A 42-year-old G3P3 presents to your office 2 weeks after undergoing a vaginal hysterectomy, anterior colporrhaphy, and mid-urethral sling for POP and stress incontinence. She is concerned because she has noticed that she constantly leaks urine throughout the day. She reports no urgency or dysuria.
Which of the following is the most likely explanation for this complaint?
Both vesicovaginal and ureterovaginal fistulas are complications that occur rarely after benign gynecologic procedures. Classically, urinary tract fistulas present with painless and continuous loss of urine 8 to 12 days after surgery. UTIs and detrusor overactivity present with dysuria, urgency, and frequency. Since this patient has no symptoms of stress incontinence, failure of the procedure would not be the correct answer. The first step in evaluation for a vesicovaginal fistula is a careful physical examination. It may be possible to identify a fistula as a defect in the mucosa, or as a erythematous area of granulation tissue. In many cases, the actual fistula cannot be seen. An in-office dye study may be performed by retrograde filling the bladder with a mixture of saline and indigo carmine dye. Speculum examination may then be performed to evaluate for a fistula directly, and the patient may be asked to Valsalva to encourage leakage. Alternatively, a tampon may be placed in the vagina, and evaluated to see if it stains blue, indicating a fistula.
What is the next step to try to confirm you suspected diagnosis?
A 90-year-old G5P5 with multiple medical problems is brought into your office accompanied by her granddaughter. Her medical history is significant for hypertension, chronic anemia, coronary artery disease, and osteoporosis. She is alert and oriented, and lives in an assisted living facility. She takes numerous medications, but is very functional at the current time. She is a widow and is not sexually active. Her chief complaint is a sensation of heaviness and pressure in the vagina. It is uncomfortable when she sits. She reports no significant urinary or bowel problems. On physical examination, you note that the cervix to the level just inside the introitus.
Based on the physical examination, which of the following is the most likely diagnosis?
The degree or severity of pelvic relaxation is rated on a scale of 1 to 3, based on the descent of the organ or structure involved. First-degree prolapse involves descent limited to the upper two-thirds of the vagina. Second-degree prolapse is present when the structure is at the vaginal introitus. In cases of third-degree prolapse, the structure is outside the vagina. Total procidentia of the uterus is the same as a third-degree prolapse, which means that the uterus would be located outside the body.
Uterine prolapse that does not bother the patient or cause her any great discomfort does not require treatment. This especially applies to patients who are elderly or poor surgical candidates. Placement of a pessary provides mechanical support to pelvic tissue, while hysterectomy and the Le Fort procedure are surgical treatments for prolapse. An anterior colporrhaphy is a surgical method to reduce a cystocele. Pessaries provide mechanical support for the pelvic organs. These devices come in a variety of sizes and shapes and are placed in the vagina to provide support. Pessaries are ideal for patients who are not good surgical candidates. Potential complications from pessaries include vaginal trauma, necrosis, discharge from inflammation, and urinary stress incontinence.
What is the best next step in the management of this patient?
If instead of the scenario described earlier, this patient told you that she was asymptomatic from this pelvic organ prolapse, what would be the best next step in management?
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