Question of the Week # 405

405)  A 80 year old woman with advanced dementia is sent to your office for evaluation of a vaginal ulcer. The patient has a history of Stage III uterine prolapse. She had been fitted with a pessary for control of her symptoms about 6 months ago. She has no history of fever or chills. On examination, she is afebrile, blood pressure is 130/80. Pelvic examination revealed complete procidentia with impacted pessary and a 2  x 2 cm ulcer without any exudate. An attempt to remove the pessary is unsuccessful. Biopsies of the ulcer have been obtained. Which of the following is the appropriate initial management?

A) Vaginal Estrogen

B) Oral Antibiotics

C) Surgical removal of Pessary

D) Hysterectomy

E) Admit for parenteral antibiotics

12 Responses

  1. C) Surgical removal of Pessary?

  2. vaginal estrogen

  3. Vaginal Estrogen Trail
    if no response then Surgical removal of pessary

  4. c

  5. C-

  6. D…. we need to treat her primary problem, the complete procidentia, for which they tried the pessary at first and it failed… go for hysterectomy and rule out any abnormal pathology in the vaginal ulcer.

  7. ~D.
    80y old lady with complete procidentia came with pessary impacted and ulcer. I think hysterectomy with biopsy follow up would be next best step in this case.

    Correct me I’m wrong.

  8. 80 years old lady with complete uterine procedentia, impacted pessary, vaginal ulcer. Causes of vaginal ulcer can be decubitus ulcer because of procedentia and lack of estrogen, or chronic irritation with pessary. For 80 years old lady, I don’t want to go straight to the surgery. I want to try with estrogen cream that can help to moist the vaginal and promote healing of ulcer and easier to remove the pessary.
    Answer : A

    • I want to change the answer, the patient has advanced dementia and she did not come back to renew pessary in 6 months. I do not want her to send with pessary again. She is not reliable, so remove the pessary surgically and plan to do hysterectomy if she is fit enough.

      • Answer C

  9. since it asks for initial management vg estrogen seems correct
    dr archer pls post the rite answer

  10. I think to start with local estrogen therapy to treat the ulcer and improve vaginal mucosa followed by removal of impacted pessary so answer is A

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