A 76-year-old woman, gravida 4 para 4, comes to the office with pelvic pressure and heaviness, lower back pain, and constipation. Her constipation has not improved with daily laxative use. She has no melena, hematochezia, or changes in stool caliber. The patient has hypertension and peptic ulcer disease controlled with oral medications. Surgical history is significant only for an appendectomy. A screening colonoscopy performed 2 years ago was negative. Her mother had coronary artery disease and died from a myocardial infarction. The patient has a 52-pack-year smoking history and occasionally drinks hard liquor. Temperature is 36.7 C (98 F), blood pressure is 140/90 mm Hg, and pulse is 72/min. Pulse oximetry is 98% on room air. BMI is 35 kg/m². Cardiac examination reveals a normal rate and rhythm; there are no rubs, murmurs, or gallops. Pulmonary examination reveals decreased breath sounds in bilateral lung bases. On pelvic examination, a protrusion of the posterior vaginal wall expands with increased intraabdominal pressure and with standing. The patient is bothered by these symptoms. Which of the following is the most accurate statement regarding this patient's condition?

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Explanation: 11ec2b69_bf09_e564_8f63_39c16732fffd_MD0005_00 Rectocele, a type of pelvic organ prolapse (POP), is the result of herniation of the rectum through a defect in the posterior vaginal wall. POP develops due to an injury of the pelvic floor muscles (eg, herniation) typically incurred during vaginal delivery. Herniation and POP are further exacerbated by increased intraabdominal pressure (eg, Valsalva maneuver) and the effect of gravity. Risk factors include multiparity, increasing age, and obesity. Symptoms of a rectocele include pelvic pressure, lower back pain, constipation, and fecal incontinence. Typical physical examination findings include a posterior vaginal mass that increases with the Valsalva maneuver. Treatment options include pelvic floor muscle exercise and either surgical repair or conservative management (eg, pessary placement), which are equally efficacious in symptom improvement. Rectocele pessary placement (Choice B) Patients with rectocele often have concomitant constipation, incomplete emptying, and obstruction symptoms (eg, splinting). However, improved treatment of the constipation does not fix the underlying vaginal wall defect and does not resolve this patient's symptoms of pelvic pressure. (Choice C) POP is a progressive process until menopause, after which symptoms can either improve or worsen. In addition, there is no association between POP and cessation of tobacco use. (Choice D) Systemic hormone replacement therapy is indicated in the treatment of menopausal vasomotor symptoms (eg, hot flashes); it is not used in the management of POP. In addition, it is not recommended in this patient; candidates are women age <60 who have undergone menopause within the past 10 years. Topical estrogen can be used with other treatments to improve vaginal atrophy but does not improve prolapse symptoms. (Choice E) Although obesity increases the risk of developing POP, weight loss may or may not improve it and therefore is not the most effective treatment. Educational objective: Rectocele, herniation of the rectum through a defect in the posterior vaginal wall, typically presents with constipation, pelvic pressure, lower back pain, fecal incontinence, and a pelvic mass that increases with the Valsalva maneuver. Management options include pessary placement and surgical repair. References: Posterior wall prolapse and repair. (http://www.ncbi.nlm.nih.gov/pubmed/20142644)

A 76-Year-Old Woman, Gravida 4 Para 4, Comes to the Office