A 74-year-old woman, gravida 5 para 5, comes to the office due to vaginal spotting and discharge for several months. She reports a mass coming out of her vagina. She is now having difficulty defecating; increased straining causes the mass to increase in size. The patient has hypertension, type 2 diabetes mellitus, and NYHA class III heart failure. Her last hemoglobin A1c was 11.8. She had 5 spontaneous vaginal deliveries and has no history of abnormal Pap tests. The patient has a 40-pack-year smoking history. Blood pressure is 150/90 mm Hg, pulse is 84/min, and respirations are 16/min. Oxygen saturation is 89% on room air. BMI is 41 kg/m². Cardiopulmonary examination reveals decreased breath sounds bilaterally. The abdomen is nontender and has no palpable masses. Pelvic examination reveals the cervix at the level of the vaginal introitus. The vaginal mucosa is thin with multiple areas of excoriation and erosion. Ultrasonography reveals a thin endometrial stripe. Which of the following is the best next step in management of this patient?

Question

Quizplus · Accepted Answer

11ec25c8_d9dd_c7a9_bc81_39f2bcb46f3c_MD0003_00 Uterine procidentia is a form of pelvic organ prolapse (POP) in which the uterus and anterior and posterior vaginal walls herniate through the vagina. POP occurs due to weakened pelvic support and increased intraabdominal pressure, which are exacerbated by increasing parity, obesity, and advancing age. Typical symptoms include vaginal pressure and a bulging mass that increase with Valsalva maneuver. Posterior prolapse and rectal involvement lead to difficulty with defecation, as seen in this patient. POP may be asymptomatic and does not require treatment. However, when patients have symptoms such as pelvic pressure, bowel-bladder dysfunction, sexual dysfunction, or tissue damage (eg, erosions), treatment is indicated. herniate through the vagina Patients with symptomatic POP can be treated with either surgical or nonsurgical management, and both are equally efficacious. Therefore, treatment strategy is dependent on patient preference and surgical risk assessment. This patient is a poor surgical candidate due to her age, obesity, class III heart failure, and poorly controlled diabetes mellitus (Choice E). Therefore, she would be better managed with the nonsurgical option of a pessary fitting, which helps support the prolapsing pelvic organs and restore normal anatomy. The majority of patients using a pessary have resolution of prolapse and bowel and bladder symptoms. pessary (Choice A) An endometrial biopsy is used to evaluate for endometrial cancer in patients with postmenopausal bleeding, but it is not indicated with a thin endometrial stripe on ultrasound and physical examination with an obvious non-uterine source of bleeding. (Choice B) Hormone replacement therapy may be used to treat vaginal atrophy and heal erosions but does not correct pelvic organ prolapse. Systemic hormone replacement therapy is contraindicated in this patient due to the increased risk of thromboembolic events associated with estrogen and her comorbidities. (Choice C) Pelvic floor muscle exercises work to strengthen these muscles and help with stress incontinence and mild pelvic organ prolapse. Complete herniation of the uterus requires mechanical correction (eg pessary or surgery). Educational objective: Uterine procidentia is a form of pelvic organ prolapse in which the entire uterus herniates through the vagina along with the anterior and posterior vaginal walls. Conservative management with pessary placement is appropriate in poor surgical candidates with multiple comorbidities. References: Surgical management of pelvic organ prolapse in women. (http://www.ncbi.nlm.nih.gov/pubmed/23633316) Epidemiology and outcome assessment of pelvic organ prolapse. (http://www.ncbi.nlm.nih.gov/pubmed/24142054)

A 74-Year-Old Woman, Gravida 5 Para 5, Comes to the Office