Clinical Review

Fortnightly review: Diagnosing and managing genitourinary prolapse

BMJ 1997; 314 doi: 10.1136/bmj.314.7084.875 (Published 22 March 1997)
Cite this as: BMJ 1997;314:875

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  1. Simon Jacksona,
  2. Phillip Smitha
  1. Department of Obstetrics and Gynaecology Southmead Hospital Bristol BS10 5NB
  1. Correspondence to: Mr Jackson

    Introduction

    Genitourinary prolapse occurs when faults develop in the mechanisms for vaginal and uterine support (fig 1). An understanding of these mechanisms and systematic repair of these faults will restore normal structure and function. Treatment of prolapse comprises about 20% of gynaecological surgical workload,1 and with an aging, yet more active, population this contribution will increase. Cystourethrocele is seen most commonly, followed by uterine descent and rectocele. After a hysterectomy the vagina may be susceptible to prolapse owing to loss of support of the vaginal vault.

    Fig 1

    Coronal section of pelvis showing cystourethrocele, enterocele, and rectocele

    Methods

    We conducted a Medline search from January 1966 to July 1996 and identified 8802 references to the term prolapse; these were reduced to 544 when we used the additional terms vagina, surgery, genitourinary, conservative, pessary, randomised, and outcome. We identified further references by hand searching relevant textbooks in the library of the Royal College of Obstetricians and Gynaecologists. We did not find any prospective trials comparing the effect of different treatments on outcome measures for prolapse. Observational studies have been published examining the pathophysiology and anatomy of prolapse, and these have stimulated interest in this subject.

    • Minor degrees of prolapse should be treated conservatively

    • Sexual activity should be borne in mind when considering appropriate surgical procedures

    • Long term results of surgery for prolapse are uncertain

    • There is little published work comparing alternative procedures and techniques

    • Reconsideration of what is normal pelvic anatomy has stimulated interest in restorative, reconstructive surgery for prolapse

    • Concurrent urinary incontinence is not always secondary to prolapse and if present should be investigated before surgery

    Anatomy

    The pelvic viscera are supported by the pelvic floor, with the pubococcygeal portion of the levator ani decussating around the lower vagina and urethra before attaching anteriorly to the pubic bone (fig 2). The vaginal wall consists …

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