Subjective
Date of visit
Reason for visit (initial presentation, follow-up)
History of present illness:
Symptoms of prolapse:
Feeling of heaviness or pressure in the pelvis
Bulging or sensation of something coming down in the vagina
Urinary leakage (stress incontinence, urgency)
Difficulty emptying the bladder (urinary retention)
Difficulty passing stool (bowel dysfunction)
Back pain or discomfort
Dyspareunia (painful intercourse)
Onset, duration, and severity of symptoms
Worsening factors (straining, heavy lifting, coughing)
Relieving factors (lying down, emptying bladder)
Past childbirth history (number of deliveries, vaginal deliveries, use of instruments)
Past medical history (relevant conditions like hysterectomy, connective tissue disorders)
Past surgical history (pelvic surgeries)
Medications (current medications, hormonal therapy)
Sexual history (activity level, impact of prolapse)
Objective
Vital signs (temperature, heart rate, blood pressure)
Physical exam:
Abdominal examination (distention, masses)
Pelvic exam (internal and external):
Pelvic organ descent staging (using standardized system like POP-Q) – identifies severity of prolapse
Assessment of muscle tone and strength of pelvic floor muscles
Stress test to evaluate for urinary leakage
Digital rectal exam (if indicated) to assess rectal prolapse
Assessment
Pelvic organ prolapse (POP):
Stage of prolapse (based on POP-Q system)
Organs involved (anterior vaginal wall prolapse, cystocele, posterior vaginal wall prolapse, rectocele, uterine prolapse)
Type of incontinence (stress incontinence, urge incontinence)
Consider differential diagnoses (urinary tract infection, pelvic tumors)
Plan
Treatment will depend on severity of symptoms, patient’s age, and desire for future childbearing:
Conservative management (recommended for mild to moderate cases):
Pelvic floor muscle training (Kegel exercises) with a physical therapist specializing in pelvic health
Lifestyle modifications (weight management, avoiding heavy lifting)
Bladder retraining techniques for stress incontinence
Pessaries (silicone inserts) to support pelvic organs
Surgical intervention (consider referral to a urogynecologist in severe cases or if conservative measures fail):
Vaginal repair procedures (anterior colporrhaphy, posterior colporrhaphy, sacrocolpopexy)
Abdominal laparoscopic procedures (may be suitable for some cases)
Patient education:
Information about the condition and treatment options
Importance of lifestyle modifications and pelvic floor muscle training
Follow-up
Schedule for next appointment:
Monitor response to treatment
Re-evaluate pelvic organ descent
Address any ongoing symptoms
Note: This is a template and may need to be modified based on the individual patient’s presentation and severity of prolapse.
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of pelvic organ prolapse.