Case 11 A retired schoolteacher presents with a feeling of ‘something coming down

 Case 11 A retired schoolteacher presents with

a feeling of ‘something coming down’

Mrs Milne, a 63-year-old retired schoolteacher presents with

a feeling of something coming down. She has noticed this is

becoming more pronounced and sometimes she experiences

an ache in the vagina, especially after a bout of

constipation. She is now concerned because the lump is

growing in her vagina and as a consequence she has

abstained from intercourse with her husband. Mrs Milne

knows a friend has similar symptoms, but she does not want

to discuss such a personal issue with her. When she is

requested to attend for a routine cervical smear, she asks

the nurse for advice. The nurse suggests making an

appointment with her GP.

What is the differential diagnosis?

• Prolapse of bladder, uterus or bowel

• Subcutaneous cysts in vagina or uterus wall

• Abscess within the vagina

What would you like find out from

her history?

Presenting complaint

• Duration of feeling something coming down and any

relieving or precipitating factors

• Urinary symptoms and duration:

 dysuria

 urinary frequency

 incomplete emptying

 manoeuvres to empty her bladder

 nocturia

• Bowel symptoms and duration:

 constipation

 diarrhoea

 any manual compression of vagina to empty rectum

• Vaginal discharge

• Sexual function:

 pain on intercourse

 obstruction on intercourse

Medical history

• Previous gynaecological surgery

• Connective tissue disorders

• Respiratory disease

Menstrual history

Age at menopause.

Obstetric history

• Parity

• Type of delivery

• Pregnancy or labour complications

Family history

Presence of connective tissue disorders.

Social

• Activities/job, such as heavy lifting, increasing pressure

on pelvic floor

• Smoking

Drug history

• Steroids

• Anticlotting medication (e.g. aspirin, clopidogrel,

warfarin)

Mrs Mine informs you her last period was 9 years ago and

she has no bleeding since. She has always tended to be

constipated, although she eats sensibly. She has no urinary

incontinence, but she comments that after micturition she

has had to stand and sit back on to the toilet to empty her

bladder fully, especially if she has been on her feet all day.

Since retirement, she enjoys hill walking, but her symptoms

have put her off going out with her walking group because

the lump causes discomfort the longer she stays on her feet.

Obstetrics and Gynaecology: Clinical Cases Uncovered.

By M. Cruickshank and A. Shetty. Published 2009 by Blackwell

Publishing. ISBN 978-1-4051-8671-1.84 Part 2: Cases

PART 2: CASES

She has no previous surgery or connective tissue disorder

(nor in her family) and is on no medication. However, she

did have one child who was delivered by forceps 41 years

ago and she had an extensive tear at the time which

required several stitches.

What would you look for on physical

examination?

General

Body mass index (BMI); obesity can increase the intra -

abdominal pressure and precipitate prolapse. Evidence of

smoking such as nicotine - stained fingers and hair may

indicate respiratory problems.

Chest examination

Any respiratory disease should be assessed and can precipitate prolapse if persistent and long term, especially

from bouts of coughing. Any untreated condition or

smoking should be addressed in addition to the presenting complaint.

Abdominal examination

A pelvic mass (benign or malignant) can increase intra -

abdominal pressure and cause pelvic floor descent. Any

mass identified should be managed appropriately (see

Case 12 ).

Pelvic examination

A bimanual examination will exclude any pelvic mass

contributing to prolapse (Fig. 11.1 ).

The speculum examination enables staging of the

prolapse (its anatomical severity) to be undertaken.

There are several types of staging classifications, some

involving the vaginal introitus, with others using the

hymenal ring as the reference point. Using a Sims speculum enables parts of the vaginal wall which are descending to be retracted, allowing all aspects of the wall to be

assessed. You need to ask the patient to cough to allow

the true extent of descent to be identified. Sometimes

both anterior and posterior vaginal walls are descending

and two Sims specula can be used, or a sponge - holding

Normal positions

of pelvic organs

Bladder

Pelvic

floor muscle

(levator ani)

Urethra

Rectum

Vagina

Uterus

Cystocoele and urethrocoele

Prolapsed

bladder

Prolapsed

urethra

Rectocoele

Anal sphincter

Prolapsed

rectum

(rectocoele)

Vagina

Prolapsed

uterus

Uterine prolapse

Figure 11.1 Prolapse.Plate 9.1 Cervical ectopy with mucous discharge.

Plate 10.1 A cervical cytology sample with normal cells. Plate 10.2 A cervical cytology sample with dyskaryotic cells.

Plate 10.3 Cervical intraepithelial neoplasia 3 (CIN 3).

Plate 10.4 Colposcopic findings after the application of 5% acetic

acid showing acetowhitening and mosaic and punctuation capillary

vessel pattern.Plate 13.1 Vulual and peri-anal erythema and lichenification with

loss of labia minora. Superficial ulceration on right side of

fourchette.

Plate 13.2 Complete midline fusion from lichen sclerosus.Case 11 85

PART 2: CASES

forceps (ovum forceps) to see the top of the vagina. You

need to look for any uterine or vault descent (the middle

compartment).

In patients who have had long - standing prolapse,

trauma can occur on the exposed prolapsed area, sometimes in the form of an ulcer (decubitus). This can

present with bleeding and the exposed cervix lying

outside the vagina will be obvious on examination. It is

important to check for incontinence of urine or faeces.

Sometimes, urine will spontaneously expel on coughing

at examination (stress incontinence). Sometimes, reduction of the prolapse precipitates incontinence. This may

indicate distension of the prolapsed bladder with overflow incontinence. If faecal incontinence is present or has

been suggested in the history, it may be appropriate to

assess the anal sphincter by digital rectal examination.

Now review your findings so far

A 63-year-old woman presents with a 12-month history of a

feeling of something coming down. She has given up her

favourite pastime because of ‘heaviness down below’ and

sometimes she has difficulty emptying her bladder. She is

only slightly overweight, with a BMI of 28, is a non-smoker

and has no medical problems. Abdominal examination has

shown no mass, but on speculum examination the anterior

vaginal wall descends 2cm past the hymenal ring on

coughing but is easily reducible on digital pressure. There is

no presence of urinary or faecal incontinence or trauma on

the exposed vaginal skin.

What other investigations would

you recommend?

• Mid - stream specimen of urine (MSSU). If urinary

symptoms are present, urine microscopy and culture

should be performed

• Urodynamic investigations. Consider if stress urinary

incontinence is identified

• Surgical referral. If there is faecal incontinence, referral

to a colorectal surgeon as endoanal ultrasound and anorectal manometry may be required

What would you do next?

The most important action is to identify what the patient

considers an acceptable management plan and how the

prolapse affects her life. Not all prolapses require treatment and further questioning may be required as to the

impact on lifestyle and any changes that can be made

without further medical intervention.

Now review your differential diagnosis

Prolapse of bladder, uterus or bowel

The speculum examination has isolated the location of

the prolapse to the anterior wall and thorough examination excludes concurrent descent elsewhere.

Sebaceous cyst or abscess in vaginal wall

Bimanual and speculum examination has excluded cysts

in the vaginal wall or an abscess, which would be painful

on palpation and possibly be discharging.

What treatment options would

you offer?

1 Conservative management. As prolapse is not a life -

threatening condition, further discussion should take

place to identify an appropriate management plan.

Sometimes all that is necessary is reassurance that this

lump is not a cancer; however, in Mrs Milne ’ s case, it has

affected her quality of life and this should prompt you to

discuss further management.

2 Lifestyle factors. You will have identified those likely to

cause an increase in abdominal pressure in your history.

These should be addressed, and you should give advice

on weight loss and smoking as necessary.

3 Pelvic floor exercises. Exercises can successfully

improve prolapse symptoms and also possibly improve

surgical success if carried out preoperatively. These can

be performed at home on a regular basis either with the

tuition of a physiotherapist or a patient information

leaflet. This type of management, however, does depend

on the patient ’ s commitment to undertaking their own

treatment and continuing to perform them long term.

4 Pessary. For those who would prefer to have an instant

‘ fix ’ , but not necessarily an operation, a pessary that

elevates the prolapse can be an alternative. However, it is

important to assess vaginal access and the dimension from

the posterior fornix of the vagina to the pubis symphysis

to identify the size of pessary that can be used. There are

different shapes of pessary and the clinician ’ s choice is

dependent on the location of the prolapse. However,

sometimes a pessary does not remain in situ and

expels spontaneously, most notably when raised intra -

abdominal pressure is present (such as defaecation).

5 Surgery. This is an option for patients who would

prefer not to have a pessary and are found to have a

prolapse sufficient to warrant surgery. The type of operation is very dependent on prolapse location and may

involve the use of prosthetic material such as nylon mesh

or biological grafts. Most prolapse surgery is performed86 Part 2: Cases

PART 2: CASES

vaginally, but some techniques require abdominal access

(either as minimal access or an open procedure via

the abdomen). If surgical treatment is to be considered,

biochemical renal and hepatic assessment as well as

haematological indices are performed and checked preoperatively. Elderly women and those with hypertension,

respiratory or cardiac disease would also require a chest

X - ray and electrocardiogram (ECG) for anaesthetic

assessment. Prolapse surgery can be performed under

regional block, e.g. spinal or epidural anaesthetic.

KEY POINT

Remember to stop any anticlotting agents 10 days before

the operation to prevent intraoperative pelvic bleeding

and to reduce the occurrence of intrathecal haemorrhage

for those who have a regional anaesthetic for the

operation. To compensate, most patients are given

subcutaneous heparin pre - or postoperatively, dependent

on what type of anaesthetic they have.

Mrs Milne decides to have a ring pessary inserted. She is

assessed and a 71-mm diameter ring pessary is fitted

comfortably. However, 4 days later, during a bowel

movement, it falls into the toilet. She returns to the clinic

and has a larger pessary inserted (81mm). She is seen for

review 6 months later. Although the ring has remained in

place, she has noticed some vaginal discharge and she is

unhappy about having to attend for a ring change every 6

months. She thinks surgery would be a ‘one-off’ solution

and asks to have ‘the operation’. She has no risk factors for

surgery or an anaesthetic and is admitted routinely. The

operation consists of repairing the supporting tissues

between the bladder and vaginal skin. She does not need

a hysterectomy as she has no uterine prolapse.

Mrs Milne, after sufficient convalescence, is able to return

to her hobby of hill walking and has no symptoms of

prolapse. She understands the activities that could be

detrimental to the repair of her prolapse given there is a

30% risk of failure with the operation. Mrs Milne performs

her pelvic floor exercises daily to improve the postoperative

success.

CASE REVIEW

This postmenopausal woman presented with a feeling of

something coming down and urinary symptoms of incomplete emptying which impacted on her quality of life. She

was primiparous having had a traumatic delivery but had

no other factors impacting on her pelvic floor; she was only

slightly above average BMI and did not smoke. Speculum

examination indicated a cystocoele which descended

beyond the hymenal ring on increased abdominal pressure, but this was easily reducible.

First line treatment was a ring pessary which was subsequently successful after appropriate sizing. However, Mrs

Milne decided upon surgical management and continued

to monitor her activities and promote success by continuing pelvic floor exercises.

KEY POINTS

• Any factor affecting abdominal pressure must be

addressed in conjunction with any prolapse

• The anatomical site of the prolapse may affect the activity

of pelvic organs such as the bladder and bowel

• Trauma can occur on the exposed prolapsed vaginal skin

or cervix

• Pelvic floor exercises can successfully reduce symptoms

and descent of prolapse but must be performed regularly

to be effective