Management of genital prolapse
BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7348.1258 (Published 25 May 2002) Cite this as: BMJ 2002;324:1258
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Editor
The excellent review of Thakar and Stanton about the management of genital
prolapse mentions the high recurrence rate after surgical repair: in 29%
reoperation was required sooner or later.This percentage seems to me a bit
high , but up to 20% is generally accepted and disappointing high. Still
surgery seems to be first choice for the authors as it was for me until a
few years ago, mainly because the usual conservative treatment with a
pessary is far from ideal: vaginal discharge with an offensive smell is
common and some years after the start of the treatment many women develop
pressure ulceration, only very slowly healing and quickly returning after
reinsertion of the pessary. For this reason a large number of the patients
opting for a pessary in the first place end up in the theatre sooner or
later, strengthening the gynaecologist in his opinion that primary surgery
is the best treatment anyway. However there is an easy way to prevent the
complaints and complications of the pessary treatment: every night the
device should be removed and after cleaning be reinserted in the morning.
That is what we normally do with contact lenses and with dentures to
prevent irritation and inflammation and it should be adviced for all
vaginal pessaries as well, not only for the cube pessary. Since I made a
start with this method patient satisfaction with the pessary became much
higher, the percentage of patients selected for surgery decreased from
about 80 to 20%, and to be honest, my own pleasure in treating patients
with the condition did grow considerably. Instructing the woman how to
remove and reinsert the pessary is not difficult and can be delegated to a
nurse. Most women have no problem at all in mastering the technique using
there forefinger, sometimes it will be more easy for them if a thin cord
is attached. Routine visits are reduced, after 3 visits with intervals of
one month, three months and one year no further checking is needed. The
results of this simple change in my practice was for me so spectacular
that I can only wonder how the common habit of leaving the device in place
could ever have developed. Perhaps it has something to do with old beliefs
that women are not supposed to touch their own genitals. The easy
acceptance of the new procedure by almost all women proves that this idea,
if ever true, nowadays certainly is old fashioned and cannot be an
obstacle any more. The advantages of a general introduction of this
approach are obvious both for the individual patient as for society as a
whole.
Willem Vlaanderen,
Vinkenlaan 24,
6581 CK Malden,
The Netherlands
Competing interests: No competing interests
Barium is not suitable for use in the urinary tract
CLINICAL REVIEW: Management of genital prolapse.
Editor – I was concerned to read in a recent clinical review that
barium instilled into the bladder was being advocated as a means of
investigating genital prolapse (1). Barium is not a contrast medium
suitable for use in the urinary tract. Review of the cited paper on four
contrast defecography reveals that a water-soluble contrast agent, and not
barium, was used to fill the bladder (2). Barium was used, in this
context, to opacify the small bowel, with barium paste used to delineate
the vagina and rectum.
There is increasing interest in the use of dynamic Magnetic Resonance
Imaging to image global pelvic floor dynamics and this may be a viable
alternative to cystoproctography in the future (3).
Sara C. Williams
Department of Radiology,
University Hospital Birmingham NHS Trust, Selly Oak Hospital,
Raddlebarn Road, Birmingham, B29 6JD.
REFERENCES
(1). Thaker R, Stanton S. Management of genital prolapse. BMJ 2002; 324:
1258-1262.
(2). Altringer WE et al. Four contrast defecography: pelvic “floor-
oscopy”. Dis Colon Rectum 1995; 38: 695-699.
(3). Halligan S. Dynamic pelvic MRI. Imaging 2001; 13: 435-461.
Competing interests: No competing interests