Walden University Post Bladder Prolapse Discussion
Respond to at least two of your colleagues’ posts on two different days and explain how you might think differently about the types of tests or treatment options that your colleagues suggested and why. Use your learning resources and/or evidence from the literature to support your position.
Week 5 Main Discussion Post- Bladder Prolapse
Response to the SOAP note below
Patient Information:
Initials: D. J. Age: 79 Sex: Female Race: Caucasian
S.
CC (chief complaint): “incontinence and my insides feel like they are protruding out of my body.”
HPI: This 79-year-old Caucasian female, postmenopausal and post hysterectomy with BSO presents today with symptomatic cystocele. Her symptoms started 3-4 years ago, progressively worsening over the past year. She has not used a mirror to visualize the prolapse of organs, yet describe well the feeling of abnormal bulge outside of vaginal area. Her symptoms include pain and irritation of exposed tissue, constipation if standing for a long time, stress incontinence, and feeling like she does not empty bladder. She describes her symptoms as moderate and increasing. Sneezing, coughing, straining for BM, and physical activity are exacerbating factors for her. She denies any bowel incontinence, or having to stent to expel stool. She has used Estrace vaginal cream twice weekly with no changes that she noticed. She was offered a pessary at one time, but no follow up on that offer from another provider. No previous prolapse repair, incontinence repair, or anticholinergic therapy. Wanting treatment as it is affecting her quality of life. Wearing a pad all the time and feels embarrassed to go out.
Current Medications:
- Fexofenadine-pseudoephedrine ER (Allegra-D 24 hour) 180mg-240 mg, 1 tab po q am- started 12/23/18 for seasonal allergies.
- Estradiol (Estrace) 1 gm vaginally twice weekly-started 6/17/21 for vaginal dryness and urinary incontinence.
- OTC arthritis strength Tylenol per label po BID- started 2/15/22 for joint pain.
- Fluticasone furoate 100 mcg-vilanterol 25 mcg/dose inhalation as needed- started 2/15/22 for allergies.
Allergies: NKDA; Denies food allergies; Endorses seasonal environmental allergies.
PMHx:
IMMUNIZATIONS: Flu 10/2021; Tetanus 2/10/20; Pneumonia 10/2018; Covid (moderna) 4/15/21, 6/7/21.
MEDICAL HX: Menopause, Breast cancer, CAD, DIC (40 yrs ago)after cholecystectomy, Diverticulosis, environmental allergies, GERD with stricture, Peptic ulcer disease in 2017, pneumonia, arthritis.
Soc & Substance Hx: D. J. is married with two adult children. She lives in a single family home with her spouse of 54 years. She has been a stay at home mother and housewife. She is a member of a local book club and involved in her church. She denies ever smoking, drinking, or illicit drugs. She drinks approximately 3-4 caffeinated drinks per day. She denies routine exercise other than housework and gardening/yardwork. She always wears her seatbelt.
Fam Hx:
- Father: Deceased age 80- no problems identified.
- Mother: Deceased age 75 diabetes complications.
- Children: alive-healthy
Surgical Hx: Partial mastectomy right breast; hysterectomy with BSO 1990; Carpal tunnel release bilateral hands; Colon resection 2010; gastric surgery; laparoscopic cholecystectomy 1974.
Mental Hx: No formal diagnosis of depression or anxiety, reports occasional situation depression.
Violence Hx: Feels safe at home and in her neighborhood.
Reproductive Hx: Age of Menarche-12, G2P2002, Postmenopausal. Not sexually active, not intending to become sexually active.
ROS:
GENERAL: Denies weight loss or fever
CARDIOVASCULAR: Denies palpitations, chest pain, or edema.
RESPIRATORY: Denies dyspnea, cough, or wheeze.
GASTROINTESTINAL: Denies nausea/vomiting. Endorses constipation. Denies bleeding
GENITOURINARY: Burning on urination. Pregnancy. LMP: MM/DD/YYYY.
NEUROLOGICAL: Denies headache, syncope, ataxia, or paresthesia. Endorses bladder incontinence.
GENITOURINARY/REPRODUCTIVE: Endorses irritation. Denies vaginal discharge. Postmenopausal. Denies breast pain, lumps or discharge.
O.
Physical exam:
VITAL SIGNS: Ht 63 in. Wt. 141.0 lbs. BMI 25.0. BP 126/84 sitting in rt arm, RR 18, HR 71 pulse ox, O2 97% RA.
GENERAL: Oriented to person, place, time, and situation. Well nourished, appears comfortable.
Cardiovascular: Normal PMI, regular rate and rhythm, S1 normal, S2 normal
Respiratory: Normal effort, able to speak in complete sentences. Clear throughout all fields posterior.
GI: Soft, non-tender, no hepatosplenomegaly. Bowel sounds active x 4 quadrants. Last BM today, formed, brown.
GU: Normal external appearance, urethra visualized and palpated with no abnormalities noted.
- Speculum exam: Vaginal canal appearance without lesion or erosion, no cervix.
- Bimanual exam: No uterus, ovaries, or fallopian tubes. Non-tender, cystocele and enterocele.
- Pelvic support: A very large cystocele, protruding about 2 cm past introitus, was noted when the patient bared down. An enterocele, small, was involved as well. No rectocele noted.
Diagnostic results:
- Urinalysis and culture if needed- To rule out infection causing urinary incontinence (Shenot, 2021).
- CBC- This test measures the patient’s blood cells, can provide information about infections from the WBC, and blood health. This patient had a history of DIC, so baseline would be important to monitor.
- CMP- to measure kidney function with BUN and creatinine levels (Shenot, 2021).
A.
Primary and Differential Diagnoses
Cystocele: This is the bladder prolapsing into the vagina most often due to a weak pelvic floor, vaginal births, and pelvic surgery all can contribute to damage of the pelvic tissue and nerves (Makajeva, Watters, & Safioleas, 2022). In this case, the cystocele was viewed during the physical exam. Other ways to assess for the prolapse is by the pelvic exam or by use of radiologic exams to view abnormalities in the pelvis (Dr. Lin, 6/27/22, personal interview).
Enterocele- This is prolapse of the intestines through the abdominal as in a hernia but through the pelvic floor as well. A likely cause is from increased intra-abdominal pressure with a weakened pelvic floor unable to support the structures from prolapsing (Aziz et al., 2021). In this patient, an enterocele was visualized during the physical exam.
Urinary incontinence – the patient has mixed urinary incontinence from possibly many factors. Her age, hysterectomy with BSO which contributed to menopause, two pregnancies contributing to weak pelvic floor and possible urethra injury all can play a role in her incontinence (Alperin et al., 2019).
P.
The primary diagnosis for this patient is the cystocele. It is reasonable to believe that her symptoms of pain, irritation, and urinary incontinence were coming from the cystocele (Dr. Lin, 6/27/22, personal interview). Through counseling of available options for her symptoms, this patient chose to have an anterior colporrhaphy, sacrospinous ligament suspension (right-sided only) to correct her cystocele and enterocele. Her Estrace was stopped and she is currently only taking her allergy medications. Start cephalexin 500 mg po QID x 5 days post-surgery. Start oxycodone-acetaminophen 5-325 mg tablet, 1 tablet po QID PRN for pain x 14 days.
Referral: This patient was referred to gynecology for her urinary incontinence and cystocele. Her procedure, anterior colporrhaphy, sacrospinous ligament suspension and cystoscopy was performed by my preceptor in the OR not the clinic. He performed a cystoscopy afterwards to examine the ureters and bladder.
Lab: Prior to surgery, the above mentioned CBC, CMP, and urinalysis were obtained to monitor the patient’s homeostasis prior to surgery and verify if she would be able to have surgery. Labs drawn the day after surgery were a CBC with a WBC count of 12.2 likely elevated due to the surgery, pathology is still pending on the tissue sent from the surgery.
Health Promotion: 1) Screening for osteoporosis is recommended for all women over the age of 65. 2) Exercise of interventions to prevent falls is recommended for all community-dwelling adults over the age of 65 (Prevention TaskForce, 2022).
Education: 1) No lifting greater than 20 pounds for 3 weeks. 2) May use a sitz bath BID for 2 weeks. 3) No driving on pain medications. 4) Call the clinic for any complaints or concerns.
Disposition: Discharged home post-op day 1, Follow up at clinic in 2 weeks.
REFLECTION:
This case was very interesting because there was several thing that could have caused her incontinence. Some of the treatments for urinary incontinence would be approved for the advanced practice nurse practitioner (APRN) to provide. In cases without a cystocele, medications and physical therapy for pelvic floor strengthening are within the scope of practice for the APRN. In this case, her referral to a gynecologist that does urology studies and surgeries was warranted for a pessary fitting or surgery. I learned a lot about management of urinary incontinence. Patient education about options for treatment and using the shared decision making process.
References
Alperin, M., Burnett, L., Lukacz, E., & Brubaker, L. (2019). The mysteries of menopause
and urogynecologic health: Clinical and scientific gaps. Menopause, 26(1), 103-
111. https://doi.org/10.1097/GME.0000000000001209
Aziz, M., Gaurav, K., Hess, D., & Philippe, Z. (2021). Anterior enterocele as an etiology
for anterior vaginal wall prolapse: A magnetic resonance defecography case series. Abdominal Radiology, 46(4), 1390-1394. https://doi.org/10.1007/s00261-019-02327-2
Makajeva, J., Watters, C., & Safioleas, P. (2022, January 10). Cystocele. In: StatPearls
[Internet]. Treasure Island, FL: StatPearls Publishing. https://www.ncbi.nlm.nih.go
v/books/NBK564303/
Prevention TaskForce. (2022, June 24). Fall prevention in community-dwelling
older adults, [Interactive Application]. U.S. Preventive Services Task Force.
Shenot, P. J. (2021). Urinary incontinence in adults. Merck Manual Professional
Version. https://www.merckmanuals.com/professional/genitour…
Voiding-disorders/urinary-incontinence-in-adults
Schuiling, K. D., & Likis, F. E. (2022). Gynecologic health care (4th ed.). Jones and Bartlett Learning.
- Chapter 23, “Urinary Tract Infections” (pp. 469–478)
- Chapter 24, “Urinary Incontinence” (pp. 479–492)
- Chapter 23, “Menstrual-Cycle Pain and Premenstrual Syndrome” (pp. 495–510)
- Chapter 26, “Normal and Abnormal Uterine Bleeding” (pp. 511–526)
Resources for LGBTQ+
Office of Disease Prevention and Health Promotion (ODPHP). (2020, April 18). Lesbian, gay, bisexual, and transgender health. https://www.healthypeople.gov/2020/topics-objectiv…
Sadlak, C. A., Boyd, C. J., & Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ)
Health Expert Panel (2016). American Academy of Nursing on Policy: Health care services for transgender individuals: Position statement. https://www.nursingoutlook.org/action/showPdf?pii=…
FNP Resources
American Academy of Nurse Practitioners Certification Board (AANPCB). (2018). Welcome to the American Academy of Nurse Practitioners Certification Board. https://www.aanpcert.org/
American Academy of Nurse Practitioners National Certification Board, Inc. (AANPCB). (2018). FNP & AGNP Certification Candidate Handbook. https://www.aanpcert.org/resource/documents/AGNP%2…
Clinical Guideline Resources
As you review the following resources, you may want to include a topic in the search area to gather detailed information (e.g., breast cancer screening guidelines; CDC for zika in pregnancy, etc.).
American Cancer Society, Inc. (ACS). (2020). Information and Resources about Cancer: Breast, Colon, Lung, Prostate, Skin. https://www.cancer.org/
American College of Obstetricians and Gynecologists (ACOG). (2020). https://www.acog.org/
American Nurses Association (ANA). (n.d.). Lead the profession to share the future of nursing and health care. https://www.nursingworld.org/
Centers for Disease Control and Prevention. (CDC). (n.d.). CDC in action. https://www.cdc.gov/
HealthyPeople 2030. (2020). Healthy People 2030 Framework. https://www.healthypeople.gov/2020/About-Healthy-P…
The American Association of Nurse Practitioners (AANP). (2020). What’s Happening at your association. https://www.aanp.org/
