ABDOMINAL AND BACK PAIN
83-year-old woman complains of a dragging sensation in the
lower abdomen and lower back pain when
standing or walking. It has been
present for some
years but she
can now only stand
for a short time before
feeling uncomfortable. It is not noticeable at night.
She has had four vaginal
deliveries. She had her menopause at 52 years
and took hormone-replacement
therapy for several years for vasomotor symptoms. She has not had any
postmenopausal bleeding and has not had a smear for several years.
is generally constipated and sometimes finds
she can only defecate by placing her fin-
gers into the vagina and compressing a ‘bulge’ she can feel. She has mild frequency
and gets up twice
most nights to pass urine.
There is no dysuria or haematuria. Occasionally she does not get
to the toilet
in time and
leaks a small
amount of urine,
but this does
not worry her unduly.
Medically she is very well and does not take any medications regularly. She lives alone and
does her own shopping and housework.
examination she appears
well. Blood pressure
and heart rate are normal.
She is of average build. The
abdomen is soft
and non-tender. There
is a loss of vulval
anatomy con- sistent with atrophic changes.
On examination in the supine
position there is a mild pro-
lapse. On standing, the cervix
is felt at the level
of the introitus. There is a large posterior wall prolapse and a minimal anterior
What is the diagnosis for her discomfort and pain?
How would you manage this patient?
diagnosis is of second-degree uterovaginal prolapse with rectocoele. Prolapse is trad- itionally categorized according to the level
of descent of the cervix
in relation to the
first degree: descent within
second degree: descent to the introitus
third degree: descent of the cervix
outside the vagina
procidentia: complete eversion of the vagina
outside the introitus.
More complex grading systems
are used by some specialists that involve specific
measure- ments using the hymen as a reference
Common presenting symptoms are of ‘something coming down’, a ‘lump’ or a dragging sensation. Symptoms are always
worse on standing
or walking because
of the effect of gravity. Prolapse is more common
in women who
are parous, have
had long or traumatic
deliveries, have a chronic
cough or constipation. However it may occur in any woman, even if
she is nulliparous, as it relates to collagen strength.
Initial management involves treating
the constipation with dietary manipulation and laxatives. This
may relieve some
of the symptoms and is also
important to prevent
recur- rence if surgery is to be performed.
Pelvic floor exercises are helpful for mild prolapse
and to preserve the integrity
of repair postoperatively, though in this case they are unlikely
to make any significant difference to the presenting symptoms. If surgery is not wanted
then she can try a ring pessary
to hold up the prolapse, which
can work extremely well and only needs replacing every 6 months.
Although she is 83 this woman
has no medical
problems and should
be offered definitive prolapse surgery
which for her involves vaginal
hysterectomy and posterior vaginal wall repair (colporrhaphy). As there is no abdominal incision involved, recovery
is quick and she
would expect to be in hospital for around 3 days.