A 78-year-old woman with chronic obstructive pulmonary disease, chronic hypertension, and history of myocardial infarction requiring angioplasty presents to your office for evaluation of something hanging out of her vagina. She had a hysterectomy for benign indications at age 48. For the past few months she has been experiencing the sensation of pelvic pressure. Last month she felt a bulge at the vaginal opening. Two weeks ago something fell out of the vagina. On pelvic examination the patient has total eversion of the vagina. There is a superficial ulceration at the vaginal apex. Which of the following is the best next step in the management of this patient?
a. Biopsy the vaginal ulceration
b. Schedule abdominal sacral colpopexy
c. Placement of a pessary
d. Prescribe oral estrogen
e. Prescribe topical vaginal estrogen cream
the answer is below…
The United States Medical Licensing Examination, or USMLE for short, is a three-part licensing examination that is required in order to receive a license to practice medicine within the United States.
The USMLE assesses a physician’s ability to apply knowledge, concepts, and principles, and to determine fundamental patient-centered skills that are important in health and disease and that constitute the basis of safe and effective patient care.Examination committees composed of medical educators and clinicians from across the United States and its territories prepare the examination materials each year.
This exam is designed by the Federation of State Medical Boards and the National Board of Medical Examiners to determine whether or not an individual understands and can apply the knowledge necessary to practice medicine safely and intelligently.
The USMLE is actually comprised of three different exams that are referred to as steps, which examine the individual’s knowledge of specific topics related to the field of medicine such as basic science, medical knowledge, medical skills, clinical science, and the application of all of these skills and areas of knowledge in the medical field.
All three steps of the USMLE include a series of computerized multiple-choice questions, but the format of the exam and the information covered in each multiple-choice section is different for each step of the USMLE. The USMLE Step II also has a clinical skills portion that examines an individual’s ability to work with real patients and the USMLE Step III has a computerized patient simulation portion in addition to the multiple-choice section of the exam. In order for an individual to receive a license to practice medicine, the individual must pass all three steps of the USMLE.
The correct answer is e; Prescribe topical vaginal estrogen cream.
Vaginal vault prolapse occurs in up to 18% of patients who have undergone hysterectomy. Symptoms include pelvic pressure, backache, and a mass protruding from the vagina. Depending upon the duration of the prolapse the patient may also have vaginal ulcerations from the rubbing of the prolapsed vagina against the undergarments. This patient is a poor surgical candidate given her multiple medical problems; therefore abdominal sacral colpopexy is contraindicated. For the same reasons she should not be given oral estrogen treatment. The preferred treatment is to have her apply a topical estrogen cream to the lesion and the prolapsed vagina to help with healing of the ulcer. If the ulcer does not resolve, biopsy is indicated. A pessary may be tried, but only after the ulcer has healed.