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Chapter 39: Obstetrics and Gynecology

A 50-year-old, gravida 2 para 2, woman status post total abdominal hysterectomy (TAH), bilateral salpingo-oophorectomy (BSO) for a myomatous uterus presents with a 6-month history of pelvic pain and pressure. What is the most likely diagnosis?

(A) Bartholin gland duct cyst

(B) Vaginal vault prolapse

(C) Urethral diverticulum

(D) Vaginal neoplasm

(B) Pelvic organ prolapse is a common diagnosis affecting millions of American women. Risk factors in the development of pelvic organ prolapse include the following: childbirth, smoking, menopause, chronic medical conditions such as collagen vascular diseases, chronic obstructive pulmonary disease, obesity, prior pelvic surgery, and other social or environmental factors associated with chronic increased abdominal pressure. The common exposure in these conditions is increased abdominal pressure, which leads to nerve and muscle devascularization along with ligamentous stretching and tearing, resulting in pelvic floor laxity and dysfunction.

The vagina is a fibromuscular tube extending from the vestibule to the uterus in the standing position. The upper vagina runs horizontally. It is commonly at a 90-degree angle with the uterus. The vagina is held in its position by the surrounding endopelvic fascia and ligaments. Endopelvic fascia is a fine meshwork of collagen, elastin, and neural fibers.

The uterus is a thick-walled, hollow muscular organ located centrally in the female pelvis. Anterior to the uterus is the bladder with the rectum posteriorly and broad ligaments laterally. The dome-shaped upper portion of the uterus is termed the fundus. The short area of constriction in the lower uterus is termed the isthmus below which is the uterine cervix, which extends into the upper portion of the vagina.

Extending from the uterus are five pairs of ligaments (see Fig. 39-1). The pelvic ligaments, however, are not classic ligaments but are thickenings of retroperitoneal fascia and consist primarily of blood and lymphatic vessels, nerves, and fatty connective tissue. The retroperitoneal fascia is referred to by surgeons as endopelvic fascia. Extending from the superior portion of the uterus are the paired round ligaments and utero-ovarian ligaments. The round ligament provides minimal support to the uterus but is an important surgical landmark in making the initial incision into the parietal peritoneum, allowing access to the retroperitoneal space. The round ligament is composed of fibrous tissue and muscle fibers and runs via the broad ligament to the lateral pelvic side wall, entering into the inguinal canal and terminally inserting into the labia majora. The utero-ovarian ligament is one of three ligaments that provide anatomic mobility to the ovary. This is a narrow, short, fibrous band extending from the lower pole of the ovary to the uterus. The broad ligaments are a double reflection of peritoneum, stretching the lateral pelvic ...

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