A 46-year-old woman comes to the office for evaluation of a vaginal mass. The patient has had intermittent vaginal pressure for the past 2 years that is now constant and worse with intercourse. She now notices a vaginal mass when voiding and sometimes sees light blood on the toilet paper after wiping. The patient has no chronic medical conditions. Her only surgery was a cervical conization 4 years ago; repeat Pap testing has since been normal. The patient had 3 uncomplicated vaginal deliveries in her 20s and a tubal ligation with her last delivery. She is recently divorced and has had 3 new sexual partners in the past year. The patient smokes a half pack of cigarettes daily and drinks 1-2 glasses of wine on the weekends. BMI is 23 kg/m². Vital signs are normal. On pelvic examination, there is a small erosion over the anterior vaginal wall but no lesions on the cervix. The cervix protrudes to the hymenal ring with Valsalva maneuver. The uterus is mobile and nontender, and there is a 2-cm pedunculated fundal uterine fibroid. Which of the following is the most likely contributing factor to this patient's clinical presentation?

Question

A 46-year-old woman comes to the office for evaluation of a vaginal mass.  The patient has had intermittent vaginal pressure for the past 2 years that is now constant and worse with intercourse.  She now notices a vaginal mass when voiding and sometimes sees light blood on the toilet paper after wiping.  The patient has no chronic medical conditions.  Her only surgery was a cervical conization 4 years ago; repeat Pap testing has since been normal.  The patient had 3 uncomplicated vaginal deliveries in her 20s and a tubal ligation with her last delivery.  She is recently divorced and has had 3 new sexual partners in the past year.  The patient smokes a half pack of cigarettes daily and drinks 1-2 glasses of wine on the weekends.  BMI is 23 kg/m².  Vital signs are normal.  On pelvic examination, there is a small erosion over the anterior vaginal wall but no lesions on the cervix.  The cervix protrudes to the hymenal ring with Valsalva maneuver.  The uterus is mobile and nontender, and there is a 2-cm pedunculated fundal uterine fibroid.  Which of the following is the most likely contributing factor to this patient's clinical presentation?

Quizplus · Accepted Answer

11ec25c8_d98d_5e2d_bc81_898fc48d1b53_MD0003_00 This patient has apical compartment (uterine) prolapse, a form of pelvic organ prolapse (POP). POP is the abnormal herniation of the uterus, bladder, or rectum through the vagina wall due to weakening of the pelvic floor muscles (eg, levator ani muscle complex), ligaments, and nerves caused by chronic, increased intraabdominal pressure and pelvic floor injury. apical compartment (uterine) prolapse The most common risk factor for POP is multiparity because pregnancy causes increased intraabdominal pressure with subsequent pelvic floor weakening and laxity; vaginal deliveries, even if uncomplicated as in this patient, can cause additional microinjury to the pelvic floor muscles and nerves. With increasing age, the herniation can progress, resulting in the development of vaginal pressure or a vaginal mass that worsens with Valsalva maneuver (eg, voiding). Some patients (such as this one) can also develop vaginal erosions as the prolapsed vaginal wall protrudes past the hymenal ring, rubs against clothing, and becomes denuded and friable (abnormal vaginal bleeding). Treatment of POP includes pelvic floor muscle exercises in combination with either medical (eg, pessary placement) or surgical management. (Choices A and C) Chronic tobacco use and multiple sexual partners are risk factors for cervical cancer, which can present with vaginal bleeding, particularly in those with prior cervical dysplasia (such as this patient with a prior cervical conization). However, this patient does not have a fungating or friable cervical lesion and has had normal Pap testing since her cervical conization, making this diagnosis less likely. (Choice D) Cervical conization increases the risk of cervical insufficiency (eg, painless second trimester pregnancy loss) because a portion of the cervix is removed. It does not cause weakening of the pelvic floor muscles associated with POP. Cervical conization (Choice E) Uterine leiomyomata can cause POP if they are numerous or large enough to weigh down the uterus; however, a 2-cm fibroid is unlikely to cause POP. Uterine leiomyomata Educational objective: The most common risk factor for pelvic organ prolapse is multiparity because pregnancy causes pelvic floor muscle weakening from chronic, increased intraabdominal pressure and pelvic floor injury. References: Pelvic organ prolapse. (http://www.ncbi.nlm.nih.gov/pubmed/20433127) Prevention and management of pelvic organ prolapse. (http://www.ncbi.nlm.nih.gov/pubmed/25343034)

A 46-Year-Old Woman Comes to the Office for Evaluation of a Vaginal