A 37-year-old G6P5015 with irregular menses and some right lower quadrant pain presented to her gynecologist for her annual examination. The patient’s examination was normal as was pelvic ultrasound she had approximately 2 months before this appointment. The plan was to obtain another pelvic ultrasound and, if negative, place the patient on oral contraceptives for 2 months. No medical therapy or follow-up was documented.
The patient’s past medical history was significant for four prior laparoscopies: one for a possible ectopic pregnancy (not confirmed, with decreasing quantitative hCG levels); one for sterilization, with a normal pelvis documented; and two for pelvic pain, one demonstrating a “window” in the posterior broad ligament. Also, the patient had a history of fibromyalgia, anxiety, and depression, which required treatment with three different psychotropic medications. She saw her psychiatrist monthly.
Eighteen months later, the patient was seen for another “annual” examination. She had complaints of heavy vaginal bleeding. The examination revealed a “retroverted uterus, of top-normal size, descending to 1 cm above the introitus.” A thinning rectovaginal septum was noted. The following plan was documented, “Schedule vaginal hysterectomy. Risks and benefits have been reviewed and these have been discussed over the past year-and-a-half since tubal ligation. These symptoms are unremitting to conservative medical modalities. The patient wishes to proceed with surgical intervention.” No documented examinations or discussions since the previous examination, 18 months earlier, were noted. The patient was referred to her psychiatrist for evaluation prior to surgery.
One month later, the patient underwent a total vaginal hysterectomy with removal of Hulka clips. Pathology revealed a 112-g uterus with proliferative endometrium, no adenomyosis or myomas, chronic endocervicitis, and the Hulka clips. Two weeks later the woman was admitted for cuff cellulitis, which was treated with antibiotics. One week after this second admission, she was seen in the physician’s office with persistent pain and discomfort. Computed tomography (CT) revealed a
5 x 7 cm tubular mass in the left adnexa, with a differential diagnosis of a lymphocele, tuboovarian abscess, or cystic mass of left ovary. Two weeks later the patient underwent laparoscopic adhesiolysis of omental adhesions covering the left ovary and bilateral salpingo-oophorectomy (BSO). Pathology revealed only one tube, which was normal, with normal ovaries bilaterally, one with a simple cyst. The patient was placed on oral estrogen replacement.
A month after the laparoscopy (2 months after the hysterectomy), the woman was seen by her psychiatrist and diagnosed with enhanced anxiety and post-traumatic stress disorder (PTSD). A fourth psychotropic medication was added, as she continued to see her psychiatrist on a monthly basis.
Nine months after the hysterectomy and 8 months after the BSO the patient was seen for complaints of intermittent stress urinary incontinence for 2 months, with pressure in the vagina. Examination revealed a thin rectovaginal septum and a probable cystocele. She was scheduled for surgery, with her preoperative history documenting “…progressive debilitating loss of urine, minimal valsalva, unable to handle daily activities…” The documented consent discussion in the office consisted of, “Risk & benefit ready.” Three weeks later the patient underwent a cystourethropexy and a posterior colporrhaphy, complicated by a 1200-mL blood loss requiring transfusion. She was discharged with an in-dwelling catheter, which was removed 1 week later with a postvoid residual (PVR) less than 100 mL. She had a mildly odiferous vaginal discharge that was treated with metronidazole vaginal gel.