Case Study Pelvis and Perineum
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mod8_case_study_questions.docxCase Study - Pelvis and Perineum
Presentation/History
A farmer's wife, 42 years old, comes to the outpatient department with the following complaints. She has a bearing down sensation in her womb, "something seems to come down." This discomfort increases when she strains or lifts heavy loads. She often has backaches, particularly if she is on her feet all day. She also complains of urinary symptoms, such as frequency of and burning on urination. She fatigues easily. The patient has had four children and two miscarriages. Her menstrual flow is increased and her periods are somewhat irregular.
Examination
On general examination the patient appears nervous and anxious. She is underweight and rather frail. Otherwise the general examination does not show any abnormalities. Gynecological examination reveals a moderate downward bulging on the anterior vaginal wall that increases on straining. On examination in the erect position the cervix of the uterus is found in the vagina close to the vestibule. It recedes somewhat when the patient is supine, yet does not assume its normal position. The cervix is elongated.
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Discussion Thread
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Questions |
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Uterine prolapse, often combined with a cystocele as we find it in this patient, is one of the most frequently encountered gynecological disorders. What is the cause of the uterine prolapse and the cystocele? With advancing age there is increased relaxation and loss of tonus of the muscular and fascial structures that constitute the support of the pelvic viscera. This fact is mainly responsible for the disorder. Do multiple childbirths contribute to the occurrence of uterine prolapse? Lacerations and overstretching of the supporting tissues during childbirth greatly enhance the chances for prolapse.
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How do you explain the discomfort of the patient, consisting of a feeling of heaviness in the lower abdomen and backache?
How do you explain the urinary symptoms such as frequency and burning in cystocele?
What is the normal position of the uterus?
How does its position change with an empty versus a full bladder?
In what direction does the ostium of the uterus face if the uterus is in its typical anteverted position?
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Intra-abdominal pressure further accentuates the downward displacement of the cervix. Congestion and swelling gradually result in elongation of the cervix as in our patient.
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What are the main supporting structures of the uterus?
What is the main muscular constituent of the pelvic diaphragm?
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It is variable in thickness and is often partly replaced by connective tissue after having been lacerated and stretched during childbirth. Its two halves are separated in front by a narrow gap.
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Give the name of the gap and state what partially closes it.
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The importance of this muscular component for the support of the uterus is exemplified by cases where, due to congenital paralysis of the muscle in malformations of the spinal cord, there is already a prolapse of the uterus in the early years of childhood. The support of the uterus by these structures is mainly indirect, however, in that the uterus rests on organs that on their part are sustained in their position by the intact pelvic and urogenital diaphragms. These organs are the bladder, on which the normally anteverted and anteflexed uterus rests, and the ampulla of the rectum, which supports the cervix uteri and the vagina caudally and posteriorly. Finally the fibrous connective tissue between the vagina and bladder and vagina and urethra should be mentioned as a supporting factor. The former is loosely areolar, the latter denser. Clinicians have given them the names of vesicovaginal and urethrovaginal septa or fasciae. They are a part of the pelvic visceral fascia and fuse with the outer layers of the organs previously mentioned.
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Submit your completed exercise as an attachment to the drop box for this module. Please be sure to include your last name and the course number in the title of the document, like so: "your name X 104 Assignment_Mod8.
When you have submitted this drop box assignment, go to the Discussion Forum for this module in the course and develop a working diagnosis and associated treatment plan for this patient.
