Grade III Uterine prolapse, grade III cystocele, grade II rectocele

Conservative/operative

1. Good morning, I'm dr. xxx, Im doctor on duty, i want to ask you something

and i will do some examination before I know the conclusions from your

complaints and the plan that will be done.

2. Taking History:

a. How long the complaints occur ? 8 months

b. Are the lumps feels out when you do some activities? Stand up? defecate?
c. Are the lumps reduced when you lying/rest?
d. Are you still having sex with your husband? Yes, but rarely, maybe once a

1 week
e. Are you already menopause? How long you do not menstruation? > 5

Years
f. Obstetrics History
i. How many children do you have? 5
ii. If you had a miscarriage? 1
iii. Are all your children was born with spontaneous/normal? Yes
iv. How the most your children birth weight? 3900 grams
g. Present Status
i. Height/weight ? 150/67, BMI : 29.71
ii. BP/Pulse/RR/ Tax: DBN
h. General Status: In a normal limits

KIE: get into the examination table please.

I will do the examination in lithotomy position, the felt may uncomfortable fro

you because I will do the vaginal toucher examination, just relax so that doesnt

hurt and do not straining.

i. Gynecology Status
 o How the Abdomen? How much the height of fundus? Are you can

palpable the mass? (-)

o Inspection of the vulva/vagina: found the cervical mass outside the

vagina, the surface was smooth, portion, no erosion, no mass, the

vagina was smooth.

o Speculum examination of the vulva/vagina: found the cervical mergeal

atrophy
Walls of vagina is pale
o VT: corpus uteri < normal
Adnexal mass (-)
Tenderness (-)
Uterine Sondage test? 5cm, ante flexion

KIE: Ok, try coughing please.

Cough test? (-)

Now you can straining please.

cystocele uterus

rectocele

TVL cut off point TVL -2

Tonus levator ani (Oxford scale)? 2

Ok, from the examination, I found that you have grade III uterine prolaps

Grade III uterine prolapse, grade III cystocele, rectokel grade cIII
o Overweight

There are 2 options therapy that can be done :

 Conservative using pessaries
Operative TVH + SSF + KA + colpoperineorrhaphy

Non TVH Sacrospinosus hysteropexy + KA +

colpoperineorrhaphy

The complaint you should ask

1. Anterior Compartment: urinary incontinence, retention

Are you difficult to delay the urinate? Do you can complete the urinate?

Are you feel the pain when urinate?

2. Apical Compartments: Uterine / Peak Vagina
3. Posterior Compartment: retention
4. Impairment of sexual function

But, from our consideration

1. You have enough children

2. Your age was 60 years old & Already menopause
3. There are hormonal changes due to menopause
4. Still have sex with your husband (sexual functions)

Compared to using pessaries (ring), with several complications like:

o You should to visit every 3 months

o Having less comfortable sex
o vaginal discharge may occur
o Risk factor for vaginal abrasion

I suggest you to undergo surgery :

TVH + SSF + KA + colpoperineorrhaphy Yes doc

Oke, I should preparing you for the surgery, because you are > 50 years old. I will

preparing you for:

 Laboratory tests: complete blood count, ECG
Preparation of Patients:
o Consult to anesthetist
o Consult to Internist
o Consult to Cardiologist
Prepare the operations schedule

KIE post-op

1. You can go home if you can completely to urinate.

2. Urine catheter is released until 24 hours post-operation, then I will do 6

hours observation for your urinate.

3. Recurrence rate 29% not caused by surgical technic, but your

tissue was not good like when you are young

4. Recurrence can be prevented, you should do this at home:

o Reduce your body weight (set yout Diet & exercise) because the

patient is overweight.
o Do not lift heavy loads.
o Reduce straining (High-fiber diet, drinking water 2 L/day)
o Kegel training to strengthen the pelvic muscles

Kegel no limits

More longer, more

Patients in lithotomy position

Identification the trained muscles



Insert the finger to the vagina (introitus)

Pinch the finger Repetitive Strength