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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:
Symptoms and Signs
Pelvic or vaginal fullness, pressure, and a sensation of organs falling out are common. Organs may bulge into the vaginal canal or 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
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's) glands are differentiated by their more anterior and lateral urethral location, tenderness, and occasionally expression of pus during palpation. Enlarged Bartholin's 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
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).
Kegel exercises involve isometric contractions of the pubococcygeus muscle. Isolation of the correct muscle is difficult (about 50% of patients cannot do it) but important because a Valsalva maneuver is detrimental and buttock or thigh contraction is unhelpful. Contraction of the correct muscle is best initiated by asking patients to simulate attempting to hold in urine. Three sets of 8 to 10 contractions are done daily; contractions are initially held for 1 to 2 sec and increased up to 10 sec each when possible. 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.
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. 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.
Last full review/revision December 2008 by S. Gene McNeeley, MD
Content last modified February 2012
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