An 86-year-old woman comes to the office due to a vaginal bulge and difficulty urinating. The patient first noticed the bulge several years ago but did not seek care. Over the last few months, as the bulge has enlarged, she has experienced increasing pelvic pressure. In addition, she now has to manually elevate the bulge to urinate. The patient has no vaginal bleeding or difficulty with defecation. She has chronic obstructive pulmonary disease managed with an inhaled combined long-acting beta agonist and corticosteroid. She had 2 vaginal deliveries in her early 20s; the second was complicated by a fourth-degree perineal laceration. The patient has a 50-pack-year smoking history, but quit 15 years ago; she does not use alcohol or illicit drugs. Blood pressure is 150/90 mm Hg, pulse is 78/min, respirations are 20/min, and pulse oximetry is 91% on room air. BMI is 34 kg/m². Auscultation of the lungs reveals decreased breath sounds bilaterally. Pelvic examination reveals anterior vaginal wall prolapse and protrusion of the cervix through the vaginal introitus. During the examination, the uterus is elevated and the prolapse is reduced; the patient is asked to cough and no leakage of urine is observed. Post-void residual urine volume is 40 mL. Which of the following is the best next step in management of this patient?

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Explanation: 11ec2b69_bf0c_2f55_8f63_3b38df15fb28_MD0005_00 This patient has severe, symptomatic pelvic organ prolapse (POP) that is caused by the uterus and bladder (eg, cystocele) herniating through the vagina, resulting in vaginal pressure and a bulging mass. Patients with POP often have associated urinary, defecatory, and sexual dysfunction. POP is a result of damage or atrophy of the ligaments, muscles, and nerves that support the pelvic organs. Risk factors for POP include obesity, increasing age, high parity, and history of operative vaginal delivery. herniating through the vagina Patients with symptomatic POP can be treated with either surgical or nonsurgical management, and both are equally efficacious. Therefore, treatment choice is dependent on patient preference and surgical risk assessment. Patients who are poor surgical candidates due to cardiovascular or pulmonary comorbidities are managed conservatively. Therefore, this patient would be better managed with the nonsurgical option of a pessary, a medical device that, when placed in the vagina, helps support the prolapsing pelvic organs and restore normal anatomy. Most patients using a pessary have resolution of the prolapse and bowel and bladder symptoms. pessary (Choice A) Surgical management (eg, hysterectomy with prolapse repair) is indicated for patients who have not improved despite conservative management and have no contraindications to surgery. (Choice B) Intermittent self-catheterization is indicated for management of urinary retention, which is diagnosed by an elevated post-void residual (>200 mL). POP can cause distortion of the bladder and urethra that results in urinary obstruction and incomplete bladder emptying. To facilitate urination, patients often manually elevate the bladder to relieve the obstruction (splinting). This patient's obstruction is reducible, allowing for a normal post-void residual (ie, no retention). (Choice C) Pelvic floor muscle exercises improve pelvic organ support and decrease symptoms associated with stress urinary incontinence and mild POP. Advanced POP requires mechanical correction via a pessary or surgery. (Choice D) A mid-urethral sling procedure is indicated in the management of stress urinary incontinence, which presents with involuntary leakage of urine associated with increased intraabdominal pressure. Patients with stress incontinence have a positive cough-stress test (ie, leakage with coughing). Educational objective: Pelvic organ prolapse can present with a vaginal bulge and urinary, defecatory, or sexual dysfunction. Patients who are poor surgical candidates can usually be treated with pessary placement. References: Prevention and management of pelvic organ prolapse. (http://www.ncbi.nlm.nih.gov/pubmed/25343034)

An 86-Year-Old Woman Comes to the Office Due to a Vaginal