PLANNING MATRIX

Goal To imprint on the interns a firm know-how about pelvic organ prolapse in order to benefit the patients they see at the Gynecology OPD Output At the end of the small group discussion, the group should have been able to discuss the definition, presentation, pathophysiology, diagnosis (POP-Q scoring), and best practices in the work-up and treatment options of pelvic organ prolapse, applying it to the index case presented, according to the POGS November 2010 Clinical Practice Guidelines on Urogynecology Specific Objectives

Specific Objectives To define pelvic organ prolapse To describe its pathogenesis and correlate it with its clinical findings To differentiate it from other introital masses To identify best practices in ancillary procedures for its definite diagnosis To learn how to use the POP-Q classification To identify its various complications To identify various treatment options and apply it to the patient - To establish risk factors

Guide Questions 1. What is pelvic organ prolapse? 2. How does it present, and correlate these with the patient. 3. What other pathologies would you consider given the finding of an Introital mass? 4. How do you establish its diagnosis?

5. How do you grade pelvic organ prolapse? 6. What are its complications if left untreated, i.e. the natural course of the disease? 7. What are the various treatment options (medical and surgical)? 8. How will you apply this to the patient? 9. How can one prevent pelvic organ prolapse? 10. How will you advise the patient and her family?

Activity Selection of case Review of related literature for the case topic Small Group Discussion

Resources Gynecology patients in wards and OPD POGS CPG on Urogynecology (2010) Katz Comprehensive Gynecology, 5th edition Powerpoint Case protocol

Personw Responsible Block W Dr. Mendoza Block W

Time Weeks 13 Week 3-4

Evaluation Approval/rejection by Dr. Mendoza Guide Questions provided

Block W Consultant

Week 4

Performance at SGD Care of grading sheets Feedback from consultant

CASE PROTOCOL
SS, 50, married from San Pablo, Laguna Chief Complaint: Vaginal Bleeding Medical History No co-morbidities Family History No heredofamilial diseases Personal Social History

BS commerce graduate, works as a sales person, (-) vices, first coitus at 26 to one non-promiscuous sexual partner, (-) history of OCP, IUD, STI use Obstetric-Gynecologic History G4P4 (4004) G Year AoG 1 2 3 4 1989 1992 1994 1997 FT FT FT FT

Delivery SVD SVD SVD SVD

By MD MD MD MD

Place San Pablo Medical Hospital Immacul ate Concepci on Hospital

Sex Male Femal e Femal e Femal e

Weig ht 8.6 lbs 8.6 lbs 8 lbs 7.8 lbs

Complicat ion (-) FMC (-) FMC (-) FMC (-) FMC

s/p bilateral tubal ligation- 1997, Laguna Menstrual History Menarche: 13 years old, Intervals: regular, monthly, Duration: lasting 5-6 days, Amount: 2 pads per day, fully soaked; Symptoms: (+) dysmenorrhea, VAS 5-7/10, pain relieved by Mefenamic Acid LNMP: approximately 1st week of May, 2012. PMP: April 2012 History of Present Illness: 5 years prior to admission: Patient noted an introital mss, 4x3 cm in size, noted to protrude from the vagina whenever the patient was straining or standing. No consult was done, no urinary or bowel symptoms at this time. 2 years prior to admission, patient had sudden onset fever and generalized abdominal pain, associated with heavy menstrual bleeding. She was then hospitalized at San Pablo Medical Hospital. She was then transfused blood, and diagnosed to have dengue fever. However, she reported to the physician that she had a mass prolasing into her vagina, and TV-UTZ was done, and an assessment of Pelvic organ prolapsed was made, with an incidental finding of myoma uteri. She was then discharged stable with take home medications of Tranexamic acid 500 mg TID and FeSO4 tab OD. At the time, there was no dysuria, no BM changes, and no weight loss. Surgery was advised, but she deferred due to financial constraints. Second opinion was sought instead. 8 months prior to admission, patient decided to seek consult for her condition, despite allegedly feeling well, and consulted at the PGH OPD. KUB and TV-UTZ were done, revealing multiple myoma uteri, mild pelvocaliectasia and severe urinary retention. Surgery was scheduled 1 month prior to admission. Review of Systems: (-) nausea, vomiting, weight loss, fever (-) change in appetite (-) dyspnea, chest pain, chest tightness (-) palpitations, claudication, PND, easy fatigability, orthopnea (-) abdominal pain, BM changes (+) intermenstrual bleeding (+) hesitancy, intermittency, nocturia; (-) oliguria (-) stress or urinary incontinence (-) polyuria, polydipsia, polyphagia Impression at the time: POP Stage IV, Multiple myoma uteri, Adenomyosis Reactive thrombocytosis Admission PE: Patient is conscious, coherent, cooperative, ambulatory, and not in cardiorespiratory distress

BP: 120/80 HR: 92 RR: 16 T: 36.3 HEENT: Anicteric sclerae, pink conjunctivae. (-) anterior neck mass, cervical lymphadenopathies Breast: Grossly normal. (-) masses/lesions CVS: Adynamic precordium, distinct S1S2, normal rate, regular rhythm. (-) murmurs Respiratory: Equal chest expansion, clear breath sounds. (-) adventitious breath sounds. (-) retractions, use of accessory muscles. Abdomen: Abdomen was soft and globular. Normoactive bowel sounds. Cervix prolapsed out of the vagina. GU (IE): Gaping introitus, lax anterior and posterior vaginal mass, on reduction, smooth vagina. Cervix 4x4 cm, smooth. Corpus enlarged to 10 weeks size. (-) adnexal masses or tenderness. POP-Q grading +3 +10 +10 8 3 10 +2 +6 +8 Extremities: Full equal pulses, pink nailbeds. Capillary refill time of less than 2 seconds. (-) cyanosis, edema, clubbing. Neurologic exam: Oriented to 3 spheres, (-) sensorium changes Labs at Admission: BT: A+ CMG (12/7/11): Normal stable bladder. Max capacity: 525 mL/2.9cm H2O (-) cough stress test. Induced volume: 500 mL (7/6/12): CXR: No significant chest findings. 12L ECG: RSR, NA, IVCD Blood Chemistry FBS: 80.18 mg/dL BUN: 3.10 Crea: 62 AST: ALT: 11 Na: 140 K: 3.7 Cl: 103 PT PT: 11.8/11.6/1.02/0.98 PTT: 35.6/45.7 CBC WBC: 8.50 RBC: 4.36 HgB: 121 Hct: 0.351 MCV: 80.5 MCH: 27.7 MCHC: 345 RDW: 13.3 Plt: 423 Neutrophil: 0.662 Lymphocyte: 0.241 Monocyte: 0.080 Eosinophil: 0.013 Basophil: 0.005

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PBS: No toxic granulation, slight poikilocytosis (ovalocytes), adequate platelets, normochromic. TV-UTZ: (7/6/12) The uterus is retroflexed with irregular contour and heterogenous echopattern measuring 9.7 x 8.3 x 7.1 cm. (Cervix measures 2.8 x 3.0 x 3.3 cm). The endomterium is hyperechoic with small cystic spaces measuring 2.3 cm thick with intact subendometrial halo. There is a well-circumscribed heterogenous mass measuring 4.3 x 4.3 x 3.8 cm at the posterior myometrium, intramural with subserous component. The right ovary measures 5.4 x 5.1 x 4.5 cm with a unilocular anechoic cystic mass measuring 4.2 x 4.2 x 4.0 cm. The left ovary measures 2.8 x 2.3 x 2.2 cm. There is minimal anechoic free fluid in the cul de sac. I: Myoma uteri, intramural with subserous component. Thickened endometrium consider endometrial pathology. Right ovarian cyst probably physiologic. Normal right ovary. Urinalysis: (7/5/12) Straw, hazy. Sg 1.010, pH 8.0. (-) sugar, (-) protein 5-10 RBC/hpf, 2-6 WBC/hpf, few epithelial cell,s 3+ bacteria, negative mucus threads. (-) casts/crystals (-)bilirubin,ketones Normal urobilinogen 1+ leucocytes (+) nitrite Hgb 2+ Urine GS/CS: 7/6/12 (-) PMN, G (-) bacilli >20/oif Final: Mixed culture, please repeat. Urinalysis: 7/8/12 Straw, clear. Sg 1.005, pH 6.5. (-) sugar, (-) protein. 0.1 RBC / hpf; 2-4 WBC/hpf; few epithelial cells, few bacteria. (-) mucus threads (-) casts/crystals. (-) bilirubin, ketones, nitrite. Normal urobilinogen. Trace leukocytes, trace hemoglobin. Course in the Wards: 07/05/2012: Admitted to Ward 14B. Initial plans: For OR Scheduling, DAT, increase OFI. No IVF or meds for now. PH, FBB daily, Monitor VS q4. 07/06/2012: Referred to Uro-Gyne for UA findings, SAPOD for clearance, and Hematology due to CBC findings 07/07/2012: SAPOD: Pt is low clinical risk for intermediate surgical risk procedure. 07/08/2012: Scheduled for OR on 07/12/12. Started on general liquid diet. IVF: PNSS 1L x 10h. Start on metronidazole 500 mg/tab TID, Dulcolax tab, 2 tab at HS Hematology: No contraindication to surgical procedure, repeat CBC post-op. 07/09/2012: Uro-gyne: IE revised. +1 +7 +10 7 3 10 +1 +6 +8 OR rescheduled to 07/12/11. Soft diet then GL now, CL tomorrow, NPO at midnight of OR. 07/10/2012: Latest PE:

Patient is conscious, coherent, cooperative, ambulatory, and not in cardiorespiratory distress BP: 120/80 HR: 88 RR: 20 T: 36.8 HEENT: Anicteric sclerae, pink conjunctivae. (-) anterior neck mass, cervical lymphadenopathies Breast: Grossly normal. (-) masses/lesions CVS: Adynamic precordium, distinct S1S2, normal rate, regular rhythm. (-) murmurs Respiratory: Equal chest expansion, clear breath sounds. (-) adventitious breath sounds. (-) retractions, use of accessory muscles. Abdomen: Abdomen was soft and globular. Normoactive bowel sounds. Cervix prolapsed out of the vagina. GU (IE): Gaping introitus, lax anterior and posterior vaginal mass, on reduction, smooth vagina. Cervix 4x4 cm, smooth. Corpus enlarged to 10 weeks size. (-) adnexal masses or tenderness. Extremities: Full equal pulses, pink nailbeds. Capillary refill time of less than 2 seconds. (-) cyanosis, edema, clubbing. Neuro: Oriented to 3 spheres, (-) sensorium changes Current Impression: POP St. IV Multiple Myoma Uteri Adenomyosis. Management: For VHAPR, BSO, McCull Culdoplasty, BICF / RA Final pre-op plans: Clear liquids, NPO after midnight. IVF: D5N$ 1L x 8h once on NPO. No further labs. Continue meds: FeSO4 tab OD, Metronidazole, 500 mg/tab, TID. Dulcolax suppository, 2 tabs at HS. Abdominoperineal prep. PH, FBB daily.