What are the next steps for a postmenopausal woman with altered bowel habits, pelvic discomfort, and vaginal pressure, who has a history of vaginal deliveries and previous urinary incontinence?

Evaluation and Management of Pelvic Floor Dysfunction in a Postmenopausal Woman

This 67-year-old woman with alternating bowel habits, pelvic pressure, vaginal fullness, and prior stress incontinence requires a comprehensive pelvic examination to evaluate for pelvic organ prolapse and rectal prolapse, followed by appropriate imaging if structural abnormalities are confirmed. 1, 2

Immediate Clinical Assessment

Perform a thorough pelvic examination including:

• Visual inspection of the vulva, perineum, and anus to assess for prolapse and exclude vulvar pathology 2
• Speculum examination to evaluate for vaginal wall prolapse (cystocele, rectocele) and uterine descent 2
• Bimanual examination to assess for pelvic masses, given the 8% risk of ovarian neoplasm in postmenopausal women with pelvic symptoms 3
• Digital rectal examination to evaluate for rectal prolapse, which commonly presents with alternating bowel habits and sensation of a lump with straining 1, 4

The combination of alternating diarrhea/constipation, sensation of a lump with straining, pelvic pressure, and vaginal fullness strongly suggests pelvic floor dysfunction, potentially including rectal prolapse and/or pelvic organ prolapse. 1, 2 Her history of vaginal deliveries and prior stress incontinence indicates pre-existing pelvic floor weakness, which are established risk factors for progressive pelvic floor disorders. 1

Key Diagnostic Considerations

Rectal prolapse is the primary concern given her specific symptom pattern. Chronic straining during defecation leads to weakening of pelvic floor support structures, and when complicated by external prolapse, frequently causes fecal incontinence due to mechanical stretching of anal sphincters. 1 The sensation of a lump at the back when straining is pathognomonic for rectal prolapse. 1

Pelvic organ prolapse must be evaluated concurrently, as these conditions frequently coexist in postmenopausal women with multiparity. 5, 2 The vaginal pressure sensation and pelvic discomfort are consistent with cystocele, rectocele, or uterine prolapse. 5

Imaging Strategy

If examination confirms structural abnormalities, proceed with MRI of the abdomen and pelvis. 5 MRI is the optimal imaging modality because it:

• Effectively diagnoses pelvic organ prolapse and associated cystoceles 5
• Provides excellent soft-tissue contrast for evaluating the entire pelvic floor 5
• Allows multiplanar assessment of prolapse severity 5
• Can identify coexisting pathology including masses or fistulae 5

Defecography may be considered if rectal prolapse or dyssynergic defecation is suspected but not clearly demonstrated on physical examination. 4 However, MRI with dynamic sequences can often provide similar functional information. 5

Red Flag Exclusions

Rule out malignancy urgently in this postmenopausal woman, as ovarian neoplasm accounts for 8% of pelvic pain cases and ovarian cysts represent one-third of gynecologic causes in this age group. 3 Any palpable adnexal mass requires immediate imaging and potential tissue diagnosis. 3

Assess for colorectal pathology given the altered bowel habits. While rectal prolapse is likely, inflammatory bowel disease, diverticulitis, and colorectal malignancy must be excluded. 6, 3 If examination does not clearly explain symptoms, colonoscopy should be performed. 4

Initial Management Approach

Continue and intensify pelvic floor muscle training as first-line conservative therapy. 7, 8 Pelvic floor exercises remain effective for stress incontinence and can improve pelvic organ prolapse symptoms in postmenopausal women, with up to 80% efficacy in stage I stress incontinence. 8

Address constipation and straining behavior immediately to prevent progression of prolapse. 1 The repetitive straining behavior—whether from constipation or paradoxical pelvic floor contraction—is the actual mechanism driving prolapse progression, not constipation alone. 1

Consider vaginal estrogen therapy for urogenital atrophy, which is common in postmenopausal women and contributes to both urinary symptoms and pelvic discomfort. 6, 7

Specialist Referral Indications

Refer to colorectal surgery if rectal prolapse is confirmed on examination, as surgical intervention is typically required for definitive treatment. 1, 4 Biofeedback therapy should be attempted first if dyssynergic defecation coexists, as randomized trials have established its efficacy. 4

Refer to urogynecology if significant pelvic organ prolapse is identified and conservative measures fail. 7 Surgical options should be considered for symptomatic prolapse affecting quality of life. 7

Common Pitfalls to Avoid

Do not attribute symptoms solely to constipation without recognizing the broader context of pelvic floor dysfunction and chronic straining behavior. 1 The actual mechanism is repetitive straining, which can occur with various defecatory disorders including paradoxical pelvic floor contraction. 1

Do not assume gynecologic origin without systematic evaluation of gastrointestinal and urologic systems, as chronic pelvic pain has a broad differential. 6, 3 The altered bowel habits and sensation of rectal fullness point toward colorectal pathology that must be thoroughly evaluated. 1, 4

Do not delay examination in symptomatic women. Any woman with pelvic complaints including pelvic organ prolapse symptoms, urinary incontinence, or new gastrointestinal symptoms should undergo appropriate pelvic examination components to identify benign or malignant disease. 2