Case 20: Abdominal and back pain

 

Case 20: Abdominal and back pain

CASE 20: ABDOMINAL AND BACK PAIN

History

An 83-year-old woman complains of a dragging sensation in the lower abdomen and lower

back pain when standing or walking. It has been present for some years but she can now only

stand for a short time before feeling uncomfortable. It is not noticeable at night. She has had

four vaginal deliveries. She had her menopause at 52 years and took hormone-replacement

therapy for several years for vasomotor symptoms. She has not had any postmenopausal

bleeding and has not had a smear for several years.

She is generally constipated and sometimes finds she can only defecate by placing her fingers into the vagina and compressing a ‘bulge’ she can feel. She has mild frequency and gets

up twice most nights to pass urine. There is no dysuria or haematuria. Occasionally she

does not get to the toilet in time and leaks a small amount of urine, but this does not worry

her unduly.

Medically she is very well and does not take any medications regularly. She lives alone and

does her own shopping and housework.

Examination

On examination she appears well. Blood pressure and heart rate are normal. She is of average

build. The abdomen is soft and non-tender. There is a loss of vulval anatomy consistent with

atrophic changes. On examination in the supine position there is a mild prolapse. On standing, the cervix is felt at the level of the introitus. There is a large posterior wall prolapse and a

minimal anterior wall prolapse.

Questions

• What is the diagnosis for her discomfort and pain?

• How could the prolapse be more thoroughly assessed?

• How would you manage this patient?100 Cases in Obstetrics and Gynaecology

48

ANSWER 20

The diagnosis is of second-degree uterovaginal prolapse with rectocoele. Prolapse is traditionally categorized according to the level of descent of the cervix in relation to the introitus:

• first degree: descent within the vagina

• second degree: descent to the introitus

• third degree: descent of the cervix outside the vagina

• procidentia: complete eversion of the vagina outside the introitus.

A more thorough assessment using the Pelvic Organ Prolapse Quantification (POP-Q)

System is now standard practice. It is a validated tool to quantify, describe and stage pelvic support. The hymen is used as the main reference point with measurements taken (and

recorded on a grid) from six defined reference points plus three further measurements, with

positive or negative numbers assigned according to whether the reference points are located

above or below the hymen.

Common presenting symptoms are of ‘something coming down’, a ‘lump’ or a dragging sensation. Symptoms are always worse on standing or walking because of the effect of gravity.

Prolapse is more common in women who are parous, have had long or traumatic deliveries,

have a chronic cough or constipation. However it may occur in any woman, even if she is nulliparous, as it relates to collagen strength.

Management

Initial management involves treating the constipation with dietary manipulation and laxatives. This may relieve some of the symptoms and is also important to prevent recurrence if

surgery is to be performed.

Pelvic floor exercises are helpful for mild prolapse and to preserve the integrity of repair

postoperatively, though in this case they are unlikely to make any significant difference to the

presenting symptoms. If surgery is not wanted then she can try a ring pessary to hold up the

prolapse, which can work extremely well and only needs replacing every 6 months.

Although she is 83 this woman has no medical problems and should be offered definitive prolapse surgery which for her involves vaginal hysterectomy and posterior vaginal wall repair

(colporrhaphy). As there is no abdominal incision involved, recovery is quick and she would

expect to be in hospital for around 3 days.

KEY POINTS

• Prolapse incidence increases with age, parity, constipation and chronic cough.

• Conservative management with a ring pessary, or surgical prolapse repair may be

appropriate.

• Relief of exacerbating factors is important to prevent symptoms worsening or to

maintain the integrity of the repair.