403) A 68 year old woman with history of Diabetes mellitus is evaluated in your office during routine follow-up visit. She reports that lately she has been experiencing pressure and bulge in her vaginal area and has a sensation of something falling out of her vagina. She denies any fever, burning, frequency or urgency of urination. She has normal bowel movements and has no problems with defecation. She is sexually active with her husband and enjoys it. She denies any urinary incontinence even upon coughing or sneezing. On examination, vitals are stable. Pelvic examination reveals changes consistent with vaginal atrophy and a Grade 1 Cystocele. Which of the following is the most appropriate recommendation?
A) Screen for latent Stress incontinence
B) Observation
C) Pessary
D) Surgery
E) Raloxifene
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B) Observation
a
A
B
a
A. screen for latent stress incontinence because insertion of a pessary may unmask it
b for now, if continua or increase or urinary incontinence appear them suergery..
B … Oberve for mild nonbothering cystocele
~A.
Detailed hx is next best step.
B) observation for asymptomatic small cystocele. screen for latent urinary incontinence will do before procedure (pessary or surgery)
It is important to ascertain the level of sphincteric competence preoperatively in any patient undergoing cystocele repair. Clearly, if the patient is incontinent, some type of procedure to increase outlet resistance is needed in addition to cystocele repair. However, many patients presenting with cystoceles may not have associated symptoms of stress incontinence. In these patients sphincteric incompetence may be masked by the valvular effect of the cystocele. If the cystocele is repaired in isolation, the protective valvular effect of the cystocele on the urethra and outlet will be lost. In this case, despite adequate repair of the cystocele, the unsuspended urethra will remain in a low-lying unprotected position, and the patient will have a substantial risk of postoperative incontinence.
b