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You are an F1 doctor on a taster in a GP surgery. Cat Aracks is a 62 year old lady who has presented with a problem passing water.

Please take a history from Cat and perform the appropriate examination. You will then be asked to discuss the case with the examiner.

You are Cat Aracks, a 62-year-old lady who has become more than a little frustrated and embarrassed by the problem that has brought her in today. You tried to ignore and put up with this problem for long enough, but now you have had enough. You were recently diagnosed with a uterine prolapse. Your main concern following this is that you keep having ‘accidents’, as your mum used to call it in her old age: leaking urine and having to rush to the toilet, not quite making it. You would normally consider a lot of these issues to be ‘private’, you have come to the end of your tether – the symptoms, after all, are threatening to become anything but private!

Your “bladder problems” all started after you had Steph (your fifth child) but it’s really only gotten worse within the past two months. Occasionally when you cough or sneeze you trickle some urine into your underwear. As a result, you started to wear pads to “just in case”. Further to this, you find yourself going to the bathroom to urinate more frequently and never feel as though you’ve completely emptied your bladder. Your stream is weaker than it used to be and sometimes it only returns to a “normal” stream when you change your position on the toilet.

This has really impacted on your life. You no longer wish to go out with your daughters for shopping as you find yourself wanting to go to the bathroom at least once every hour. This urge is very strong at times and if you do not make it in time to go to the bathroom you would wet yourself.

You also have a dragging sensation “down below” whenever you stand up, which worsens as the day progresses. You have not noticed a bulge down from your vagina but more recently you feel as though “something falling out of my vagina”. Within the past few months, you’ve noticed that you’ve had more difficulty when you go to the bathroom to open your bowels. You no longer engage in sexual intercourse with your husband after developing pains during intercourse. The pain is particularly worse with deep penetration. He is sixty and not being sexually intimate with him has begun to put some strain on the relationship. You do not bleed during or after intercourse.

ICE: Your main concern is the incontinence and hope that this can be resolved without an operation. You really had no idea what the problem was at the time, but now you know you have a prolapse.

Past medical history: You never visited our GP for any medical problems nor have you had any previous surgeries.

Past obstetric history: You have been blessed with five healthy girls who were born by vaginal deliveries. You gave birth to Steph (the last child) twenty years ago and had each of her sisters two years before that. They are all married and in good health. All your pregnancies were unremarkable. All your daughters were “a bit chunky” (weighing between 4 - 4.4kg) but you blamed your husband and his genetics for that attribute. You never had an instrumental delivery, nor did you have any caesareans. You recovered quickly after each of the births and had no mood problems afterwards.

Past Gynaecological History: You have never visited a gynaecologist. You don’t know when your last smear nor when the next one is due- or if you even need one! However, you are confident you always go to get it whenever you get a letter. You went through the menopause when you were 52 and you have not had any bleeding since then.

Social History: You are a retired school teacher. You do not currently smoke or drink any more. You used to smoke 10 cigarettes a day, like all of your friends.

Family History: You do not have a family history of any medical conditions.

Drug history: You don’t have any allergies. You do not use any over the counter medications or recreational drugs.

Systemic Review: No other symptoms.

A gynaecological examination on the provided mannequin would be appropriate. The student should however be able to select the correct speculum and mannequin. If the individual does not do this, prompt them to have this discussion at the end. There is no need to perform a cervical smear as this patient’s smear is likely to be up to date.

Allow the student time to summarise, give a differential and discuss management of a uterine prolapse.

Discussion points - What is a prolapse? - Can you tell me about some of the risk factors for uterine prolapse? - What structure would you use to classify prolapses? - What type of prolapse is this patient likely to have? - How would you categorise incontinence? - If this patient presented with only stress incontinence how would you manage them differently?