Mrs. B is a 58-year-old woman who presents with a 3 year history of urinary urgency and frequency as well as a dragging sensation in her private parts, exacerbated by straining. Examination reveals stage 3 uterine prolapse and stress urinary incontinence. She seeks treatment for worsening symptoms interfering with her daily activities and sex life. Management options discussed include pessary, hysterectomy, hysteropexy or sacrocolpopexy surgery given her symptomatic uterine prolapse and stress incontinence.

1. Case Scenario
 Mrs B, a 58 year-old postmenopausal lady complains of a feeling of
'dragging‘ sensation over her private parts for the last 3 years. Recently she
has noticed a mass appearing at her introitus every time she strains or
when she opens her bowels.
 She also complains about urinary urgency and increased frequency for
almost 3 years. This urinary problem has restricted her outdoor activities.
 She has had 4 vaginal births, the last birth being complicated by shoulder
dystocia 15 years ago.
 She seeks for your assistance for the current problem which worsening and
quite troublesome to both sexual life and work.

2. • There is evidence of urinary incontinence during
cough reflex.
• A mass of atrophied cervix is seen about 2 cm from the
introitus
• There is no discharge or ulcer
• The vaginal mucosa is thin and dry
• After reduction of mass – the cervix is 6cm from the
introitus; the total vaginal length is 8cm, mild anterior
and posterior wall prolapse, vaginal tone is 3/6 with 4 cm
width of genital hiatus and 1 cm perineal body.
EXAMINATION

3. STAGE 3 –
Uterovaginal Prolapse (UVP)
with SUI

4. UteroVaginal
Prolapse with Stress
Urinary Incontinence
(SUI)

5. Uterine Prolapse
is the downward displacement of the uterus into the vaginal canal or a
gradually descends of the uterus in the axis of the vagina taking the
vaginal wall with it.
Urinary Incontinence
the unintentional loss of urine. Stress incontinence happens when physical
movement or activity — such as coughing, sneezing, running or heavy
lifting — puts pressure (stress) on your bladder.
Stress incontinence is not related to psychological stress.
Definition

7. Various termiologies have been used to classify the UV
prolapse according to POP-Q system
 Stage 0:no descent of pelvic organ during straining
 Stage 1:leading surface of prolapse descends up to 1 cm
above the hymen ring
 Stage 2 :leading surface of the prolapse descents up to
the point 1 cm below the hymen ring
 Stage 3:descent s beyond the stage 2 but without
complete vaginal eversion
 Stage 4 :the vagina is completely everted and the fundus
of uterus lies below the introitus of the vagina

8. First degree prolapse

9. 3rd degree prolapse

10. 4th degree prolapse

13. Presenting Complaint
• Dragging sensation. This is worse with standing or straining (cough,
defecation) and relieved by lying down
• Urinary symptoms
 Stress incontinence may be present if there is descent of the bladder
neck associated with cystocoele.
 Might complaint incomplete emptying of the bladder – predisposes to
UTI and over flow incontinence
• It may interfere sexual function
• Uterine descent can give symptoms of backache
• Can cause bloody, sometimes purulent or discharge as it rubs on the
patient’s clothing
• Bowel symptoms: Incontinence

14. Examination
1. Local examination
2. Sims’ speculum examination
i. Should be performed in the left lateral position to exclude
a vaginal wall prolapse
ii. Conversely, if the anterior vaginal wall is retracted, then
an enterocoele or retrocoele will be seen
3. Bimanual examination
4. Bonney’s stress test
5. Evaluation of tone of pelvic muscles
6. Position of patient for examination
i. standing & straining
ii. dorsal lithotomy

15. Investigations
• This is a clinical diagnosis so there are few relevant investigations. If the
patient has urinary symptoms the following would be appropriate
1. Mid-stream urine specimen
2. To look for a cause consider a PELVIC ULTRASOUND if a pelvic
mass is suspected.
3. Urodynamic testing is required if urinary incontinence is the principal
complaint. It assesses how the bladder and urethra storing and
releasing urine
• To assess fitness for surgery
1. ECG
2. CXR
3. FBC
4. Renal function

17. Management (for this case)
• Pessaries
• Not completed family yet
• Prefer conservative management
• Medically unfit
• Surgical treatment
• Uterine prolapse –
• Vaginal hysterectomy
• Hysteropexy
• Vaginal vault prolapse
• Sacrocolpopexy
• Sacrospinous fixation
• Surgery for urodynamic stress incontinence
• Tension-free vaginal tape (TVT)
• Trans-obturator (TOT) procedures.

18. preventive measures:
• Early visits to HC provider = early detection
• Teach Kegel’s exercises during PP period
preoperative nursing care:
• Thorough explanation of procedure, expectation and effect on future
sexual f(x)
• Laxative and cleansing edema (rectocele) – independently, at home a
day prior procedure
• Perineal shave prescribed also
• Lithotomy position for surgery
postop nursing care:
• Pt. is to void few hours after surgery; catheter if unable (after 6 hrs)
Collaborative Care