Question of the Week # 404

404)  A 70 year old woman in excellent physical health presents to your office because she has noticed a mass falling out of her vagina for the past one year which is progressively worse. For the past six months, she has difficulty voiding. During voiding, she has to constantly change her position and sometimes, needs to push the mass inside in order to urinate. Lately, voiding has become even more difficult despite all these measures. She has problems with defecation which she describes as having to apply pressure on her vagina in order to completely evacuate her bowel. . She denies any fever or burning  urination.  She has normal bowel movements and has no problems with defecation. She is embarrassed to have sex anymore after having had urinary incontinence during sex. She blames herself for neglecting the mass without seeking medical attention for such a long time. Otherwise, she is in excellent physical health and has no other co-morbidity. She is willing to consider any option including surgery if feasible. On examination, vitals are stable. Pelvic examination revealed a total prolapse with total eversion of the vagina which was oedematous with marked ulceration in the dependent portion of the mass. Which of the following is the appropriate initial management?

A) Obtain Urodynamic studies

B) Biopsy

C) Admit for daily Vaginal packing with estrogen

D) Vaginal estrogen and Pessary

E) Vaginal Hysterectomy

10 Responses

  1. C) Admit for daily Vaginal packing with estrogen – to reduce edema and ulceration before surgery

  2. she is an an increased risk of developing acute urinary retension as well as fecal impaction as she is quite symptomatic already …E surgery is her only aption at this time …. if she was a poor surgical candidate, then D would have been the right choice as post menopausal women can develop uterine prolapse due to estrogen deficiency which then causes vaginal atrophy and decreased strenght of the supporting muscles, so u give intra vaginal estrogen and pessaries to hold the prolapsed section in place.

    she also has marked ulceration of the prolapsed mass, she could develop severe complications like sepsis, hence , surgery.

    B … biopsy ??? could be right too …. plz lemme know

  3. DR. what is the answer?

    I like to go for surgery

  4. ~B
    Prolonged prolapse with ulceration-biopsy.
    Dr. Red please shed light on this.

  5. ccc to reduce oedema and promote ulcer healing first.

  6. right answer??

  7. correct answer?

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