CASE 04: ANATOMIC DEFECT ON PELVIC FLOOR & UROGYNECOLOGY

CASE 4
65 year old G7P7 (7007) consulted because of an introital mass, which she noted 3 years. Lately she feels the need to reduce
the mass inside the vagina to be able to urinate. PMH: COPD on pulmonary rehabilitation since 2008. She has been menopausic
since age 52 with no episodes of postmenopausal bleeding. OB history: 7 NSD, biggest baby: 8 lbs. PPE: external genitalia –
\ anterior and posterior vaginal walls protrude 3 cms beyond the hymen, cervix is smooth and descends 3 cms below the level of
the hymen; uterus is small; adnexa – no masses & tenderness; RVE: (+); Stress test (+); Bonney test (+).

CC: Introital Mass: POP Q numbers:

 Is it a mass within the vagina or protruding out the vulva?
 For the case, the mass is already out of the vulva because
she has to push the mass inside the vagina for the past 3
years

ADDITIONAL DATA NEEDED:

Gen Data: Occupation - heavy lifting, prolonged standing
 NSD
 Where were these deliveries done?
 Hospital: performed Episiotomy In the past, there are no numbers. The products of anterior
 Home delivery: unlicensed to perform Episiotomy vaginal wall correspond to what used to be called a Cystocoele.
 Menopause
 Still important that after she have menopause, did
she had any symptoms? Did she receive any
hormonal treatment? (Symptomatic: 50% Women)
ROS: Urinary System (very important)
 Frequency of urination
 How often do you urinate during the day?
 Presence of urinary incontinence:
 Can you still control urination? Is there involuntary
voiding when you laugh, cough or strain?
 What descends? BLADDER
 To know kind of UI (stress, overflow, detrusor
 Prolapse of anterior vaginal wall is represented by Aa & Ba
muscle), Do URODYNAMIC STUDIES
Symptoms of Anterior Vaginal Wall Prolapse:
Risk Factor for the weakening of the pelvic masses or
 Urinary frequency
supporting structures for the uterus:
 Introital mass (felt when washing)
 65 years old, menopausic since age 52
 Residual urine (when the residual urine does not come
PE: (Lithotomy position) out, some place their finger in the vagina then push
Inspection: bladder up)
 Grand multiparous - see the beginning of the vaginal  Stagnant urine makes the patient prone to frequent
canal, the labia are already apart from one another attacks of urinary infection
 Nulliparous – only the labia minora & majora
 Cystocoele represented by the new term: Aa & Ba
 When you ask the patient to strain, you will see the  If C prolapses, uterus will start to go down held by several
gradual appearance of the cervix, recognized by external ligaments
os  Strongest ligament: Cardinal or Mackenrodt's ligament
 As you strain further, you will be able to observe the:  What happens? The ligaments that hold the uterus in
o Prolapse of the anterior vaginal wall, posterior place becomes lax as an effect of pregnancy, delivery,
vaginal wall & uterus. occupation, menaupasal state…
o Involuntary loss of urine
Uterine prolapse: "Buwa"
PREPARATION FOR PELVIC EXAM:  Uterus going down to the vagina, to the vulva
 Normally: Empty Bladder  Most likely accompanied by the prolapse of both anterior
 Case, Presence of Urinary Incontinence: Full bladder & posterior vaginal wall

(+) Stress Test Recommended treatment:

 (+) = Incontinence  Principle:
 Urinary Stress Incontinence – due to weakness of the o Take off the uterus that prolapses,
urethra-vesical angle o Strengthen the pubocervical fascia,
o Strengthen the posterior pararectal fascia.
(+) Bonney test  Vaginal hysterectomy (not abdominal) with anterior and
 (+) = No loss of urine, can be corrected surgically posterior repair + suspension operation for the stress
incontinence
 2 fingers placed in below the urethral orifice to make the
urethra-vesical angle smaller  make the patient strain
IF patient just had MI, she cannot be operated. You can push it
back inside the pelvis & block the prolapse by means of a
DIAGNOSIS:
PESSARY.
 POP AaBaApBp,C + 3
 Anterior (Aa,Ba) & posterior vaginal walls (Ap,Bp)
protrude 3 cms beyond the hymen, cervix (C) is smooth
and descends 3 cms below the level of the hymen