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Abstract: This patient presented to our hospital after delivering a huge baby in her second child, with damage to the pelvic floor muscles due to forceps assisted delivery, long term chronic cough, and increasing age, with worsening symptoms of urinary leakage and even prolapse of the vaginal mass. On examination, she showed obvious bladder prolapse and uterine prolapse, and her condition was severe. She was given anterior and posterior vaginal wall repair + shortening of the main ligament + partial hysterectomy, and postoperative pelvic floor rehabilitation. The patient recovered well, and the symptoms of urinary leakage and mass prolapse disappeared.
Basic information】Female, 45 years old
Disease Type】Chronic cough, vaginal laxity, bladder prolapse, uterine prolapse Ⅱ degree heavy
Hospital】Guangxi Zhuang Autonomous Region Jiangbin Hospital
Date of Consultation】May 2021
Treatment plan】Surgery (anterior and posterior vaginal wall repair + shortening of the main ligament + partial hysterectomy) + medication (ceftriaxone sodium for injection + metronidazole injection) + pelvic floor rehabilitation (electrical stimulation therapy + biofeedback therapy) + physiotherapy (perineal scrubbing)
Treatment period】8 days of hospitalization, 2 months of outpatient treatment
Treatment effect】The treatment effect is good, and the symptoms of urinary leakage and vaginal mass prolapse disappeared.
I. Initial consultation
The patient reported that she had 3 abortions and 2 normal deliveries in the past, and her first delivery went smoothly in 2010, and her second delivery was a huge baby in 2015, which was assisted by forceps. In recent years, the patient had recurrent chronic cough and occasional urinary leakage during the second pregnancy and postpartum period, but it did not affect her daily life and was not treated. From January 2021, the symptoms of urine leakage worsened, and the leakage occurred easily when coughing, laughing and holding urine. In the past month, the coughing symptoms worsened, and a swelling was found to come out of the vagina after severe coughing, which could return to the vagina when lying down. She was diagnosed with “1. bladder prolapse; 2. uterine prolapse, degree II, heavy” and was admitted to the hospital.
II. Treatment history
After admission, the patient completed relevant blood tests and pelvic floor function assessment, including pelvic floor 3D ultrasound and pelvic floor function measurement, and the report indicated that the patient had significant bladder and uterine prolapse, poor pelvic floor muscle strength and significant fatigue. The patient currently has pelvic floor dysfunction, specifically including vaginal laxity, bladder bulge, and uterine prolapse grade II heavy. This condition is associated with the patient’s multiple abortions, pregnancies, and difficult deliveries, plus the patient’s history of chronic coughing and the usual constant use of abdominal pressure, which leads to pelvic organ prolapse. The patient was advised to undergo surgery + pelvic floor rehabilitation, and the patient expressed understanding and agreed to the treatment. As the patient was only 45 years old, she was given preservation of the uterus, and on the 3rd day of admission, an anterior and posterior vaginal wall repair + shortening of the main ligament + partial hysterectomy was performed under intralesional anesthesia in a femoral fashion. After completion of surgery, the patient was given intravenous anti-inflammatory treatment with ceftriaxone sodium for injection and metronidazole injection, as well as daily perineal scrubbing to prevent infection.
One month postoperative outpatient follow-up, pelvic floor rehabilitation therapy (electrical stimulation + biofeedback therapy) was given for 2 months, and daily vaginal dumbbell exercises were performed.
III. Treatment results
The patient recovered well after the operation, and because the negative surgery was performed with absorbable sutures, there was no need to remove the sutures, the patient’s vaginal opening was free of masses after the operation, and the bladder was basically restored to its normal position, and she was discharged from the hospital 5 days after the operation. 1 month later, the patient came to the outpatient clinic for a follow-up examination, the surgical wound was completely healed, and pelvic floor rehabilitation therapy (electrical stimulation + biofeedback therapy) was performed. After 2 months of pelvic floor treatment, the patient recovered well and the symptoms of urinary leakage and uterine prolapse disappeared.
IV. Precautions
Many women are too busy taking care of their children after childbirth to have a 42-day postpartum checkup, which eventually leads to urine leakage and pelvic organ prolapse. Fortunately, the patient in this case gradually recovered after treatment. While we are happy for the patient’s recovery, we still need to remind her that she needs to pay attention to the following points.
1. After the patient’s surgery and pelvic floor rehabilitation, it is recommended to avoid lifting heavy objects and doing strenuous exercises, especially those that use abdominal pressure. Actively treat other diseases in the body and avoid long-term coughing and constipation, otherwise recurrence may still occur after treatment.
2. It is recommended that after the patient completes the surgery and pelvic floor rehabilitation treatment, in order to further consolidate the treatment effect, he can insist on pelvic floor muscle exercises, mainly through Kegel training, anal lifting exercises and pubic reduction exercises, etc. It is recommended to exercise for 15 minutes each time, once a day.
V. Personal insight
Pregnancy, childbirth, especially obstructed labor forceps or fetal suction are the most common causes of pelvic floor function damage and pelvic organ prolapse. In addition, chronic cough, long-term constipation, obesity, aging, etc. are also likely to lead to pelvic organ prolapse. In this case, the patient developed postpartum leakage symptoms, which were not treated in time and eventually developed pelvic organ prolapse. It is recommended that women should have a 42-day postpartum checkup after delivery, including routine blood, routine leukorrhea, pelvic floor 3D ultrasound and pelvic floor function assessment, etc. If there are abnormalities in pelvic floor function, they can be detected and treated as early as possible to reduce pelvic floor organ prolapse after delivery.