A 78-year-old woman with chronic obstructive pulmonary disease, chronic hypertension, and history of myocardial infarction requiring angioplasty presents to your office for evaluation of “something hanging out of her vagina.” She had a hysterectomy for benign indications at the age of 48 years. For the past few months, she has been experiencing pelvic pressure and a bulge at the vaginal opening. She reports that 2 weeks ago, something fell out of her vagina. Pelvic examination demonstrates total eversion of the vagina. There is an arc of superficial ulceration at the vaginal apex measuring 2 to 3 cm in diameter.
Which of the following is the best next step in the management of this patient?
Vaginal vault prolapse occurs in up to 18% of patients who have undergone hysterectomy. Symptoms include pelvic pressure, backache, and a mass protruding from the vagina. Depending on the duration and degree of the prolapse, the patient may also have vaginal ulcerations from the prolapsed vagina rubbing against the undergarments. This patient is a poor surgical candidate given her multiple medical problems; therefore abdominal sacral colpopexy is not the ideal treatment. Her age and medical history also preclude oral estrogen treatment. The preferred treatment is to place a pessary to prevent the vagina from rubbing against clothing and to relieve her sense of pelvic pressure and vaginal bulge. The patient could also apply a topical estrogen cream to the lesion and the prolapsed vagina to help with healing of the ulcer. If the ulcer does not resolve, biopsy is indicated.
A 40-year-old G3P3 presents for a routine annual examination. She tells you that she gets up several times during the night to void. She also reports that during the day she sometimes gets the urge to void, but cannot quite make it to the bathroom in time. She does not leak urine when she coughs or sneezes. Upon further questioning, she admits to drinking several large glasses of iced tea and water on a daily basis, because her mother always told her to drink lots of liquids to decrease her risk of developing a UTI. She attributes this to getting older and is not extremely concerned, although she often wears a pad when she goes out because she is afraid she will leak urine. The patient is otherwise healthy, and does not take any medication. She has had three vaginal deliveries of infants weighing between 7 lb and 8 lb. An office dipstick of her urine does not indicate any blood, bacteria, WBCs, or protein. Her urine culture is negative.
Based on her office presentation and history, which of the following is the most likely diagnosis?
This patient’s presentation is most consistent with urge incontinence. Urge incontinence is the involuntary loss of urine associated with a strong desire to void. Most urge incontinence is caused by detrusor overactivity, in which there is an involuntary contraction of the bladder during distension with urine. The initial management includes lifestyle modification such as weight loss, smoking cessation, relief of constipation, minimizing caffeine, and normalizing fluid intake. Other conservative treatments may include bladder training or biofeedback. If conservative measures fail, treatment with anticholinergic medications such as oxybutynin chloride may be successful. These medications inhibit the contractile activity of the bladder. Kegel exercises may strengthen the pelvic musculature and improve bladder control in women with SUI.
Which of the following treatments should you recommend to the patient as the next step in the management of her problem?
This patient returns to your office 3 months later, and continues to be symptomatic after following your advice for conservative self-treatment.
Which of the following is the best next step in management?
An 18-year-old G0 comes to see you with a chief complaint of a 3-day history of urinary frequency, urgency, and dysuria. She panicked this morning when she noticed bright red blood in her urine. She also reports some midline lower abdominal discomfort. She had intercourse for the first time 5 days ago and reports that she used condoms. On physical examination, there are no lacerations of the external genitalia, there is no discharge from the cervix or in the vagina, and the cervix appears normal. Bimanual examination is normal except for mild suprapubic tenderness. There is no flank tenderness, and the patient’s temperature is normal.
Which of the following is the most likely diagnosis?
Approximately 11% of women report at least one documented UTI per year, and up to 60% of women will have UTI during the course of their lifetime. Acute cystitis usually presents with the symptoms of dysuria, frequency, and urgency. In contrast, patients with pyelonephritis may have the same symptoms accompanied by fever, chills, and/or flank pain. A UTI may be diagnosed by evaluating a clean, mid-stream urine sample and finding at least 100,000 single isolate bacteria per mL. A urine dipstick is a fast and inexpensive way to diagnose a simple UTI, and has a sensitivity of 75%. Women with a normal urine dipstick who are symptomatic should have a urine culture, because false negative results are common. The most common causative organism is E coli, which is responsible for 80% to 95% of infections. Other organisms include Proteus, Pseudomonas, Klebsiella, Enterobacter, and Staphylococcus Saprophyticus. Uncomplicated UTIs may be treated with a 3-day course of an antibiotic regimen with trimethoprimsulfamethoxazole or nitrofurantoin, which have good coverage against E coli and are relatively inexpensive. Patients treated for a UTI who have persistent symptoms after treatment should have a urine culture performed to evaluate for the presence of resistant organisms. Patients with acute pyelonephritis may be treated on an outpatient basis unless they cannot tolerate oral antibiotic therapy or show evidence of sepsis. Women who experience recurrent UTIs with intercourse benefit from voiding immediately after intercourse. If this treatment method fails, then postcoital prophylactic treatment with an antibiotic effective against E coli may help prevent recurrent UTIs. Urinary antispasmodics do not prevent infection.