Pelvic Floor Disorder

An 83-year-old woman complains of a dragging sensation in the lower abdomen and lower back pain when standing or walking.  It has been present for some years but she can now only stand for a short time before feeling uncomfortable.  It is not noticeable at night.  She has had four vaginal deliveries.  She had her menopause at 52 years and took hormone replacement therapy for several years for vasomotor symptoms.  She has not had any postmenopausal bleeding and has not had a pap smear for several years.

She is generally constipated and sometimes finds she can only defecate by placing her fingers into the vagina and compressing a “bulge” she can feel.  She has mild frequency and gets up twice most nights to pass urine.  There is not dysuria or hematuria.  Occasionally she does not get to the toilet in time and leaks a small amount of urine, but this does not worry her unduly. 

Medically she is very well and does not take any medications regularly.  She lives alone and does her own shopping and housework

Examination – on exam she appears well.  Blood pressure and heart rate are normal.  She is of average build.  The abdomen is soft and non-tender.  There is a loss of vulval anatomy consistent with atrophic changes.  On examination in the supine position there is a mild prolapse.  On standing, the cervix is felt at the level of the introitus.  There is a large posterior wall prolapse and a minimal anterior wall prolapse.

Questions:

1. What is the diagnosis for her discomfort and pain?
2. How would you manage this patient?

Responses need to address all components of the question, demonstrate critical thinking and analysis, and include peer reviewed journal evidence to support the student’s position.