Reproductive · Year 2 · from Reproductive
Case 3: Pelvic Organ Prolapse
Clinical Image
Source: Wikipedia - Pelvic organ prolapse - CC BY-SA 4.0
Case Presentation
A 62-year-old G4P4 postmenopausal woman presents with a sensation of vaginal pressure and fullness that has progressively worsened over the past 2 years. She reports a "bulge" that she can feel protruding from the vagina, especially after prolonged standing. She also experiences urinary urgency and frequency, and incomplete bladder emptying requiring her to manually reduce the prolapse to urinate. She has had four vaginal deliveries, with her largest baby weighing 4.2 kg. She underwent menopause at age 52 and has not used hormone therapy. Physical examination with the patient straining reveals a stage III cystocele (bladder prolapse through the anterior vaginal wall extending beyond the hymen), a stage II uterine prolapse, and a stage I rectocele. Post-void residual is 150 mL. Given her symptomatic prolapse affecting quality of life and bladder function, she is offered surgical repair. She undergoes vaginal hysterectomy with anterior and posterior colporrhaphy and uterosacral ligament suspension. Post-operatively, her symptoms resolve and bladder emptying normalizes.
Key Learning Points
- Pelvic organ prolapse results from weakening of the pelvic support structures (levator ani muscles, cardinal and uterosacral ligaments) due to childbirth trauma, aging, and estrogen deficiency
- Risk factors include vaginal delivery (especially of large babies), multiparity, chronic straining (constipation, chronic cough), obesity, and connective tissue disorders
- Prolapse can involve the anterior compartment (cystocele), apical compartment (uterine/vaginal vault prolapse), and posterior compartment (rectocele)
- Treatment options include pelvic floor physical therapy, pessary placement, and surgical repair depending on symptom severity and patient goals