STUDENT PROBLEM-BASED LEARNING SESSION

Pelvic Organ Prolapse and Urinary Incontinence

Clinical Case:

A 75-year-old woman G 5 P 5 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. A pessary is placed and you prescribe vaginal estrogen to address atrophic changes.

Discussion questions:

  1. What increases this patient's risk for pelvic organ prolapse?
  2. What are the symptoms of pelvic organ prolapse?
  3. What are the different types of pelvic organ prolapse?
  4. What are the different types of urinary incontinence?
  5. What is the role of vaginal estrogen in patients with pelvic relaxation?
  6. When is surgery indicated?
  7. What are nonsurgical treatments?

References:

  1. Obstetrics and Gynecology by Beckmann 5 th Edition, 2006; Chapter 29 Pelvic Relaxation, Urinary Incontinence, and Urinary Tract Infection. Pages 288-298.
  2. Essentials of Obstetrics and Gynecology by Hacker and Moore 4 th Edition, 2004; Chapter 24 Genitourinary Dysfunction: Pelvic Organ Prolapse, Urinary Incontinence, and Infections. Pages 309-324.

Patients with conditions of pelvic organ prolapse and urinary incontinence present in a variety of ways. The physician should be familiar with the types of pelvic organ prolapse and incontinence, and the approach to management of these patients.

The APGO Educational Objectives related to this topic are the following:

  1. Incorporate screening questions for urinary incontinence when eliciting a patient history*
  2. Discuss the difference between stress, urge and overflow incontinence
  3. Obtain pertinent history components to differentiate between incontinence types
  4. Identify the following elements on physical exam: cystocele, rectocele, vaginal vault/uterine prolapse
  5. List behavioral, medical and surgical methods to appropriately treat incontinence and pelvic organ prolapse

*Designated as Priority One in the APGO Medical Student Educational Objectives, 8 th Edition

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