Vaginal/vulvar disorders: The Daily PANCE Blueprint
A 52-year-old postmenopausal woman presents with a sensation of a bulge in her vagina and difficulty with bowel movements for the past year. She reports needing to manually reduce the bulge to complete defecation. She has had two vaginal deliveries and underwent a hysterectomy 5 years ago. Physical examination reveals a posterior vaginal wall bulge that is reducible. What is the most appropriate next step in the management of this patient?
A. Initiate estrogen replacement therapy
B. Refer for surgical repair
C. Start pelvic floor muscle training
D. Prescribe stool softeners
E. Perform a colonoscopy
Answer and topic summary
The answer is C. Start pelvic floor muscle training
The patient’s symptoms and physical findings are consistent with a rectocele, which is a herniation of the rectum into the posterior vaginal wall. This condition is often seen in postmenopausal women and those who have had multiple vaginal deliveries or pelvic surgeries. It can cause symptoms like a sensation of a vaginal bulge, difficulty with defecation, and the need for manual reduction of the bulge to complete bowel movements. Pelvic floor muscle training (Kegel exercises) is the first-line treatment for mild to moderate cases of rectocele. These exercises aim to strengthen the pelvic floor muscles, thereby providing better support to the rectum and improving symptoms. It’s important to note that rectocele can often coexist with other forms of pelvic organ prolapse, so a thorough pelvic examination is crucial.
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