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Difficulty: MediumPelvic Floor Disorders and Urogynecology

A 76-year-old woman comes to the clinic reporting a 6-month history of a vaginal bulge and pelvic pressure. She notes significant difficulty with bowel movements, frequently needing to press on the skin between her vagina and rectum to completely empty her bowels. Today, she noticed a few spots of blood on her undergarments. Her medical history is significant for severe chronic obstructive pulmonary disease requiring continuous home oxygen therapy, and a myocardial infarction 3 months ago. Her current medications include aspirin, metoprolol, atorvastatin, and a tiotropium inhaler. On pelvic examination, there is a prominent bulge of the posterior vaginal wall that extends 3 cm beyond the hymenal ring with the Valsalva maneuver. The cervix is flush with the vaginal vault and has no active bleeding or lesions. There is a superficial 3-mm mucosal ulceration on the dependent portion of the prolapsed posterior vaginal wall that oozes a small amount of blood when touched. Which of the following is the most appropriate next step in management?

  1. Fitting for a vaginal pessaryAnswer
  2. B
    Posterior colporrhaphy
  3. C
    Abdominal sacrocolpopexy
  4. D
    Endometrial biopsy
  5. E
    Pelvic floor muscle training

Answer

Fitting for a vaginal pessary
The most appropriate next step in management for this patient is fitting for a vaginal pessary. She presents with advanced, symptomatic pelvic organ prolapse (specifically, a rectocele), evidenced by the vaginal bulge and the need to manually splint to defecate. The spotting is clearly attributed to the mucosal friction ulcer on the prolapsed tissue. While definitive treatment for a rectocele is surgical repair (posterior colporrhaphy), this patient has a history of a myocardial infarction 3 months ago and severe COPD on continuous oxygen. Elective surgery is generally contraindicated within 6 months of an MI due to a high risk of reinfarction and mortality. Therefore, non-surgical management with a pessary is the safest and most effective intervention to provide anatomical support and relieve her symptoms.

Step-by-Step Solution

1
Identify the primary diagnosis and source of symptoms.
The patient has a symptomatic posterior vaginal wall prolapse (rectocele) causing defecatory dysfunction, and a friction ulcer on the prolapse causing vaginal spotting.
The history of a vaginal bulge, the need to manually splint the perineum to defecate, and the physical exam finding of a posterior wall defect protruding beyond the hymen confirm the diagnosis.
2
Evaluate the patient's surgical candidacy.
The patient is at an extremely high risk for surgical morbidity and mortality.
Elective surgery is generally contraindicated within 6 months of a myocardial infarction, and her concurrent severe COPD on home oxygen further increases anesthetic risk.
3
Select the most appropriate management based on the patient's risk profile.
Fitting for a vaginal pessary is the safest and most effective choice.
A pessary provides conservative, non-surgical support for the pelvic organs, alleviating the prolapse and allowing the friction ulcer to heal without subjecting the patient to prohibitive surgical risks.

Key Concept

Management of symptomatic pelvic organ prolapse in poor surgical candidates
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Topics

Pelvic Floor Disorders and Urogynecology

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