What is the most appropriate next step in management for an 88-year-old woman with a prolapsed uterus, coronary artery disease (CAD), and diabetes mellitus (DM), presenting with a reducible vaginal mass and symptoms of pelvic pressure?

Management of Prolapsed Uterus in an 88-Year-Old Woman with Comorbidities

A vaginal pessary is the most appropriate next step in management for this 88-year-old woman with a prolapsed uterus, coronary artery disease, and diabetes mellitus.

Assessment of the Current Presentation

The patient presents with:

• Recent onset of pelvic pressure/bulge sensation following coughing
• Ability to reduce the prolapse herself
• Symptoms that worsen throughout the day
• Mild discomfort
• No urinary or defecatory dysfunction
• Significant comorbidities: CAD and DM
• Physical examination confirming an easily reducible vaginal mass

Rationale for Pessary as First-Line Treatment

Vaginal pessaries are particularly appropriate in this case for several reasons:

1. Age and Comorbidity Considerations:

   • At 88 years with significant cardiovascular disease and diabetes, the patient has increased surgical risk
   • Pessaries provide effective symptom relief without surgical risks 1

2. Symptom Severity:

   • The patient has mild symptoms without complications
   • No urinary or bowel dysfunction is present
   • The prolapse is easily reducible

3. Evidence-Based Support:

   • Pessaries are a viable conservative form of treatment for POP for many older women 1
   • They can lead to substantial improvements in quality of life and other clinical outcomes in geriatric patients 1
   • Pessaries have been shown to improve prolapse symptoms and prolapse-specific quality of life 2

Advantages of Pessary Treatment in This Case

• Non-invasive approach: Avoids surgical risks in an elderly patient with cardiovascular disease
• Immediate symptom relief: Can be fitted and provide relief during the initial visit
• Reversibility: If not tolerated, can be easily discontinued
• Outpatient procedure: No hospitalization required
• Cost-effective: Less expensive than surgical options

Pessary Management Considerations

1. Fitting:

   • Proper fit determined by trial is essential for effectiveness 3
   • The type of pessary depends on the direction and extent of the prolapse

2. Follow-up:

   • Regular follow-up is important to assess fit and check for complications
   • Continuity of clinical care helps maintain success and prevent complications 1

3. Potential complications:

   • Increased vaginal discharge
   • Vaginal erosion or irritation
   • These are generally minor and can usually be successfully treated with targeted therapy such as vaginal estrogen supplementation 1

Why Other Options Are Less Appropriate

1. Total vaginal hysterectomy with vaginal suspension:

   • High surgical risk given the patient's age and comorbidities
   • Excessive intervention for symptoms that are mild and manageable with conservative treatment
   • Longer hospitalization period (approximately 4.2 days for hysterectomy group vs. 1.5 days for non-surgical approaches) 4

2. Topical estrogen and pelvic floor physical therapy:

   • May be helpful as an adjunct but insufficient as primary treatment for anatomical prolapse
   • More appropriate for mild prolapse or as preparation/supplement to other treatments

3. Laparoscopic supracervical hysterectomy with vaginal suspension:

   • Even higher surgical risk than vaginal approach in an elderly patient with CAD
   • Unnecessarily invasive for a patient with mild, reducible prolapse

In conclusion, for this 88-year-old woman with multiple comorbidities and a reducible uterine prolapse causing mild symptoms, a vaginal pessary represents the safest and most appropriate initial management strategy.