A 54-year-old woman, gravida 3 para 3, comes to the office due to difficulty voiding for the past few weeks. When the patient voids, she has difficulty initiating the urine stream and emptying completely, but has no dysuria or hematuria. The patient has 2 episodes of nocturia every night, but no involuntary leakage of urine. She also has pelvic pressure that is worse with standing. Ten months ago, the patient underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy for epithelial ovarian cancer and has completed a course of chemotherapy. Vital signs are normal. BMI is 36 kg/m². The abdomen is without masses or ascites. Pelvic examination shows a protruding soft, nontender mass at the level of the hymen that descends past the introitus with the Valsalva maneuver, which does not cause leakage of urine. The uterus and ovaries are surgically absent. Sensation and deep tendon reflexes are intact. Urinalysis is normal. Which of the following is the most likely cause of this patient's symptoms?

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11ec25c8_d9de_63ea_bc81_2b7aa73f084b_MD0003_00 Pelvic organ prolapse is a common gynecologic condition that occurs due to the herniation of pelvic organs (eg, bladder, uterus, rectum) through the vagina. Risk factors for prolapse include multiparity, postmenopausal age, hysterectomy, and obesity. These result in weakened connective tissue, decreased muscle tone, and increased intraabdominal pressure, all of which contribute to the prolapsing structures. Pelvic organ prolapse Symptoms include pelvic pressure, voiding dysfunction (eg, urinary retention, difficulty initiating stream, incontinence), and bowel dysfunction (constipation, fecal incontinence). Patients often report having to reduce the herniated vaginal mass (eg, "splinting") to void or defecate. Pelvic examination with vaginal wall prolapse after hysterectomy typically reveals a vaginal mass that increases in size with the Valsalva maneuver. Examination also stages the extent of individual organ descent and guides management. Treatment of pelvic organ prolapse includes weight loss, pelvic floor muscle exercises, and vaginal pessary placement or surgical repair. pessary (Choice A) Intrinsic sphincter deficiency, a form of stress urinary incontinence, causes involuntary leakage and loss of urine with the Valsalva maneuver. Patients have no urinary retention or any difficulty initiating micturition. (Choice B) Ovarian cancer metastasis typically presents as an abdominal, rather than vaginal, mass and may cause urinary symptoms (eg, frequency) due to mass effect of the tumor compressing the bladder. This diagnosis is unlikely in this patient due to lack of ascites. (Choice D) Urethral diverticulum may present with dysuria and postvoid dribbling, but not urinary retention or pelvic pressure. A pelvic examination typically reveals a tender, anterior vaginal wall mass with expression of urine or pus. (Choice E) Urge incontinence (eg, overactive bladder) presents with a sudden onset of urinary urgency and involuntary loss of urine. Urinary retention and difficulty initiating voiding are not features. (Choice F) Urinary tract infection can present with the sensation of incomplete bladder emptying but typically also includes dysuria, hematuria, and an abnormal urinalysis, none of which are seen in this patient. (Choice G) Vesicovaginal fistula is a complication of pelvic surgery characterized by a continuous involuntary loss of urine in the absence of other urinary symptoms (eg, incomplete emptying, difficulty initiating stream). Leakage of urine from the fistula opening is typically visualized on pelvic examination. Vesicovaginal fistula Educational objective: Pelvic organ prolapse is the descent of pelvic organs through the vagina and can present with pelvic pressure, urinary retention, incontinence, and obstructed voiding. Risk factors include multiparity, postmenopausal age, hysterectomy, and obesity. References: Definitions of apical vaginal support loss: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/27640944) Epidemiology and outcome assessment of pelvic organ prolapse. (http://www.ncbi.nlm.nih.gov/pubmed/24142054) Can pelvic floor dysfunction after vaginal birth be prevented? (http://www.ncbi.nlm.nih.gov/pubmed/27525694)

A 54-Year-Old Woman, Gravida 3 Para 3, Comes to the Office