Female pelvic problems


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Clinical Challenge

Volume 44, No.7, 2015 Pages 527-528

Questions for this month’s clinical challenge are based on articles in this issue. The clinical challenge is endorsed by the RACGP Quality Improvement and Continuing Professional Development (QI&CPD) program and has been allocated 4 Category 2 points (Activity ID:27758).Answers to this clinical challenge are available immediately following successful completion online at http://gplearning.racgp.org.au. Clinical challenge quizzes may be completed at any time throughout the 2014–16 triennium; therefore, the previous months answers are not published.

Each of the questions or incomplete statements below is followed by five suggested answers 
or completions. Select the most appropriate statement as your answer.

Case 1

Jane, aged 32 years, comes to see you to discuss her mother’s recent operation for pelvic organ prolapse. Jane has also spoken to other women of her age who are troubled by this condition. Jane is keen to take preventive measures, if at all possible, and asks you a series of questions about her personal risks.

Question 1

The most common modifiable risk factor for pelvic organ prolapse is:

  1. congenital predisposition
  2. obesity
  3. asthma
  4. lower uterine segment caesarean section (LUSC)
  5. vaginal delivery.

Question 2

The more commonly noted presenting symptom in younger women with pelvic organ prolapse is:

  1. sexual dysfunction
  2. constipation
  3. urinary incontinence
  4. vaginal lump.

Question 3

The most helpful diagnostic test for pelvic organ prolapse is:

  1. trans-abdominal ultrasound
  2. trans-labial ultrasound
  3. magnetic resonance imaging (MRI) of the pelvis
  4. computed tomography (CT) scan of the pelvis.

Question 4

Which of the following is helpful in the treatment of pelvic organ prolapse?

  1. Weight loss
  2. Treatment of constipation
  3. Vaginal ring pessary
  4. Pelvic floor exercises
  5. All of the above

Case 2

Margaret, aged 41 years, comes to see you regarding ongoing pain and discomfort that she has been experiencing in her pelvis for more than 6 months.

As the diagnosis of persistent pelvic pain (PPP) has important prognostic and management implications, you ask her about the frequency of her symptoms.

Question 5

Which one of the following pain patterns is the most consistent with PPP?

  1. Once per week
  2. Twice per week
  3. Almost every day
  4. Continuous

Question 6

Which one of the following symptoms is NOT suggestive of pelvic organ pain?

  1. Dysmenorrhea
  2. Difficulty initiating urination
  3. Irritable bowel
  4. Recurrent candidiasis
  5. Vulval pain

Question 7

Several muscle groups have been implicated in PPP. Which one of the following is more suggestive of the obturator internus than pelvic floor musculature?

  1. Pain aggravated by movement or prolonged positions
  2. Stabbing pains in the vagina or lower bowel
  3. Difficulty initiating a void, or poor emptying despite urge
  4. Pain with intercourse
  5. Pain on insertion of the speculum

Question 8

Margaret has a laparoscopy, which did not reveal any specific pathology. A follow-up laparoscopy should be conducted:

  1. Routinely at 6 months
  2. Routinely at 12 months
  3. Routinely at 24 months
  4. When specifically indicated

Case 3

Sonia, aged 26 years, has chronic vulvar pain that is causing her great distress and embarrassment. You suspect it is localised provoked vestibulodynia (LPV).

Question 9

Which one of the following features in the history is the hallmark feature of LPV?

  1. Urinary incontinence
  2. Pain on vaginal penetration
  3. Irritable bowel syndrome
  4. Dysmenorrhea

Question 10

LPV is characterised by tenderness to which form of touch in the vulvar vestibule?

  1. Feather
  2. Gentle
  3. Firm
  4. Forceful

Question 11

Sonia is keen to have a definitive test to confirm the diagnosis. The most accurate advice is:

  1. There is no diagnostic test.
  2. Do an MRI of the pelvis.
  3. Do a CT scan of the pelvis.
  4. Take cervical swabs for microbiological testing.

Question 12

Co-existent vaginal candidiasis is an important factor when considering a diagnosis of LPV. Sonia completed a course of oral antifungal agents 1 week ago and asks you to check if there is a recurrence. The best time to do the vaginal swab is:

  1. today
  2. in 1 week
  3. in 2 weeks
  4. in 3 weeks.

Correspondence afp@racgp.org.au

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Clinical challenge