Question

Prolapse

Janice a 78-year-old G4 P4 presents to the office with a complaint of urinary frequency, urgency and a sensation of feeling as if she is sitting on a ball. She states she feels pressure in her lower abdomen and back. She is very healthy and tries to exercise but has been limited secondary to discomfort.

Past Medical History

• Hypothyroid
• Constipation
• Psychosocial history is negative

Medications

• Levothyroxine
• Calcium
• Vitamin D

Answer These Questions

1. What other subjective data do you need to gather today?
2. What objective data would you gather today?
   • Assessment Findings:
     • PE is T 98.6 P 82, R 16, B/P 112/74
     • Abdomen soft NT without masses
     • Pelvic assessment reveals – female external with urethral caruncle
     • Vulva is negative with loss of labial folds secondary to atrophy – no obvious abnormalities
     • Scant vaginal discharge, atrophic, moderate vaginal vault prolapse.
     • Cervix is primiparous - CMT
     • Cervix is primiparous - CMT
     • Uterus small, non tender no masses
     • Ovaries non palpable
     • Rectal negative
     • On Valsalva - +grade 2 cystocele
3. What is your assessment of this patient? Include 1CD10 code and rationale.
4. Your patient states she doesn't want any surgical intervention. Complete a plan of care for this patient including, diagnostics, pharmacological and non-pharmacological treatment, education, including primary and secondary prevention, referrals, and follow up.

Answer 1

Prolapse is a condition in which organs fall down or slip out of place. It is used for organs protruding through the rectum, or for the misalignment of the valves of the heart. A spinal disc herniation is also sometimes called "disc prolapse". Prolapse means "to fall out of place",

In assessment, it is found that -

1) On Valsalva - +grade 2 cystocele -

  A cystocele is mild-grade 1-when the bladder droops. With a more severe-grade 2-cystocele, the bladder sinks far enough to reach the opening . The most advanced-grade 3-cystocele occurs when the bladder bulges out.

Subjective data need to gather -

- Did you underwent any surgery such as hysterectomy?

- Do you feel any pressure while going to toilet?

- Do you have any medication or food allergies?

- Do you feel like any mass protuding while sitting, sneezing and couging?

Assessment of the patient Including 1CD10 code and rationale:

• N81.10 (Cystocele, unspecified) - Use this code when the only information you have is cystocele,
• N81.11 (Cystocele, midline)
• N81.12 (Cystocele, lateral)

Approximate Synonyms :

• Cystocele
• Cystocele without uterine prolapse
• Cystourethrocele
• Cystourethrocele without uterine prolapse
• Cystourethrocele, female
• Female cystourethrocele

Plan of care for this patient including : -

Diagnostics : -

A Grade 2 or Grade 3 cystocele can be diagnosed from a description of symptoms and from an examination.

The doctor may also perform certain tests, including the following:

• Urodynamics: Measures the bladder’s ability to hold and release urine.
• Cystoscopy (cystourethroscopy): A long tube-like instrument is passed through the urethra to examine the bladder and urinary tract for malformations, blockages, tumors, or stones.

Pharmacological and non-pharmacological treatment : -

If it is not bothersome, a mild cystocele may not require any treatment other than avoiding heavy lifting or straining that could cause the problem to get worse.

Other potential treatment options include the following:

• Weight loss.
• Estrogen replacement therapy.
• Kegel exercises to strengthen the openings of the urethra. These exercises involve tightening the muscles that are used to stop the flow of urine, holding for 10 seconds, and then releasing.
• If symptoms are modest, a device called a pessary may be placed to hold the bladder in place. Pessaries are available in a number of shapes and sizes to ensure a proper fit. A pessary has to be removed and cleaned on a regular basis in order to avoid infection or ulcers.

A moderate or severe cystocele may require reconstructive surgery to move the bladder into a normal position. There are a number of ways to perform this surgery, including an anterior repair.

Another option, for more severe prolapse, is to place a synthetic material with a robotic or laparoscopic approach through the abdomen. This method may give more support to the tissue and help prevent the condition from happening again.

In mild cases, non-surgical treatments may be all that is needed to successfully deal with a cystocele.

When surgery is performed for more serious cases, some women will eventually need another surgery because the first surgery failed, the cystocele returned or another pelvic floor problem developed.

Education including primary and secondary prevention : -

Cystocele may be mild enough not to result in symptoms that are troubling to a woman. In this case, steps to prevent it from worsening include:

• smoking cessation
• losing weight
• pelvic floor strengthening
• treatment of a chronic cough
• maintaining healthy bowel habits
  • eating high fiber foods
  • avoiding constipation and straining

Cystocele is often treated by non-surgical means:

• Pessary – This is a removable device insert to support the anterior wall. Pessaries come in many different shapes and sizes. There are sometimes complications with the use of a pessary.
• Pelvic floor muscle therapy – Pelvic floor exercises to strengthen and support can be of benefit. Specialized physical therapy can be prescribed to help strengthen the pelvic floor muscles.
• Dietary changes – Ingesting high fiber foods will aid in promoting bowel movements.
• Estrogen – intravaginal administration helps to prevent pelvic muscle atrophy