One interesting case I observed in clinic was a 49 y/o BF with C/C of urinary incontinence and feeling of fullness in her vaginal area. She had been seen the weekend before in ER because seeing her bladder upon bearing down had startled her ad she was not sure what it was. Margaret a G5P5A0 was pleasant and in no pain. The obstetrician and I took her Hx and initiated a pelvic exam. All of her children had been SVD’s. Her urinary incontinence symptoms had progressively gotten worse. She goes through multiple pads in a day and it was starting to cause her to change plans, stay home more. Pelvic exam revealed intact vaginal vault, no masses. When we had Margaret bear down you could see the bladder descend to the opening of the vagina. OB provider explained a cystocele is mild (grade 1) when the bladder droops only a short way into the vagina. With more severe (grade 2) cystocele, the bladder sinks far enough to reach the opening of the vagina. The most advanced (grade 3) cystocele occurs when the bladder bulges out through the opening of the vagina. Something I would not have thought of the OB took the speculum apart and with one half was able to introduce into vaginal vault, yet see the upper and lateral walls much more clearly. Margaret was a grade 2. He discussed use of a pessiary which is a plastic support piece placed in the vagina that provides support to the adjacent pelvic organs. Performing kegel exercises to help strengthen area, decrease heavy lifting and straining. He also discussed surgical options but wanted to give her some time doing more conservative measures first.
Once she had left we discussed the impact of decreased estrogen level on post menopausal women and its effect on musculature. The one option I brought up was referral for pelvic muscle PT evaluation. I was told they were not in that area. I mentioned you could go through HBA/tricare to help find one in the area or I provided contact: kendra.harrington@amedd.army.mil, 202-782-5716. He felt like that was a valid point and would forward to head nurse to research for future patient referral.
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Great Point Marty, I talked to the surgeon at Walter Reed who does these surgeries (pelvic floor) and she didn't understand why more providers didn't refer their patients to her. I'm sure its a lack of not knowing the resources available. As NP's we need to keep up with what's available in our region b/c that patient deserved better...
ReplyDeleteI saw quite a few patients with mild or grade 1 cystoceles, and most were asymtomatic and not aware that there was a weakening in the vaginal walls. Typically, what I saw on exam, when the patient was lying supine in the lithotomy position, the anterior vaginal mucosa appeared to be sagging when looking at the vaginal introitus, and when the patient beared down the rugae may or may not protude. The older patients did seem to have more laxity of the vainal walls and we would see occasional mild rectoceles also. As I mentioned before, these patients were asymptomatic, so we did not treat the conditions.
ReplyDeleteExcellent discussion - and thanks for the education of your colleagues about resources they might not know about.
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