"" Enhanced Anatomy Provided by Clinical Anomaly: Fourth Stage Vaginal Prolapse in a Medical Anatomy Lab

Case Report

Austin J Anat. 2015;2(2): 1037.

Enhanced Anatomy Provided by Clinical Anomaly: Fourth Stage Vaginal Prolapse in a Medical Anatomy Lab

Viscomi NS and Clough RW*

Department of Anatomy, SIUC Life Sciences III, USA

*Corresponding author: Rich W Clough, Department of Anatomy, SIU School of Medicine Carbondale, Carbondale, IL 62901, USA

Received: June 23, 2015; Accepted: July 29, 2015; Published: August 03, 2015

Abstract

There is increased emphasis in early medical education to further enhance student empathy and compassion, to model physician, patient and care-giver considerations, and to heighten professionalism. The cadaver dissection lab offers a unique venue to hone these important considerations and it remains a valuable and time-honored practice in the training of physicians and other health professionals. Discoveries of congenital and acquired anomalies, pre-mortem clinical interventions including surgeries, device implantations, etc., as well as natural anatomical variations in cadaveric remains in the medical anatomy lab can be extraordinarily useful to facilitate these emphases and augment the overall learning experience of medical professionals in training. The authors present an unusual case-discovery in the anatomy lab, of a fourth stage vaginal prolapse with complete eversion and protrusion from the pelvis through the vaginal orifice and containing a rectocele. This anomaly discovered in a cadaver of an 89-year-old Caucasian woman proved to be extraordinarily instructive as well as motivating to our medical students learning female reproductive and pelvic anatomy. Discussions regarding compassion, empathy, care-giver and physician responsibilities, and professionalism all contributed to this learning experience. This and numerous other anomalous findings in the anatomy lab provide extraordinarily valuable tools to further enlighten students regarding ‘Doctoring’, and of course, facilitate learning of human anatomy.

Keywords: Learning enhancement; Pelvic anatomy; Vaginal prolapse; Clinical anomaly; Medical gross anatomy

Introduction

Anatomical variations, anomalies, clinical pathologies and a wide variety of pre-mortem clinical and prosthetic interventions are routinely discovered in gross anatomy labs across the world. Intuitively, clinical findings and peculiar anatomical variations would seem to greatly enhance the experience of training in the anatomical sciences, perhaps particularly with regard to human clinical anatomy. Anomalies, anatomical variations, clinical interventions, etc. can be studied and learned about in several different venues, but direct, hands on experience with cadavers in the anatomy lab yields a learning experience enriched with primary discovery, pathos, professionalism and other more intangible attributes of learning. Discovery was recently made in the authors’ medical school anatomy lab of a fourth stage vaginal prolapse in a cadaver of an 89-year-old Caucasian woman. Unfortunate as the case was, this presentation proved to enhance the gross anatomy learning experience for the medical students in witness.

Investigation and research of this condition would discover the following information. Vaginal vault prolapse is a non life-threatening medical condition in which the vagina loses its internal suspensor and muscular support allowing it to fall and protrude through the vaginal opening. Estimates vary widely, but as many as 50% of parous woman may develop some degree of genital prolapse or pelvic floor dysfunction [1-3]. Hysterectomy increases the risk for more severe stages of vaginal vault prolapse, and an estimated 11% of women who have undergone hysterectomy and who have compromised internal vaginal supports will develop prolapsed [4,5]. There are four categorical stages of prolapse as described by the POP-Q (Pelvic Organ Prolapse - Quantification) system of classification: a first stage prolapse is the term used to describe when the uterus or cervix moves into the upper part of the vagina but remains greater than 1 cm above the hymenal plane; second stage prolapse describes when the uterus or cervix moves into the lower part of the vagina and is less than 1cm below the hymenal plane but above the vaginal orifice; third stage prolapse describes when the uterus or cervix is just slightly protruding through the vaginal opening and is greater than 1cm but less than 2cm below the plane of the hymen; and fourth stage prolapse describes when the vagina, containing or not the uterus, is completely everted and protruded outside the body [6,7]. The first- and secondstage prolapses are most common whereas the fourth stage vaginal prolapse is least common and indeed quite rare. When the uterus and cervix are present within the prolapsed vagina, it is referred to as procidentia. The fourth stage prolapse is often accompanied by prolapse of surrounding structures such as the rectum, bladder, urethra or small intestine. There are several predisposing factors for vaginal prolapse, which include multigravida, advanced age, menopause, hysterectomy, obesity, hypertension, or delivering a macrosomic infant [8].

Understanding the anatomical reasons for vaginal prolapse requires that the student become familiar with the normal anatomy of the internal female genitalia and particularly the suspensor components of the vagina. Thus, the discovery of this clinical anomaly greatly and directly enhanced a Need-To-Know notion regarding support of the female genitalia. Moreover, witness of this anomaly by our medical student enhanced empathy, professionalism, patient-care considerations, and other more tacit attributes of physician training.

Case Presentation

This case reports the first such discovery of a complete, fourth stage vaginal prolapse seen by the authors in over 35 years of combined teaching in a school of medicine gross anatomy lab. The cadaver of an 89-year-old female showed a previous hysterectomy and exhibited other predisposing factors for prolapse including advanced age and moderate obesity. This condition is shown in (Figures 1,2). Careful observation and subsequent dissection revealed the vagina to be completely externalized inside-out with the ovaries and fallopian tubes remaining intact and in normal anatomical position. Additionally, the urinary bladder was retained in proper anatomical position within the lesser pelvis. The uterus was found to be absent, owing to hysterectomy earlier in life. During palpation of the prolapsed vagina, a large, soft mass was found within the posterior aspect. The vagina had a total length from superior to inferior of 12 cm, a circumference at the largest site of 28.5 cm (Figure 1), an anterior to posterior length at the vaginal orifice of approximately 12 cm and a calculated volume of 904.8 ml. Once measurements were completed, the everted vagina was incised anteriorly in the sagittal plane. Once opened, the soft mass in the posterior aspect of the externalized vagina was found to be a severe rectocele (rectal prolapse, Figure 2). The externalized vaginal mucosa was of a leathery consistency suggesting that it had been externalized for some time prior to death.

Citation: Viscomi NS and Clough RW. Enhanced Anatomy Provided by Clinical Anomaly: Fourth Stage Vaginal Prolapse in a Medical Anatomy Lab. Austin J Anat. 2015;2(2): 1037. ISSN : 2381-8921 ISSN:2381-8921