Gynecologic — Pelvic organ prolapse

A 68-year-old woman, G4P4, comes to your family practice clinic because of a 2-year history of a vaginal bulge sensation that is worse at the end of the day. She also leaks small amounts of urine with coughing and sneezing. She has a chronic cough, is a former smoker, and takes no hormonal therapy or other regular medications. She has no allergies and no postmenopausal bleeding. Her BMI is 31 kg/m². On pelvic examination in the standing position, the anterior vaginal wall descends to 1 cm above the hymen with Valsalva and the vaginal mucosa appears pale and thin. The uterus and posterior wall are well supported, and there is no residual urine on bladder scan. The patient is bothered by the bulge sensation, wants to avoid surgery at this time, and has no other medical contraindications to treatment.