An 81-year-old woman is evaluated for a sensation of pelvic pressure and a mass protruding from her introitus that has worsened over the past several months. She states that the sensation is most noticeable after standing for long periods. Her medical history includes severe chronic obstructive pulmonary disease requiring home oxygen and a myocardial infarction 2 months ago. Pelvic examination reveals a large anterior vaginal wall defect that descends beyond the hymenal ring with Valsalva maneuver. The patient finds this condition highly bothersome and requests treatment. Which of the following is the most appropriate next step in management?
- Fitting for a vaginal pessaryAnswer
- BReferral for anterior colporrhaphy
- CEndometrial biopsy
- DPrescription for oral ciprofloxacin
- EReassurance and observation
Answer
Fitting for a vaginal pessary
The patient presents with a symptomatic cystocele (anterior vaginal wall prolapse). While surgical repair (e.g., anterior colporrhaphy) is often a definitive treatment for symptomatic pelvic organ prolapse, this patient has severe medical comorbidities, including a recent myocardial infarction and severe COPD requiring home oxygen. These factors make her an exceptionally high risk for anesthesia and surgery. A vaginal pessary is a conservative, non-surgical device that mechanically supports the prolapsed organs. It is highly effective at relieving symptoms and is the gold standard initial therapy for symptomatic prolapse, especially in patients who wish to avoid surgery or are poor surgical candidates.
Step-by-Step Solution
Key Concept
Management of symptomatic pelvic organ prolapse in poor surgical candidates typically involves the use of a vaginal pessary.