Question:

A 63-year-old woman comes to the office for a routine annual examination. The patient feels well and has no concerns today. She underwent menopause at age 50 and has had no episodes of vaginal bleeding. The patient exercises multiple days a week and has no urinary or fecal leakage. BMI is 29 kg/m². Blood pressure is 126/80 mm Hg and pulse is 80/min. Cardiopulmonary examination is normal. The abdomen is soft and nontender without palpable masses or hernias. On pelvic examination, vulvar atrophy is present, and the vagina appears pale and has minimal rugation but no lesions. The cervix appears normal and has no lesions or discharge. On Valsalva maneuver, there is a bulge of the anterior vaginal wall to the introitus. Postvoid bladder and renal ultrasound is normal. Which of the following is the best next step in management of this patient's pelvic organ prolapse?

Hormone replacement therapy

Pessary placement

Reassurance and observation

Surgical anterior vaginal wall repair

Urodynamic testing

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Pelvic organ prolapse
Definition	Bowel, bladder &/or uterus herniation into vagina
Clinical features	Asymptomatic (incidental finding) Vaginal/pelvic pressure Stress urinary incontinence, retention Constipation, incomplete defecation
Management	Asymptomatic Observation Symptomatic Pelvic floor muscle (Kegel) exercises Vaginal pessary Surgical repair

This patient has pelvic organ prolapse (POP), the herniation of the pelvic organs (eg, bladder, uterus, rectum) into the vagina due to weakened pelvic floor muscles (ie, levator ani complex) from chronic increased intraabdominal pressure. Risk factors include increasing parity, obesity, and advancing age. Women with anterior vaginal wall prolapse (ie, cystocele), such as this patient, can have pelvic pressure and urinary symptoms (eg, retention, stress urinary incontinence). However, many patients with POP are asymptomatic and incidentally diagnosed on routine examination.

Management of POP is based on symptoms or complications:

Asymptomatic patients, such as this one with no complications (eg, no urinary retention or hydronephrosis on ultrasound), do not require treatment and can be managed with reassurance and observation only.
In contrast, symptomatic patients (eg, pelvic pressure) or those with complications could benefit from treatment. Pelvic floor muscle (ie, Kegel) exercises are recommended in these patients. Nonsurgical treatment is with pessary placement, which helps restore pelvic anatomy and reduces the severity of symptoms (Choice B). Surgical management (eg, anterior vaginal wall repair) can be offered to patients whose condition does not improve or those who decline nonsurgical treatment (Choice D).

(Choice A) Hormone replacement therapy is used in the treatment of menopausal vasomotor symptoms (ie, hot flashes) in women age <60 or those <10 years after menopause. It is not indicated in the treatment of vulvovaginal atrophy or POP.

(Choice E) Urodynamic testing is performed in some patients with mixed urinary incontinence (eg, stress vs urgency incontinence) to help guide management. This patient has no urinary leakage and has a normal postvoid residual scan.

Educational objective:
Pelvic organ prolapse (POP) may present with pelvic pressure or urinary dysfunction (eg, retention, stress urinary incontinence). However, many patients with POP are asymptomatic and are managed with reassurance and observation only.