Urogynecology Case

Parade of Surgery
2018
No Patient Diagnosis Plan DPJP
1. Mrs. TF, P3 42 Uterine Prolapse grade 3 Total Vaginal dr. Tyas , OBGYN (
yo/4263651 with elongatio coli, Hyterectomy, Mecall C)
Cystocele grade II, culdoplasty
Rectocele grade II,
Susp Entrochel
Mild SUI
Hypertension Gd 1
 Mrs. Suni, 59 yo/ 4271998
Uterine Prolapse grade I, , Cystocele grade III, Rectocele grade II,, Hypertension
grade 2 with uncontroled blood pressure

Chief Complain: Alergy: -

Protrusion mass from vagina since 1 year before History of previous illness:
admission ( refered from siloam hospital) Cardiac disease (-), Allergy (-), Chronic cough (-),
Asthma (-), Hypertension (+) not controlled (herbal
medicine)
History: Menstruation: menarche 14 yo, regular, 4-5day,
Patient complain protrusion from vagina since 1 year before
dismenorea (-)
admission and getting bigger when. Mass can push upward. Mass
getting bigger when she stand and doing activity. She fell pain and Marriage history: 1x. Patient sexually active.
discomfrod and no vaginal bleeding, patient said came out vaginal Obstetric history:
discharge (flour albus) since 1 years. She did’n felt urinal leakage P3A0, all spontaneous, with the heaviest child was
when coughing, miction 6-8 times/day. There was no complain for 2900 g
micturition pain, dissatisfaction while urinating, and urge suddenly History of occupation: gardener
for urinating. There was no complain for defecation.
History of contraception: IUD
She still active sexual activity, She routinely take vegetables and
fruits for meal and drink a lot of water every day.
patients working in the garden, History of lifing heavy weight Physical Examination:
things (trader), history cronic cought CM, BP 145/90 mmHg, HR 83 x/min,
RR 20 x/min, T 36 C
BH: 160cm, BW:60 kgs BMI : 23,6 kg/ cm 2

General state:
Thorax : cor/pulmo wnl
Eye: No anemic conjungtiva nor icteric sclera
Abd: firm, pain (-), no mass palpable
Others wnl
Gynecology state:

Inspection :
There was bulging at anterior vaginal mucose passing the hymenal ring

Inspeculo :
Smooth portio, closed OUE, fluor positif, fluxus negatif, uterine sondage 12 cm
anteflexed

VT :
Anteflexed uterus, normal size and shape, no adnexal mass, smooth parametrium,
TLA 2

RT :
smooth rectal mucous , ampulla not collaps, TSA 3
Aa Ba C
Cough tes : negative 0 0 -5
Prolaps reduction test (Pessary test) : - GH Pb TVL
7 2 10
Uterine Sondage : 12 cm Ap Bp D
-1 -1 0
Pelvic floor US exam:
Bladder neck descent 1,30 cm
Maximal genital hiatal 30,82 cm2
Minimal genital hiatal 20,44 cm2
LUG: R L
2,28 cm 2,27 cm
2,37 cm 2,35 cm
2,47 cm 2,40 cm
Levator ani defect (-)

Perineometer :20,5
TLA: 2
Rontgen thorax (26/03/18) : Perioperatif
no abnormality in pulmonal and cor Cardiology : mild -moderate
Pulmo : mild
Hemato : mild
Laboratory: (09/03/18)
Endokrin : mild
DL : 14,3/39,7/6,540/292.000//69.2/21.5/31 Anesthesia: ASA 2
OT/PT : 16/17 , Ur/Cr 29/0.6
PT/APTT: 1,1/ 1,1 Assessments:
FBG/BG 2 PP : 92/98 Prolaps uterine grade I,
Na/K/Cl 157/5.1/112,5 Cystocele grade III,
HBsAg / Anti HIV : non reaktif Rectocele grade II,
UL : Within normal limit Hypertension grade 2 with uncontroled blood
pressure
PAP SMEAR (17/11/2017)
Negative, no malignancy cell Management:
Total vaginal Hysterectomy
Meccal Culdoplasty
Thank You