GYNAECOLOGY CASE PRESENTATION

Final MBBS / Final Year MBBS Examination

CASE HISTORY

PART I: PATIENT IDENTIFICATION

PART II: CHIEF COMPLAINTS

1. Mass descending per vagina - 3 years duration
2. Blood-stained vaginal discharge - 1 month duration
3. Dragging sensation in lower abdomen - 2 years duration

PART III: HISTORY OF PRESENT ILLNESS

A. Mass Per Vagina (3 years)

• Onset: Insidious
• Progression: Gradual, progressive over 3 years
• Size at presentation: Currently described as approximately "lemon-sized"
• Reducibility: Initially spontaneous, now requires manual reduction
• Associated with: Worsening on standing, straining, coughing, lifting heavy loads; partial relief on lying down
• Ulceration: She noticed reddening and surface irregularity of the mass in the last 3 months

B. Blood-Stained Vaginal Discharge (1 month)

• Onset: 1 month ago
• Nature: Blood-stained, mucoid, foul-smelling
• Amount: Scant to moderate
• Cyclical nature: Absent (post-menopausal)
• Post-coital bleeding: Absent
• Likely cause: Ulceration of the prolapsed, decubitus ulcer of the cervix/vaginal mucosa

C. Dragging / Bearing-Down Sensation

PART IV: ASSOCIATED SYMPTOMS

PART V: MENSTRUAL HISTORY

PART VI: OBSTETRIC HISTORY

• Four vaginal deliveries
• Prolonged second stage in multiple pregnancies
• Instrumental (forceps) delivery
• Large babies (fetal macrosomia)
• Unsutured perineal tear (damage to levator ani and perineal body)
• No postnatal pelvic floor physiotherapy

PART VII: PAST MEDICAL AND SURGICAL HISTORY

• Chronic constipation: Since age 40, treated with laxatives intermittently
• Hypertension: Diagnosed 5 years ago, on Tab. Amlodipine 5 mg once daily
• No history of: diabetes mellitus, tuberculosis, asthma, prior pelvic/abdominal surgery
• No prior gynaecological surgery
• No history of radiation to pelvis

PART VIII: PERSONAL HISTORY

PART IX: FAMILY HISTORY

• Mother: Had similar complaint of "mass per vagina" in her 60s (genetic/connective tissue predisposition)
• No family history of malignancy
• No connective tissue disorders identified in family (Marfan syndrome, Ehlers-Danlos excluded)

PART X: DRUG AND ALLERGY HISTORY

• Tab. Amlodipine 5 mg once daily (for hypertension)
• No known drug allergies
• No current use of oestrogen or hormone therapy

PART XI: RISK FACTORS SUMMARY (for UV Prolapse)

PART XII: GENERAL PHYSICAL EXAMINATION

PART XIII: SYSTEMIC EXAMINATION

PART XIV: LOCAL EXAMINATION

A. Inspection (Patient in Dorsal/Lithotomy Position)

1. External genitalia: Sparse grey pubic hair. Vulval skin appears atrophic with loss of labial fullness (oestrogen deficiency).
2. Perineum: Wide, gaping vaginal introitus. Old healed perineal scar noted. Perineal body appears deficient.
3. Prolapse on inspection:
   • A large, pinkish-red globular mass is seen protruding through the vaginal introitus
   • The mass is approximately 8 x 6 cm
   • The surface shows a decubitus ulcer - a superficial, well-defined, pale-based ulcer approximately 2 x 2 cm at the most dependent part of the cervix, with surrounding congestion
   • Blood-stained mucoid discharge is seen oozing from the ulcer surface - explaining the chief complaint
4. Ask patient to strain (Valsalva): Increased protrusion noted
5. Anterior vaginal wall: Bulging cystocele noted (anterior wall comes down with the mass)
6. Posterior vaginal wall: Rectocele seen posteriorly
7. No cystourethrogram visible in standing position

B. Per Speculum Examination (Sims' speculum - left lateral position)

1. Vaginal walls: Pale, atrophic rugae are diminished or absent (oestrogen deficiency). Mucosal folds are flattened.
2. Cervix: Elongated, hypertrophied cervix. Decubitus (pressure) ulcer present on the portio vaginalis - well defined, clean base, no irregular edges (consistent with traumatic/pressure ulceration rather than malignancy - biopsy still warranted to exclude carcinoma).
3. Anterior wall: Cystocele noted when posterior wall is retracted with Sims' speculum
4. Posterior wall: Rectocele noted when anterior wall is retracted
5. Enterocele: Suspected - high posterior bulge seen on straining
6. Cervical os: Multiparous os (transverse)
7. Discharge: Scanty mucopurulent, blood-stained discharge from cervical os and ulcer surface

C. Bimanual Pelvic Examination

1. External os: Multiparous (transverse slit)
2. Cervix: Elongated (cervical length > 4 cm on probing), soft, mobile; no hardness or nodularity (no features of malignancy on palpation)
3. Uterus: Anteverted, retroverted (or retroflexed), small (post-menopausal sized), mobile. Mild descent noted.
4. Adnexa: No adnexal masses palpable. No tenderness in fornices.
5. Fornices: Free, no thickening or tenderness
6. Uterosacral ligaments: Lax and attenuated (felt through posterior fornix)
7. Cystocele: Confirmed anteriorly - bladder base palpable through anterior vaginal wall
8. Rectocele: Confirmed posteriorly

D. Per Rectal Examination

• Rectal mucosa intact
• Rectocele felt anteriorly as a bulge
• Anal sphincter tone: slightly reduced
• No rectal masses

PART XV: GRADING OF PROLAPSE (POP-Q System)

• Uterine prolapse: Grade 4 (Procidentia / complete uterine prolapse)
• Cystocele: Grade 3 (anterior compartment)
• Rectocele: Grade 2-3 (posterior compartment)
• Elongation of cervix: Present (cervical elongation contributing to procidentia)

PART XVI: PROVISIONAL DIAGNOSIS

Third Degree Uterovaginal Prolapse (Procidentia) with Decubitus Ulcer of Cervix

1. Cystocele - Grade 3
2. Rectocele - Grade 2-3
3. Stress Urinary Incontinence (probable)
4. Post-menopausal atrophic vaginitis
5. Mild anaemia (probable, secondary to discharge and poor nutrition)
6. Hypertension (on treatment)

PART XVII: DIFFERENTIAL DIAGNOSIS

1. Cervical elongation (without true uterine descent) - excluded by bimanual noting true uterine descent
2. Fibroid polyp - excluded by non-reducibility, examination findings
3. Carcinoma cervix - must exclude by biopsy from ulcer (blood-stained discharge in post-menopausal woman is a red flag)
4. Bartholin's cyst - excluded by location and examination
5. Vaginal cyst / Gartner's duct cyst - excluded by examination

PART XVIII: INVESTIGATIONS PLANNED

1. Haemoglobin, CBC, PCV
2. Urine R/M and culture sensitivity (for associated UTI)
3. PAP smear from cervix
4. Cervical biopsy from ulcer edge (to exclude carcinoma - mandatory before any surgery)
5. Blood glucose (fasting and post-prandial)
6. Renal function tests (serum creatinine, BUN) - prior to surgery
7. Chest X-ray PA view
8. ECG (pre-operative, given age and hypertension)
9. Coagulation profile (PT, aPTT)
10. Blood group and type & cross match

PART XIX: MANAGEMENT (Outline)

A. Pre-operative Preparation

• Treat decubitus ulcer: Local oestrogen cream application for 4-6 weeks to improve tissue quality
• Pelvic floor physiotherapy (Kegel exercises)
• Treat constipation (high-fibre diet, stool softeners)
• Optimise blood pressure
• Treat anaemia if present

B. Definitive Surgical Management (Choice for this patient)

• Vaginal Hysterectomy with pelvic floor repair (colporrhaphy)
  • Anterior colporrhaphy (for cystocele)
  • Posterior colporrhaphy and perineorrhaphy (for rectocele + perineal body repair)
  • Vault suspension (Sacrospinous ligament fixation / McCall culdoplasty) to prevent vault prolapse
• If unfit for surgery: Ring Pessary insertion (replaced every 3-6 months)

C. Post-operative Care

• Pelvic floor exercises (life-long)
• Topical vaginal oestrogen (post-menopausal)
• Avoid heavy lifting
• Treat constipation

SUMMARY