Gynecology conference

4/29/20
Case #1
• 45 year old G5P4 who complains of a vaginal bulge and pressure for 4
months. She has no PSH or PMH.
• DDX?
• Evaluation?
Describe the POPQ-system of staging
Our Patient’s Pelvic exam
• Normal appearing external genitalia
• Generalized atrophic changes
• A cystocele and rectocele are noted
• The cervix descends to past the hymen
• The uterus is normal in size. Right and left ovaries are normal size
and non-tender
• Normal rectal sphincter tone
• gh 6, pb 1, tvl 10, Aa +3, Ba +4, Ap 0, Bp 0, D -4, C +2
• What stage is she?
• Treatment options?
Surgery
• The patient decides she wants a native tissue repair with no mesh.
Describe the steps of a vaginal hysterectomy
How do you close your cuff?
• How do you prevent apical prolapse?
ACOG PB Pelvic Organ Prolapse
• Detailed history
• Bulge symptoms
• Urinary incontinence/voiding dysfunction
• Bowel complaints
• Physical exam
• Include abdominal & pelvic
• Assess kegels: “absent, weak, normal, strong”
• Detailed pelvic in supine position
• Use split speculum to evaluate anterior, posterior, apical compartments
• Evaluate with valsalva, cough, standing if needed
• POP-Q is recommended
• Additional evaluation
• PVR if urinary complaints or prolapse beyond hymen
• UA/micro if has urinary urgency or LUTS
• UDS if unclear Dx, voiding dysfunction, stage II POP and incontinence
POP-Q system
• Pelvic Organ Prolapse –
Quantification
• Stage is the leading edge
• Stage is based on position of
vaginal walls relative to hymen
• Stage 2 is -1 to +1
• Stage 4 is within tvl -2
Case #2
• 68 year old G8P7 with large vaginal protrusion
• PMH: COPD, CVA, DM, HTN, colon cancer
• PSH: appendectomy, partial colectomy for colon cancer, cesarean x 1,
abdominal hernia with mesh
• Evaluation?
Our Patient’s Pelvic exam
• Normal appearing external genitalia
• Severe atrophic changes
• A cystocele and rectocele are noted
• The cervix descends to past the hymen
• The uterus is normal in size. Right and left ovaries are non-
palpable and non-tender
• Normal rectal sphincter tone
• gh 6, pb 1, tvl 11, Aa +3, Ba +10, Ap +3, Bp +10, D 0, C +10
• What stage is she?
• Treatment options
• The patient decides on a pessary.
• Which pessaries do you use?
• How do you decide on a size and a type of pessary?
• Patient presents 6 months later with brownish red vaginal bleeding.
• DDX?
• What is your next step?
Our Patient’s Pelvic exam
• Normal appearing external genitalia
• Severe atrophic changes
• Gelhorn pessary in place
• Fecal matter seen at the introitus
What is your next step?
You remove the pessary and note a 1 cm
rectovaginal fistula
• What is your plan?
• Do you order imaging?
How do you council patients about pessaries?
DDx for vaginal bleeding with pessary
• Vaginal/cervical ulcer
• Vaginal atrophy
• Uterine bleeding
• UTI
• Hematuria
• Rectal bleeding
• Vesicovaginal fistula
• Rectovaginal fistula
Evaluation
• Full pelvic/rectal
• Remove pessary and examine for ulcers, lesions, fistula, UTI,
hemorrhoids
• If rectovaginal fistula- refer to urogyn or CRS
• Do NOT put pessary back in
• If lower rectal injury, no additional imaging needed
Pearls of excellence Pessary Management
• Minor complications are common
• Pessaries alter vaginal flora, often producing a thin, watery, physiologic
discharge. This discharge does not need to be treated unless there is itching,
burning, or odor.
• Superficial vaginal mucosal erosion is the most frequently reported
complication and may result in foul odor and purulent discharge. Erosion
can usually be managed by removing the pessary until the erosion is healed.
If untreated, continued pressure of the pessary on the erosion may lead to
local ulcerations, infections, and rarely, fistulas or ulceration of the uterus.
• Risk factors for erosion include continuous long-term use and placement of
a large pessary.
Serious complications
• Some types of pessary shapes and materials are associated with more serious
complications, usually in a setting of neglect, for example, nursing homes residents
or patients with dementia.
• Vesicovaginal fistulas have been associated with the Gellhorn or shelf design
pessaries.
• Rectovaginal fistulas have a higher association with rubber or PVC pessaries use
when compared with polythene pessaries.
• A neglected pessary can also lead to fecal impaction, bowel fistula, hydronephrosis,
and urosepsis. Some small case series correlated long term use of pessaries with
very rare occurrences of primary vaginal cancer, with postulated mechanistic
pathways including chronic inflammation in the setting of viral infection or
inducement of metaplastic changes that progress to dysplasia and cancer.
Pessary Management
• Overall, pessaries remain a safe, viable and important non-surgical
treatment option for many patients.
• Complications are generally minor.
• More serious complications can occur, and are more frequent with
improper care as well as with some device designs and materials.
• Frequent removal and cleaning of the pessary as well as periodic
vaginal examinations can minimize complications.