Gynaecology Consult Letter

Urogynaecologist Consultation I reviewed "Mrs. Eleanor Vance" in the Gynaecology clinic. Mrs. Eleanor Vance is a 58-year-old female, married, presenting to the Urogynaecology clinic on 1 November 2024 for evaluation of pelvic organ prolapse. Presenting Complaint and Symptoms Mrs. Vance presents with a primary complaint of a sensation of a bulge in her vagina, which she describes as worsening over the past six months. This sensation is accompanied by symptoms of urinary incontinence, particularly with coughing and sneezing, and occasional difficulty with bowel emptying. The symptoms significantly impact her daily activities, including walking and exercise, and have led to avoidance of social engagements due to fear of leakage. Past Health History Her relevant medical history includes controlled hypertension, for which she takes Amlodipine 5mg daily, and a history of gestational diabetes during her second pregnancy. Regarding surgical history, Mrs. Vance stated she has had no prior surgeries except for two caesarean sections. She denies any other significant medical conditions. * Hypertension (controlled with Amlodipine 5mg OD) * Gestational diabetes (resolved) Occupational considerations and work modifications advised Mrs. Vance works as a primary school teacher. She has been advised to avoid heavy lifting and prolonged standing, which exacerbate her symptoms. Modifications such as sitting breaks and assistance with moving classroom equipment were discussed. Gynaecological History Mrs. Vance has an obstetric history of Gravida 2, Para 2, with both deliveries by Caesarean section. Her gynaecological history is notable for menorrhagia in her 40s, managed conservatively. Her last cervical screening was 2 years ago, with a normal result. She has not undergone any previous gynaecological surgeries or interventions aside from the caesarean sections. Examination * General: Obese, comfortable at rest. * Abdominal: Soft, non-tender, no masses. * Pelvic: Speculum examination revealed a large anterior vaginal wall prolapse (cystocele) extending beyond the introitus with straining (Grade 3). Posterior vaginal wall prolapse (rectocele) also noted, Grade 2. Uterine descent minimal. Perineal body intact. Vaginal mucosa healthy. * Bimanual: Uterus anteverted, normal size, mobile. Adnexa clear. Pelvic floor muscle strength assessed as 2/5. BMI: Raised (32 kg/m²) Discussion about Treatment, Management and Follow Up I discussed various management options with Mrs. Vance, including conservative measures such as pelvic floor physiotherapy, vaginal pessaries, and surgical repair. The risks associated with surgical intervention, including infection, bleeding, recurrence of prolapse, and pain, were explained in detail. Mrs. Vance expressed a preference for surgical management due to the significant impact on her quality of life. A detailed surgical management plan involving anterior and posterior colporrhaphy with possible perineorrhaphy was formulated. She has been placed on the waiting list for surgery. Educational materials on pelvic organ prolapse and surgical recovery were provided. A referral to pelvic floor physiotherapy has been made to commence pre-operatively. Follow-up will be scheduled post-operatively at 6 weeks and 6 months to assess surgical outcomes. Issues 1. Grade 3 anterior vaginal wall prolapse (cystocele). 2. Grade 2 posterior vaginal wall prolapse (rectocele). 3. Stress urinary incontinence. 4. Difficulty with bowel emptying. 5. Impact on quality of life and occupational activities. Management Management options, including conservative approaches (pelvic floor physiotherapy, pessaries) and surgical repair (anterior and posterior colporrhaphy), were discussed in depth. Risks of surgery, including infection, bleeding, recurrence, and pain, were explained. Surgical management plan: Anterior and posterior colporrhaphy with possible perineorrhaphy. Patient has been placed on the waiting list for surgery. Patient education materials on pelvic organ prolapse and surgical recovery provided. Occupational considerations and work modifications advised: Avoid heavy lifting and prolonged standing; utilise sitting breaks and seek assistance with classroom equipment. Referrals made: Referral to pelvic floor physiotherapy for pre-operative strengthening. Follow-up plan: Post-operative review at 6 weeks and 6 months. Investigations: None requested at this time, pending surgical outcome.