Thursday, December 23, 2010

O&G Short case: UV prolapse

Please examine this elderly lady who complained of something coming out from her vagina.

  1. Introduce, establish rapport, ask permission, position the patient (super duper mark in this)
  2. If the question asked to examine the perineum, go straight to the perineum by asking the patient to lie down in dorsal position and lift up her cloth while we cover her anterior abdomen with a blanket. Otherwise, do a general examination, or else you would miss the causes, differentials and the complications of prolapse (ie, chronic cough, cachexia to suggest malignancy)
  3. Inspect the perineum. Observe for atrophic changes in the labia majora, and any scars suggestive of trauma. Another sign of atrophic changes is that the labia minora is no longer concealed as we can see in non menopausal women. The pubic hair distribution should also be commented upon. Look hard for any PV discharge or color changes suggestive of inflammation due to infection or ischemia (due to kinking of blood supply particularly the vein)
  4. Ask the patient if she had any vaginal pessary inside her vagina. Ask permission to remove it. Observe if there is any protrusion coming out and comment on that protrusion. If there is none, ask patient to cough. You should be able to see some urine dribbling down if the patient had stress or mixed incontinence due to the prolapse. Then, ask the patient to bear down or any other way which would make the prolapse to come out (ie standing).
  5. Now that the prolapse is out, examine the anterior part of the prolapse. Comment on the dryness, discoloration, ulcer, pus. Look at the urethra opening. If there is any swelling posterior to it, it is the urethrocele. The mass had linear streak it is the bladder rugae lined by the anterior vagina mucosa. The fold behind it is the border between the vagina and the bladder...
  6. Proceed downward and you can see the cervix opening. Determine if the cervix is parous or not (ie, parous will have streak while nulliparous will just had a dot opening) or any peduculated mass, discharge, abnormal looking.
  7. Try to look at the posterior part but you should be able to see it clearer later.
  8. Palpate the uterus and determine the degree of prolapse. it is second degree if not all uterus is coming out (ie you cannot get above it while palpating the uterus upwards) or if you can get above it means that the whole uterus had prolapsed and hence the third degree prolapse.
  9. Ask patient to be in the simms speculum (like the simms speculum itself the patient head is flexed and the hip is also flexed to make a C position). Now using a simms speculum and a sponge holder with gauze inserted, move the posterior wall of the vagina back and use the sponge holder to manipulate the front. Comment on the surface of the prolapsed mucosa (ie, ulcer, skin changes, infection, pus). Move the speculum downward a bit until you see a prolapse from posterior vagina. If the prolapse is higher up it is the enterocele and if it is lower down it is the rectocele. Also, comment on the surface.
  10. Do a rectovaginal exam by inserting the index finger into the vagina (ie like a VE) and the middle finger into the anus. You Should be able to gauge the thickness of both hence the size of her perineal body. The thinner the perineal body is, the weaker the supporting muscle it attaches too.
  11. Finish the examination by reintroducing the prolapse back into the vagina and reapply the pesssary. The pessary should be compressed and inserted upwards towards the umbilicus before released inside the vagina (ie the anatomical pelvic passage) remember to gauge the size of the pessary (by measuring tape)and clean it with antiseptic prior to reinsertion.
Other systems to examine:
p/s the is controversy over doing a pap smear or not because of the dry cervix)
1. Respiratory
2. Abdomen
3. Lower limb
4. Connective tissue defect like ehlers danhlos...

A!!$!$! =p


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