An 89-year-old woman just admitted to acute geropsychiatric hospital seen because night-shift nursing staff report a mass between her legs. Has profound dementia with marked behavioral disturbance; highly resistive to all medical and nursing care. Permits brief limited supine external genital examination, which reveals apparent tiny right labial skin tag. Staff reassured. Day staff call 2 days later: "It's much worse."
Background problems include vascular dementia, hypertension, stroke, multiple drug allergies, urinary tract infection. Has 2 daughters; both born by vaginal delivery.PHYSICAL EXAMINATION
Now vulvar region contains rounded protruding mass, nontender, not fluctuant. Anus intact with no hemorrhoids. Internal examination refused.
Broad-based gait with short, dragging steps.LABORATORY RESULTS
Serum levels of B12, ionized calcium, and thyroid-stimulating hormone normal.
The centrally prolapsing mass is smooth and hemispherical, covered by smooth (non-rugate) mucosa that has predominantly horizontally oriented visible superficial vasculature. A minute vertical erosion looks as though it might be traumatic, but was nontender, and no material was expressible from its surface. No pelvic organs could be seen, felt, or inferred behind this mass.
During the brief course of examination and then clinical photography, the mass spontaneously reduced part way (Figure 1). On gentle digital pressure by the examiner, it went the rest of the way back in readily, painlessly, and completely (Figure 2). The diagnosis was severe vaginal prolapse.
Incidentally, the left labium majus appears wider and shorter than the right. This became much clearer after the mass was reduced.TRYING TO IDENTIFY AND EXCLUDE COMPETING POSSIBILITIES
The mass felt firm but not hard, nor was there any shape within it that might suggest a uterus following close behind. Supporting the impression, one could not see any place on the prolapse that could reasonably be labeled as the cervical external os or a vaginal apex scar. (There was no external scar to suggest an unreported prior hysterectomy, but a remote vaginal hysterectomy might leave no other trace.)
The prolapse felt non-fluctuant--ie, as though no fluid filled it from behind--and, of course, this is as it should be: the redundant mucosa and serosa are not accompanied by an excess of peritoneal fluid either loculated or otherwise.
No element in the protrusion looked especially anterior or posterior. Had there been such evidence of origin, one might try to infer cystocele or rectocele, respectively, though a wonderful consensus report on terminology1 proposes limiting these diagnoses to cases in which imaging studies or endoscopy2,3 have provided more solid evidence of what viscera might lie "behind the curtain" of prolapsed vaginal mucosa.
The lack of rugae did not militate against this tissue's being vaginal: since estrogen stimulation had been lost following menopause and had not been replaced either topically or systemically, flattening is expected. Autopsy experience has shown that rugae can persist for many years after menopause even without hormone replacement, but in an 89-year-old woman such persistence would be truly surprising.POSITION AND DETAIL OF EXAMINATION
Some literature advocates drawing one's conclusions about the degree of prolapse only after repeating the examination with the patient standing, so that gravity will drag contents outward to the maximum degree experienced by the patient in daily life. However, good studies using physical examination and imaging in both positions have shown that for most patients, this is unnecessary: the degree of prolapse is not routinely augmented over what is achieved with the Valsalva maneuver in the supine position.4 The authors do advocate asking the patient if what is observed during the examination corresponds to the most severe prolapse that she sees personally, providing her a hand-mirror to help in this assessment. Should the report differ, re-examination standing--something that embarrasses all parties--is an option for further investigation.
Since we so often fail to obtain a satisfactory Valsalva maneuver, let me suggest a personal method for instructing any reasonably intellectually intact and at least passively willing person: With the patient supine, place your open hand, palm down, 2 or 3 inches above the abdomen in the midline and simply say, "I want you to push out your stomach so that it comes up to touch my hand." If the patient starts to arch the back, advise, "No, it all has to come from pushing." If you try it on yourself, you'll find that you automatically then exhale against a closed glottis.WHAT ABOUT THE LABIA?
The labial asymmetry was dealt with expeditiously: Lacking evidence of edema, distended glands, inflammation, or a neoplasm beneath the surface that would account for the disparity, it was labeled normal. This constitutes an under-recognized variant in the aged, just as is atrophy or even complete resorption of labia minora in extreme age, which will be the topic of a future "What's Your Diagnosis?" column with vivid illustration.MANAGEMENT
Elective gynecological consultation was obtained, with hopes that a pessary would be prescribed. Pessaries are widely employed with good effect, though the literature includes material on adverse effects particularly in the patient with poor self-awareness and limited access to nursing and medical care; this woman, however, was returning to a nursing home after discharge from our Behavioral Health Hospital Unit, and so would retain close supervision.
Surgical approaches have been employed in selected cases.5 They have become more consistently laparoscopic and thus "minimally invasive," but in view of clearly expressed preferences and comorbidities both psychiatric and medical, surgery was not sought for this woman. Nor was imaging required: the problem distressed her caregivers but not herself. We found no evidence of any adverse physical effect, present or anticipated in the near to middle future. Diagnostic and therapeutic restraint, not dictated by financial constraints, suited the personalized care of this unique patient. *
Schneiderman H. Vaginal prolapse: making sense of a common finding. CONSULTANT. 2007;47:1074-1077.