoms urodynamics may help define the cause of the symptoms which will enable the gynaecologist to give some prognosis for treatment. Hence, if urodynamics indicate obstructed voiding there is a good prognosis for surgical repair of the cystocoele resolving the voiding dysfunction while if the urodynam-ics suggest the bladder is atonic the prognosis is less favourable. If urodynamics indicate that the bladder is overactive then it is unlikely that surgery will improve the urinary symptoms. This may influence a woman's decision on whether to proceed with surgery.

The development of stress incontinence is an irritating sequel to anterior vaginal wall repair in some women. Some clinicians perform a urinary stress test with the prolapse reduced either digitally with a sponge forceps or a ring pessary. There is no evidence that this technique reliably predicts which women will develop stress incontinence after surgery.

PROCTOGRAPHY

An anterior rectocoele may result in obstructed defaeca-tion. Rectal mucosal prolapse may also result in obstructed defaecation and will not be apparent on vaginal examination. Proctography can give some insight into factors which may be contributing to difficulty with defaeca-tion and may help avoid unnecessary, unhelpful vaginal operations.

MAGNETIC RESONANCE IMAGING

Magnetic resonance imaging has been used as a research tool to try to identify prolapse not clinically evident. It has not been proved to aid or improve treatment outcome to date.

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