Obgyn · Year 3 · from Obgyn
Case 3: Pelvic Organ Prolapse
Patient Demographics
- Age: 68 years
- Sex: Female
- Occupation: Retired nurse
Chief Complaint
"I feel a bulge coming out of my vagina and I'm having trouble emptying my bladder."
History of Present Illness
The patient has noticed a progressively worsening sensation of vaginal bulging over the past 2 years. She initially noticed pressure and heaviness in her pelvis, but over the past 6 months she can feel and see tissue protruding from her vagina, especially when standing or straining. The bulge is worse at the end of the day and improves when lying down. She reports difficulty initiating urination and feels she does not completely empty her bladder. She sometimes has to manually reduce the bulge to urinate. She denies urinary incontinence but does have occasional urinary frequency.
Gynecologic History
- Menarche: Age 13
- Menopause: Age 51
- No hormone replacement therapy
- Prior pregnancies: G4P4 (4 vaginal deliveries, largest baby 9 lbs 2 oz)
- 2 episiotomies with first two deliveries
- No prior pelvic surgeries
Past Medical History
- Chronic constipation (strains frequently)
- Osteoarthritis
- Hypertension (controlled with HCTZ)
Social History
- Former smoker (quit 10 years ago)
- No alcohol use
- Retired, lives with husband
- Active - enjoys gardening and walking
Risk Factors for Pelvic Organ Prolapse
- Vaginal deliveries (4): Major risk factor
- Macrosomic infant (>9 lbs): Present
- Chronic straining (constipation): Present
- Menopause/estrogen deficiency: Present
- Prior episiotomy: Present
- Age: Present
Physical Examination
Standing Examination:
- Visible tissue prolapsing past the vaginal introitus
Supine Examination with Valsalva:
- Anterior compartment: Cystocele - anterior vaginal wall descends 3 cm beyond the hymen
- Apical compartment: Uterus descends to 1 cm beyond the hymen
- Posterior compartment: Rectocele - posterior vaginal wall descends 2 cm beyond the hymen
POP-Q Assessment:
| Point | Measurement |
|---|---|
| Aa | +3 |
| Ba | +3 |
| C | +1 |
| gh | 4 cm |
| pb | 3 cm |
| TVL | 8 cm |
| Ap | +2 |
| Bp | +2 |
| D | -4 |
POP-Q Stage: III (leading edge >1 cm past hymen but not complete eversion)
Rectal Exam: Moderate rectocele confirmed, no rectal masses
Associated Symptoms Assessment
- Voiding dysfunction: Yes - incomplete emptying, need to reduce prolapse to void
- Stress urinary incontinence: No (but may have occult SUI masked by prolapse)
- Defecatory dysfunction: Yes - difficulty evacuating, sometimes splints vagina
Diagnostic Workup
Post-Void Residual: 180 mL (elevated, normal <100 mL) - suggests outlet obstruction
Urinalysis: Negative
Urodynamic Testing (with prolapse reduced):
- Occult stress urinary incontinence unmasked when prolapse reduced
- No detrusor overactivity
Diagnosis
Pelvic Organ Prolapse, POP-Q Stage III
- Anterior compartment: Cystocele (Stage III)
- Apical compartment: Uterine prolapse (Stage II)
- Posterior compartment: Rectocele (Stage III)
- Associated voiding dysfunction
- Occult stress urinary incontinence
Treatment Options Discussion
Conservative Management:
- Pessary:
- Non-surgical option
- Ring pessary with support often effective
- Requires ability to remove/insert or regular follow-up for care
- Trial offered
- Pelvic floor physical therapy:
- May help with mild prolapse
- Unlikely to resolve Stage III prolapse alone
- Can complement other treatments
- Vaginal estrogen:
- Improves vaginal tissue health
- Adjunct to pessary or surgery
Surgical Management:
- Reconstructive Surgery (uterine preservation or hysterectomy with vault suspension):
- Native tissue repair vs. mesh-augmented repair
- Address all compartments
- Concurrent anti-incontinence procedure for occult SUI
- Obliterative Surgery (colpocleisis):
- For patients who do not desire vaginal intercourse
- Lower recurrence rate
- Shorter surgery, faster recovery
Patient's Initial Choice: Pessary Trial
Pessary Fitting:
- Ring pessary with support, size 4
- Successfully fit
- Patient able to void with pessary in place
- Post-void residual improved to 40 mL
- Educated on removal, cleaning, and reinsertion
Follow-up (6 weeks)
- Pessary well-tolerated
- Bulge sensation resolved with pessary
- Vaginal estrogen cream started (twice weekly)
- Some vaginal discharge - normal
Follow-up (6 months)
- Patient reports pessary becoming uncomfortable
- Vaginal irritation noted
- Desires definitive surgical treatment
- Discussed options; patient elects reconstructive surgery
Surgical Treatment: Vaginal Hysterectomy with Uterosacral Ligament Suspension, Anterior Colporrhaphy, Posterior Colporrhaphy, and Midurethral Sling
Procedure Details:
- Vaginal approach
- Hysterectomy performed
- Uterosacral ligament suspension for apical support
- Anterior repair for cystocele
- Posterior repair for rectocele
- Retropubic midurethral sling for occult SUI
Operative Findings:
- Uterus 80 grams, normal
- Ovaries grossly normal (left in place given age)
- No complications
Postoperative Course
- Voiding trial passed POD 1
- Discharged POD 1
- Vaginal packing removed at discharge
- Activity restrictions: No heavy lifting, intercourse, or straining for 6 weeks
Follow-up (6 weeks postoperative)
- Healing well
- No bulge sensation
- Voiding normally, no incontinence
- Cleared for gradual return to activities
Follow-up (1 year postoperative)
- Asymptomatic
- Exam: Well-supported vaginal vault, no recurrent prolapse
- Continent of urine
- Satisfied with outcome
Teaching Points
- Vaginal delivery is the most significant risk factor for pelvic organ prolapse
- POP-Q is the standardized system for documenting prolapse severity
- Pessaries are effective first-line treatment; many patients can avoid surgery
- Occult stress incontinence should be assessed before surgery (unmasked when prolapse reduced)
- Surgical options include reconstructive (vaginal or abdominal) and obliterative procedures
- Native tissue repairs have ~30% recurrence; mesh augmentation has risks
- Vaginal estrogen improves tissue quality for pessary use and surgical outcomes
Clinical Image
Image Description: Clinical photograph demonstrating Stage III pelvic organ prolapse with the vaginal walls and cervix/uterus descending beyond the vaginal introitus. The image illustrates the anterior vaginal wall prolapse (cystocele) and uterine descent characteristic of advanced multi-compartment prolapse.
Attribution: Educational illustration. Used for medical education purposes.