An 84-year-old woman comes to the office due to leakage of urine with coughing and sneezing. She also reports increased urinary frequency and a feeling of pelvic pressure but has no dysuria or hematuria. Medical history includes congestive heart failure (last known ejection fraction: 35%), persistent atrial fibrillation, and moderate aortic stenosis.
Pelvic examination findings are consistent with pelvic organ prolapse extending to the introitus (stage 2). Urinalysis and urine cultures are normal.
Which of the following is the best next step in management of this patient?

Question

An 84-year-old woman comes to the office due to leakage of urine with coughing and sneezing.  She also reports increased urinary frequency and a feeling of pelvic pressure but has no dysuria or hematuria.  Medical history includes congestive heart failure (last known ejection fraction: 35%), persistent atrial fibrillation, and moderate aortic stenosis.
Pelvic examination findings are consistent with pelvic organ prolapse extending to the introitus (stage 2).  Urinalysis and urine cultures are normal.
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_97e2_e6fa_853d_179b0904e102_MD0002_00 This patient has pelvic organ prolapse (POP) and resultant stress urinary incontinence. POP is the descent of the female pelvic organs (eg, bladder, uterus or post-hysterectomy vaginal cuff, rectum) that causes a herniation of the vagina and/or uterus. Risk factors for POP include multiparity, increasing age, obesity, and prior hysterectomy. Patients typically present with a feeling of "vaginal bulge" (eg, pelvic pressure) or urinary (eg, retention), bowel (eg, constipation), or sexual dysfunction. Asymptomatic patients do not require treatment. Symptomatic patients can be treated with either conservative treatment (eg, vaginal pessary, pelvic floor muscle exercises) or surgery. Indications for vaginal pessaries include preference for nonsurgical treatment, poor surgical candidate (such as this patient), desire to have children in the future, or recurrent prolapse. Those who fail conservative therapy are typically referred for surgical management. vaginal pessaries (Choices A and D) This patient's comorbidities make her a poor surgical candidate for colpocleisis or total abdominal hysterectomy. (Choice B) Tolterodine is an anticholinergic used to treat urgency incontinence. However, it is not effective for the treatment of stress incontinence and would not be helpful in this patient. (Choice C) Topical or systemic estrogen therapy is not effective in treating POP. Educational objective: Pelvic organ prolapse can be treated conservatively or surgically depending on patient preference, severity of disease, and comorbidities. Vaginal pessaries and pelvic floor muscle exercises are an effective conservative treatment for most patients. __________ References: Prevention and management of pelvic organ prolapse. (http://www.ncbi.nlm.nih.gov/pubmed/25343034) Clinical use of ring with support pessary for advanced pelvic organ prolapse and predictors of its short-term successful use. (http://www.ncbi.nlm.nih.gov/pubmed/28419067)

An 84-Year-Old Woman Comes to the Office Due to Leakage