Gynaecology Letter

Specialty: Urogynaecologist 1 November 2024 Dear Dr. Smith, Re: Ms. Jane Doe, DOB: 15/03/1978, NHS No: 123 456 7890 **Consultation** I reviewed Ms. Jane Doe, a 46-year-old female, DOB: 15/03/1978, NHS No: 123 456 7890, residing at 123 High Street, Anytown, AB1 2CD, in the Urogynaecology clinic. **Presenting Complaint** * Pelvic organ prolapse symptoms. The patient reported a sensation of a 'lump coming down' from her vagina, which has been present for approximately 18 months and has progressively worsened. She describes it as a dragging sensation that is more noticeable at the end of the day or after prolonged standing. The symptoms significantly impact her daily activities, causing discomfort during walking and exercise, and she has had to reduce her physical activity level. She also expressed anxiety about the progression of her symptoms. **Review of Systems** Bladder: Patient reported occasional stress urinary incontinence, particularly with coughing or sneezing. No urgency or frequency. No dysuria. Bowel: Patient reported mild constipation, requiring increased effort during defaecation, which she believes is exacerbated by the prolapse. No faecal incontinence. Sexual function: The patient is sexually active. She reported discomfort during intercourse due to the prolapse symptoms, leading to reduced frequency of sexual activity. **Past Health History** Ms. Doe has a medical history significant for two vaginal deliveries, the last being 10 years ago. She has no known drug allergies and takes no regular medications. She underwent an appendicectomy at age 12, with no reported complications. When asked about prior surgeries, she confirmed no other gynaecological or abdominal procedures. * Gravida 2, Para 2 (both vaginal deliveries) * Appendicectomy (age 12) * No significant medical comorbidities (e.g., diabetes, hypertension). Ms. Doe works as a retail manager, which involves prolonged standing. She has been advised to consider modifications to her work schedule or duties to reduce prolonged standing, potentially reducing symptom exacerbation. **Examination** * Speculum examination revealed a Stage II anterior vaginal wall prolapse (cystocele). * Bimanual examination confirmed good uterine support but noted a mild rectocele. * Perineal body intact. Good levator ani muscle tone. * Grade 2 uterine prolapse. BMI: 28.5 kg/m² **Management Plan** We discussed various management options, including conservative measures such as pelvic floor physiotherapy and pessary use, as well as surgical intervention. The risks associated with surgical repair, including infection, bleeding, recurrence, and potential for de novo stress urinary incontinence, were thoroughly explained. Ms. Doe understood and accepted these risks. A surgical management plan for anterior and posterior colporrhaphy with perineorrhaphy was agreed upon. Ms. Doe has been placed on the waiting list for surgical scheduling. Patient education materials regarding pelvic floor exercises and lifestyle modifications for prolapse were provided. She was also given information about local pelvic floor physiotherapy services. Referral to the gynaecology physiotherapy department was made to commence pelvic floor strengthening exercises pre-operatively and provide ongoing support. This referral was made to optimise her pelvic floor muscle strength before surgery and aid in post-operative recovery. Ms. Doe will have a follow-up appointment in six weeks to review her pre-operative assessment and to discuss any further questions. Blood tests for routine pre-operative screening have been requested.