Childbirth may so injure a patient's pelvic organs that her uterus, her bladder, or her rectum may prolapse, either singly, or in combination. If her bladder or urethra prolapse as a cystocele, the standard operation is an anterior colporrhaphy. If her rectum prolapses, it is a posterior colporrhaphy. If her uterus prolapses it is either a Manchester repair, if it is to be left in, or a vaginal hysterectomy if it is to be removed. Prolapse appears to be comparatively uncommon in much of the developing world, despite the much greater multiparity of its mothers, but it is uncertain if this is a real difference; they may merely complain less.
A Manchester repair or a vaginal hysterectomy involve some fairly difficult vaginal surgery, with the risk that, if you are not expert, you may enter her rectum or her bladder and cause a fistula. If her uterus has prolapsed, they are certainly the best operations, so refer her for them if you can. If this is impossible, or she is unwilling to undergo them, Le Fort's operation, or ventrisuspension, are possible alternatives. They are old-fashioned and less effective than the modern operations, so that experts no longer do them. But if you are not an expert, you will find that they are your only way of helping an old woman whose genitalia are prolapsing. Contributors differ as to whether we should include ventrisuspension or not. Because it is disputed we have put it in small print; it may have a place.
If she has a cystocele or rectocele which are large enough to cause symptoms, without much uterine prolapse, you can, if you are sufficiently skilled, do an anterior repair (colporrhaphy), or a posterior one, which is somewhat more difficult or both.
MARY, an old lady of 80, complained that her husband was accusing her of having given him an STD, because he was having pain in pasing his urine. She wanted a letter she could take to the court saying that she was free of any STD. On examination her uterus was grossly prolapsed, ulcerated and stinking, but she had no evidence of any STD. A Manchester repair cured her completely. LESSON A patient's symptoms are not always what they seem. Pessaries for prolapse. Many old women prefer to avoid surgery, and can be treated with a pessary. Ring pessaries are suitable for most of them. If a patient is comfortable she can leave it in indefinitely, but you should see her from time to time. Menstruation (if she is still menstruating) and sex (if she still wants it) can take place as usual; she may not even be aware that she has one.
PESSARY, ring pattern, semi-rigid polythene, 40 to 120 mm, assorted sizes, predominantly the larger ones, 25 pessaries only.
Fig. 20-9a A RING PESSARY IS OFTEN very acceptable to an older patient with moderate prolapse. Choose its size as you would a diaphragm, by measuring the depth of her vagina with your fingers. After Garry MG, ''Gynaecology Illustrated', Churchill Livingstone, permission requested.
RING PESSARIES FOR PROLAPSE INDICATIONS. If surgery is impracticable. Moderate prolapse especially in an older patient; if her perineal muscles are very deficient, they will not hold a pessary. If too big a ring is required, her vaginal wall or cervix may prolapse through it.
METHOD. Choose the size of a ring pessary, as you would a diaphragm, by measuring the depth of her vagina with your fingers. It will usually be about 70 mm. Warm it in hot water to soften it, lubricate it, compress it, and insert it like a diaphragm, with the posterior part behind her cervix, and the anterior part behind her symphysis. It will resume its ring shape and take up a position in the coronal plane. If a 70 mm pessary falls out, try a larger size in 5[nd]10 mm intervals. If it feels very tight and uncomfortable, so that she cannot pass urine, try a smaller size.
See her in 3 months; if all is well then, see her annually and ask her if the pessary is comfortable. Ideally, she needs a new pessary each year. If it is not coated with solid material, you can wash and replace it.
If her pessary keeps falling out, she needs surgery.
If her vagina is ulcerated at her annual checkup, leave her pessary out for a 1[nd]2 months and give her some oestrogen cream to insert nightly. When her ulcers have healed, insert a smaller pessary, and see her in 3 months.