Prolapse/Incontinence (Gynecology)

Thank you for your referral of Margaret Jenkins, a pleasant 64 year old woman referred for symptomatic pelvic organ prolapse and stress urinary incontinence.

Reason for Visit

• Presents with a 2-year history of progressive vaginal bulge and worsening stress urinary incontinence (SUI), seeking definitive management options.

History of Present Illness

• Vaginal bulge noticed 2 years ago, progressively worsening; now palpable outside the introitus, particularly at the end of the day or after prolonged standing. SUI present for 5 years, triggered by coughing, sneezing, and exercise, requiring 2–3 panty liners daily.
• Associated pelvic heaviness and dragging sensation. Denies urgency, urge incontinence, dysuria, hematuria, or voiding dysfunction. No need for digital splinting to void.
• Completed 4 months of supervised pelvic floor muscle training (PFMT) with minimal improvement. Previously trialed a ring pessary 6 months ago, which was expelled twice; patient wishes to discuss surgical vs. repeat pessary options.

Bowel Function

• Bowel movements every 2–3 days, Bristol Stool Scale type 2–3. Occasional straining; denies fecal incontinence or need for perineal/vaginal splinting to defecate. Takes polyethylene glycol 3350 (RestoraLAX®) PRN.

Fluid Intake

• 1,500 mL of water daily
• 500 mL of caffeinated coffee (2 cups) each morning
• 250 mL of herbal tea in the evening

Past Medical History

• Essential hypertension, well-controlled.
• Hypothyroidism.
• Osteoarthritis of the bilateral knees.

Medications

• amlodipine (Norvasc®) 5 mg PO daily
• levothyroxine (Synthroid®) 75 mcg PO daily
• polyethylene glycol 3350 (RestoraLAX®) 17 g PO PRN

Allergies

• Sulfonamides (maculopapular rash). No known food or environmental allergies.

Surgical History

• Laparoscopic cholecystectomy (2012) — uncomplicated, no adverse reactions to general anesthesia.
• Bilateral tubal ligation (1995) — uncomplicated.

Gynecological History

• Menarche age 12; menopause age 51. Denies postmenopausal bleeding. Last Pap test in 2022 was normal. History of mild vulvovaginal atrophy; not currently on local estrogen. Sexually active, reports mild dyspareunia secondary to vaginal dryness and awareness of the bulge. Denies history of STIs.

Obstetrical History

• G3T3P0A0L3. Three spontaneous vaginal deliveries (1988, 1990, 1994). Largest birth weight 4,100 g (1990), complicated by a 2nd-degree perineal laceration and vacuum-assisted delivery.

Social History

• Retired elementary school teacher. Lives with husband. Lifetime non-smoker. Consumes 1–2 glasses of wine per week.

Family History

• Mother had a vaginal hysterectomy and anterior repair for uterine prolapse at age 68. Father had T2DM and CAD. No family history of gynecologic malignancies.

Review of Systems

• Constitutional: Negative for weight loss, fever, or fatigue.
• GU: Positive for vaginal bulge and SUI; negative for hematuria, nocturia (wakes 0–1x/night), or recurrent UTIs.
• GI: Positive for mild constipation; negative for hematochezia or melena.

Physical Examination

• Vitals: BP 128/76 mmHg, HR 72 bpm, BMI 26.4 kg/m².
• Abdomen: Soft, non-tender, non-distended, no palpable masses or hernias.
• Pelvic Exam: Vulvovaginal mucosa pale and dry, consistent with genitourinary syndrome of menopause (GSM). Positive cough stress test in lithotomy position. POP-Q assessment with Valsalva reveals Stage II anterior compartment prolapse (Ba +1), Stage I apical prolapse (C -4), and Stage I posterior compartment prolapse (Bp -2). Total vaginal length (TVL) 9 cm. Bimanual exam shows a small, mobile, non-tender uterus; no adnexal masses. Pelvic floor muscle tone is weak (Oxford grade 2/5) with no levator avulsion or tenderness.

Investigations

• Urinalysis (14/05/2026): Negative for nitrites, leukocytes, and blood.
• Post-void residual (PVR) via bladder scan (14/05/2026): 35 mL.

Assessment

• 64-year-old postmenopausal female with symptomatic Stage II cystocele, Stage I uterovaginal prolapse, urodynamic stress incontinence, and GSM, refractory to conservative PFMT.

Plan

• Initiate estradiol (Vagifem®) 10 mcg PV daily for 2 weeks, then twice weekly for GSM and pre-operative tissue optimization.
• Discussed conservative (Gellhorn pessary) vs. surgical management. Patient elected to proceed with surgical correction.
• Consented for anterior colporrhaphy and retropubic mid-urethral sling (TVT); risks including bleeding, infection, mesh exposure, bladder perforation, voiding dysfunction, de novo urgency, and recurrence reviewed in detail.
• Advised to increase dietary fiber and use polyethylene glycol 3350 (RestoraLAX®) 17 g PO daily to avoid straining.
• Pre-operative anesthesia clinic referral initiated; follow-up post-operatively in 6 weeks.

Once again, thank you for involving me in her care.