CASE 2 Is McCall procedure appropriate?
B.D., 57, complains of increasing pelvic pressure and a noticeable vaginal bulge. Her 2 children were delivered vaginally, the largest weighing 8 lb. B.D. reports that she remains sexually active.
Physical examination reveals the cervix to be at the level of the introitus, but it descends 2 cm beyond the introitus when the patient performs the valsalva maneuver. Although there is also some descent of the anterior and posterior vaginal walls (1 cm superior to the hymen with strain; Pelvic Organ Prolapse Quantification [POP-Q] value=-1), the predominant component of prolapse is an elongated cervix. The posterior vaginal fornix (POP-Q point D), representing apical support, descends to 7 cm superior to the hymen with strain, with a total vaginal length of 9 cm.
At surgery, the uterosacral ligaments do not appear to be attenuated. After vaginal hysterectomy, the apex of the vaginal vault is superior to the level of the ischial spines.
How do you proceed?
Given the relatively good support at the apex, this patient is a good candidate for a McCall-type culdoplasty. Whether or not this procedure will be truly prophylactic (because there is already some descent of the apex, albeit mild) is perhaps only a matter of semantics.
The author reports no financial relationships relevant to this article.