DR SHIP: Mrs
H is an 80-year-old woman with Medicare insurance who recently began feeling
tissue coming out of her vagina. She called to make an appointment to see
her longtime gynecologist.
She feels generally well and lives with her husband of more than 50
years. She has systolic hypertension and osteoporosis. Decades ago, Mrs H
had 4 vaginal deliveries of healthy, term infants. She has had regular Papanicolaou
smear screening, but her most recent smear showed atypical cells of undetermined
significance. It was her first abnormal smear. She denies vaginal bleeding
or urinary incontinence; she does experience some urinary urgency. Her bowels
are regular. She is sexually active, without dyspareunia or other problems.
A, Connective tissue support (bladder, uterine fundus removed). The
cervix is suspended by the uterosacral and cardinal ligaments. The pubocervical
fascia attaches to the anterior aspect of the vagina and laterally to the
arcus tendineus fascia pelvis. B, Pelvic diaphragm (muscular support). The
inset shows the anterior displacement of the rectum, vagina, and urethra toward
the symphysis pubis due to the resting tone of the puborectalis and pubococcygeus
muscles. C, Sagittal view of pelvic contents showing the position of pelvic
organs, the superior and inferior attachments of the pubocervical and rectovaginal
fascia, and the relationship of the pelvic diaphragm to the connective tissue
A, Sagittal view of pelvis showing both anterior and posterior vaginal
wall prolapse but preserved uterine support. Tears or weakness in the pubocervical
and rectovaginal fascia permits herniation of pelvic organs against the vaginal
wall. B, Apical prolapse. Loss of apical support by the uterosacral and/or
cardinal ligaments results in prolapse of the uterus (left) or, posthysterectomy,
of the vaginal vault (right).
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