A 68-year-old woman comes to the office due to vaginal spotting. The patient first noticed dark brown blood stains on her underwear several months ago. She now wears a perineal pad that is partially stained by the end of the day. Occasionally she notices bright red blood on the pad as well. The patient has had no passage of clots or heavy bleeding. For the past year she has been sexually active with a new partner and recently noticed some postcoital bleeding. The patient has no dyspareunia, abnormal vaginal discharge, dysuria, or hematuria. She has constipation that is responsive to a high-fiber diet and stool softeners. In addition, the patient has type 2 diabetes mellitus that is managed with an oral agent. She had a cervical conization 20 years ago for cervical intraepithelial neoplasia; all subsequent Pap tests have been normal, including her most recent test 4 years ago. The patient is a former smoker but does not use alcohol or illicit drugs. Vital signs are normal. BMI is 30 kg/m2. Speculum examination shows no active vaginal bleeding. There is an erosion near the posterior fornix. The cervix is erythematous but there are no nodules or lesions. The uterus is small, mobile, and nontender. There are no adnexal masses or tenderness. On Valsalva, a mass is noted to protrude past the hymenal ring. Anal sphincter tone is normal on rectal examination. Which of the following is the most likely diagnosis for this patient?
Pelvic organ prolapse | |
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This patient's postmenopausal bleeding is likely due to pelvic organ prolapse (POP). POP occurs as a result of damage to or atrophy of the ligaments, muscles, and nerves that support the pelvic organs. This damage leads to herniation of the uterus (apical prolapse), bladder (cystocele), or rectum (rectocele) through the vagina, resulting in vaginal pressure and a bulging mass at the introitus. Although POP can be asymptomatic, patients often have associated urinary (eg, incontinence, retention), defecatory (eg, constipation), or sexual dysfunction (eg, dyspareunia). Patients with severe, prolonged prolapse can develop vaginal or cervical erosions if the cervix and vaginal apex protrude through the introitus, rub on clothing, and become inflamed and denuded. These erosions often cause abnormal vaginal bleeding (eg, postcoital, postmenopausal).
Risk factors for POP include obesity, increasing age, high parity, and history of operative vaginal delivery. Management options for POP include a pessary and surgical correction, which are equally efficacious. In addition, administration of vaginal estrogen is indicated to facilitate healing of cervicovaginal erosions.
(Choice A) Cervical cancer can present with vaginal bleeding; however, speculum examination typically shows an exophytic cervical lesion rather than a posterior vaginal fornix lesion. In addition, this patient's normal Pap tests and postmenopausal status make cervical cancer less likely.
(Choice B) An endocervical polyp can present with abnormal vaginal bleeding and postcoital spotting; however, endocervical polyps typically have a smooth, vermiform appearance and are visible protruding through the cervical os during speculum examination.
(Choice C) Endometritis presents with vaginal bleeding and is associated with new sexual partners; however, there is also uterine and cervical motion tenderness rather than a vaginal mass or erosion.
(Choice E) Uterine leiomyoma can cause abnormal uterine bleeding (eg, heavy menstrual bleeding); however, examination typically reveals an enlarged, irregularly shaped uterus.
Educational objective:
Severe or prolonged pelvic organ prolapse can cause vaginal erosions that lead to abnormal vaginal bleeding (eg, postmenopausal bleeding, postcoital spotting). Treatment of prolapse is via pessary or surgical correction; erosions can be treated with vaginal estrogen.