A 75-year-old woman G5P5 presents for an annual exam and reports having a “fullness” in the vaginal area. The symptom is more noticeable when she is standing for a long period of time. She does not complain of urinary or fecal incontinence. She has no other urinary or gastrointestinal symptoms. There has been no vaginal bleeding. Her past medical history is significant for well-controlled hypertension and chronic bronchitis. She has never had surgery.Pelvic exam reveals normal appearing external genitalia except for generalized atrophic changes. The vagina and cervix are without lesions. A cystocele and rectocele are noted. The cervix descends to the introitus with the patient in an upright position. Uterus is normal size. Right and left ovaries are not palpable. No rectal masses are noted. Rectal sphincter tone is slightly decreased. The patient prefers non-surgical treatment.

CC: “I feel fullness in my groin area”.

classmate 1

1. What increases this patient’s risk for pelvic organ prolapse?

Pelvic organ prolapse happens when the support mechanism of the woman’s pelvis is weakened or damaged (Alexander, et. al., 2017). The most significant risks for pelvic organ prolapse is gender, aging and childbirth (Alexander, et. al., 2017). Woman who have never had children are at less risk however, after menopause this risk rises and will, at the age of 75 years old will be about the same as a woman who has given birth in the past (Alexander, et. al., 2017). And of course a history of multiple vaginal deliveries will also make the risks higher. Menopause is also major risk factor for the development of pelvic floor disorders (Tzur, Yohai, & Weintraub, 2016).

classmate 2

2. What are the symptoms of pelvic organ prolapse?

•            Complaint of a bearing-down sensation

•            Heaviness with urination/defecation, or discomfort in the lower abdomen.

•            The uterus or bladder may protrude out of the vagina grossly visible.

•            Most patients complain of stress incontinence, and complain of voiding dysfunction as a result of direct pressure on the urethra.

clasmate 3

 What is the role of vaginal estrogen in patients with pelvic relaxation? 

Estrogen plays an important role in the function of the genital and lower urinary tract with estrogen receptors being present in the bladder, urethra, vagina, and pelvic floor musculature (Weber et al., 2015). Estrogen deficiency could weaken the supporting ligaments of the pelvic organs, as well as causing thinning of the vaginal epithelium (Weber et al., 2015). These factors could contribute to POP. Vaginal estrogens alone or together with other forms of treatment (i.e. vaginal pessaries, pelvic floor muscle training or surgery), may help in the treatment of POP by increasing synthesis of collagen and improving the strength of the vaginal epithelium (Weber et al., 2015).

classmate 4

1. When is surgery indicated? 
2. According to Jelovsek (2020), candidates for surgical intervention include women with symptomatic prolapse who have not benefited from or who have declined conservative management of their prolapse.