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Clinical Crossroads | Clinician's Corner

An 80-Year-Old Woman With Vaginal Prolapse

Geoffrey W. Cundiff, MD, Discussant
JAMA. 2005;293(16):2018-2027. doi:10.1001/jama.293.16.2018.
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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.

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Figure 1. Normal Pelvic Floor Support
Graphic Jump Location

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 support.

Figure 2. Types of Pelvic Organ Prolapse
Graphic Jump Location

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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