You are FY2 in GP surgery
Personal Details:
Name: Mrs Susan Smith
Age: 62
Medical Record:
Past medical history: 4 normal vaginal deliveries.
BMI: 26kg/m2
Notes:
A 62-year-old woman has come in with an “embarrassing problem.” She hasn’t disclosed any more information.
Task:
1. Talk to her and take history.
2. Discuss the management plan.
Opening Sentence: (Looking embarrassed) “Doctor, I’ve got a rather personal problem. I feel like something is falling out down below.”
Open History (to give freely): “For the last few months, when I go to the toilet and strain, I can feel a lump coming out of my vagina. It goes back up by itself when I stand up. It’s not painful, just a dragging sensation.
ICE (Ideas, Concerns, Expectations):
Ideas: “I think my womb is falling out. Is that possible?”
Concerns: “Is it cancer? Will it affect my sex life? Will it get worse?”
Expectation: “I want to know what it is and what can be done”
How to Act: You are embarrassed but also pragmatic. You want clear information and options.
More History (only if asked):
You leak a bit of wee if I cough or laugh. It’s making me feel old and worried.
You are post-menopausal. You have no bleeding or discharge. You are otherwise fit and well.
Social History: Married, sexually active.
Questions to ask:
“What are pelvic floor exercises?”
“What is a ring pessary?”
Examination: moderate vaginal prolapse, no ulceration or bleeding.
Opening & Building Rapport:
Thanks for coming in. I understand this is a difficult thing to talk about. Please be assured, this is a very common problem, and we can talk in complete confidence.
History of Presenting Complaint:
You’ve described a feeling of a lump coming down. Can you tell me more about that?
Is it there all the time, or does it come and go?
Is there anything that makes it better or worse?
Associated Symptoms (Bladder, Bowel, Sexual):
Has this affected your waterworks at all? Do you ever leak urine when you cough or sneeze?
Has it affected your bowels? Do you have any difficulty opening your bowels?
If you don’t mind me asking, are you sexually active? And has this caused any problems?
Gynaecological & Obstetric History:
You mentioned you’ve had three children. Were they normal deliveries?
Have you had any vaginal bleeding or abnormal discharge?
ICE (Ideas, Concerns, Expectations):
What were your own thoughts about what this lump could be?
You were worried it might be cancer. What made you think that?
What were you hoping we could do for you?
Explain the situation:
Thank you for coming to talk about this. It’s a very common problem, but I know it can be difficult to discuss. From what you’re describing, it sounds very much like you have a pelvic organ prolapse. You’re right, it is essentially your womb, or uterus, dropping down into the vagina. The leakage of urine when you cough is called stress incontinence. The two conditions often go together.
Addressing and answering the patient’s ICE:
You’re worried about cancer, but I can reassure you that this is not cancer. It’s a mechanical problem. The pelvic floor muscles, which act like a hammock to support the womb, bladder, and bowel, have become stretched and weakened. As you rightly said, having children, especially multiple vaginal deliveries, is the most common cause. It’s great that you’re still sexually active.
Next Steps:
You said you want to avoid a big operation, and the good news is that there are several non-surgical options we can try first.
Self-help measures:
The most important first-line treatment is pelvic floor exercises, also known as Kegel exercises. These are exercises to strengthen that hammock of muscles. It’s like taking your pelvic floor to the gym! I will refer you to a specialist women’s health physiotherapist who can teach you how to do them correctly and monitor your progress. This can make a huge difference to both the prolapse and the stress incontinence.
Further options
Another option, which can work very well, is a device called a ring pessary. This is a soft, plastic ring that I can fit for you here in the clinic. It sits inside the vagina and acts like a scaffold to hold the womb up in the correct position. You can’t feel it when it’s in place, and it can be a very effective long-term solution.
If these conservative measures don’t work, or if the prolapse is very severe, then surgery, such as a hysterectomy or a repair operation, is an option, but we only consider that if the other treatments have failed.
The management is a stepwise, conservative-first approach. 1. Offer an examination to confirm the diagnosis. 2. Explain and refer for specialist physiotherapy for pelvic floor muscle training. 3. Explain the option of a ring pessary. 4. Mention surgery as a final option if conservative measures fail.
What is scenario testing? This case tests the candidate’s ability to handle a sensitive gynaecological problem in an older woman. It requires knowledge of the conservative management options for pelvic organ prolapse and stress incontinence. The communication should be empathetic, clear, and empowering, giving the patient a range of options and control over her treatment.