* This is the Professional Version. *
Cystoceles, Urethroceles, Enteroceles, and Rectoceles
These disorders involve protrusion of an organ into the vaginal canal: cystoceles (bladder), urethroceles (urethra), enteroceles (small intestine and peritoneum), and rectoceles (rectum). Symptoms include pelvic or vaginal fullness or pressure. Diagnosis is clinical. Treatment includes pessaries, pelvic muscle exercises, and surgery.
Cystocele, urethrocele, enterocele, and rectocele are particularly likely to occur together. Urethrocele is virtually always accompanied by cystocele (cystourethrocele). Cystocele and cystourethrocele commonly develop when the pubocervical vesical fascia is weakened. Enterocele usually occurs after a hysterectomy. Weakness in the pubocervical fascia and rectovaginal fascia allows the apex of the vagina, which contains the peritoneum and small bowel, to descend. Rectocele results from disruption of the levator ani muscles.
Severity of these disorders can be graded based on level of protrusion:
Pelvic or vaginal fullness, pressure, and a sensation of organs falling out are common. Organs may bulge into the vaginal canal or through the vaginal opening (introitus), particularly during straining or coughing. Dyspareunia can occur.
Stress incontinence often accompanies cystocele or cystourethrocele. Overflow incontinence or, particularly when sacral nerves are damaged, urge incontinence may also develop. Enteroceles may cause lower back pain. Rectoceles may cause constipation and incomplete defecation; patients may have to manually press the posterior vaginal wall to defecate.
Diagnosis is confirmed by examination.
Cystoceles and cystourethroceles are detected by applying a single-bladed speculum against the posterior vaginal wall while patients are in the lithotomy position. Asking patients to strain makes cystoceles or cystourethroceles visible or palpable as soft reducible masses bulging into the anterior vaginal wall. Inflamed paraurethral (Skene) glands are differentiated by their more anterior and lateral urethral location, tenderness, and occasionally expression of pus during palpation. Enlarged Bartholin glands can be differentiated because they develop in the medial labia majora and may be tender if infected.
Enteroceles and rectoceles are detected by retracting the anterior vaginal wall while patients are in the lithotomy position. Asking patients to strain can make enteroceles and rectoceles visible and palpable during rectovaginal examination. Patients are also examined while standing with one knee elevated (eg, on a stool) and straining; sometimes abnormalities are detected only by rectovaginal examination during this maneuver.
Urinary incontinence, if present, is also evaluated.
Treatment may initially consist of a pessary and Kegel exercises.
Pessaries are prostheses inserted in the vagina to maintain reduction of the prolapsed structures. Pessaries are of varying shapes and sizes, and some are inflatable. They may cause vaginal ulceration if they are not correctly sized and routinely cleansed (at least monthly if not more frequently).
Pelvic floor exercises (including Kegel exercises) may be recommended. Kegel exercises involve isometric contractions of the pubococcygeus muscle. Exercises can be facilitated by use of weighted vaginal cones (which help patients focus on contracting the correct muscle), by biofeedback devices, or by electrical stimulation, which causes the muscle to contract. Pelvic floor exercises can lessen bothersome symptoms of prolapse and stress incontinence but do not appear to reduce the severity of prolapse.
Surgical repair of supporting structures (anterior and posterior colporrhaphy) can help relieve symptoms that are severe or do not resolve with nonsurgical treatment. Perineorrhaphy (surgical shortening and tightening of the perineum) may also be needed. Colporrhaphy (surgical repair of the vagina) is usually deferred, if possible, until future childbearing is no longer desired because subsequent vaginal birth may disrupt the repair. Colporrhaphy and perineorrhaphy are usually done using a vaginal approach. Urinary incontinence can be surgically treated at the same time as colporrhaphy. After surgery, patients should avoid heavy lifting for 3 mo. After surgery to repair a cystocele or cystourethrocele, a urethral catheter is used for < 24 h.
Urethrocele is virtually always accompanied by cystocele, and cystocele, urethrocele, enterocele, and rectocele are likely to occur together.
To help detect cystoceles or cystourethroceles, apply a single-bladed speculum against the posterior vaginal wall while patients are in the lithotomy position, and ask them to strain.
To help detect enteroceles and rectoceles, retract the anterior vaginal wall while patients are in the lithotomy position, and during rectovaginal examination, ask patients to strain.
Recommend pessaries and/or pelvic floor exercises, but if they are ineffective, consider surgical repair.
* This is the Professional Version. *