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Anterior and Posterior Vaginal Wall Prolapse

(Cystoceles, Urethroceles, Enteroceles, and Rectoceles)

By

Charlie C. Kilpatrick

, MD, MEd, Baylor College of Medicine

Last full review/revision Apr 2019| Content last modified Apr 2019
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Anterior and posterior vaginal wall prolapse involve protrusion of an organ into the vaginal canal. Anterior vaginal wall prolapse is commonly referred to as cystocele or urethrocele (when the bladder or urethra is involved). Posterior vaginal wall prolapse is commonly referred to as enterocele (when the small intestine and peritoneum are involved) and rectocele (when the rectum is involved). Symptoms include pelvic or vaginal fullness or pressure. Diagnosis is clinical. Treatment includes conservative management with observation, pessaries, pelvic muscle exercises, and sometimes 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.

Risk factors for vaginal wall prolapse are

  • Age

  • Obesity

  • Vaginal delivery

Severity of vaginal wall prolapse can be graded by the Baden-Walker system, which is based on level of protrusion:

  • Grade 0: No prolapse

  • Grade 1: Halfway to the hymen

  • Grade 2 : To the hymen

  • Grade 3 : Halfway past the hymen

  • Grade 4: Maximal possible

Although the Baden-Walker system is commonly used, it is an older classification system that is not reproducible; thus, professional organizations recommend the Pelvic Organ Prolapse-Quantification (POP-Q) system. The POP-Q system is a more reliable and reproducible classification system that is based on predefined anatomic landmarks:

  • Stage 0: No prolapse

  • Stage I: Most distal prolapse is more than 1 cm above the hymen

  • Stage II: Most distal prolapse is between 1 cm above and 1 cm below the hymen

  • Stage III: Most distal prolapse is more than 1 cm below hymen but 2 cm shorter than total vaginal length

  • Stage IV: Complete eversion

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 through the vaginal opening (introitus), particularly during straining or coughing. Dyspareunia can occur.

Mild cases may not cause symptoms until women become older.

Stress urinary incontinence can accompany pelvic organ prolapse.

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

  • Examination of the anterior or posterior vaginal wall while patients strain

Diagnosis of vaginal wall prolapse 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.

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

  • Observation and sometimes, pessary, and pelvic floor exercises (eg, Kegel exercises)

  • Surgical repair of supporting structures if necessary

Treatment of vaginal wall prolapse is individualized, based on a patient's symptoms, and it aims to improve quality of life. Management begins with observation. Symptomatic treatment may consist of a pessary, pelvic floor exercises, and, in more severe cases, surgical repair.

Pessaries

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). Pessaries can be fitted by health care practitioners; in some countries, pessaries may be available over the counter.

Pelvic floor exercises

Pelvic floor exercises (including Kegel exercises) may be recommended. Kegel exercises involve isometric contractions of the pubococcygeus muscle. These muscles are contracted tightly for about 1 or 2 seconds, then relaxed for about 10 seconds. Gradually, contractions are held for about 10 seconds each. The exercise is repeated about 10 times in a row. Doing the exercises several times a day is recommended.

Exercises can be facilitated by

  • Use of weighted vaginal cones (which help patients focus on contracting the correct muscle)

  • Biofeedback devices

  • 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

Surgical repair can help relieve symptoms that are severe or do not resolve with nonsurgical treatment. The surgical approach used depends on the type of prolapse, the clinical situation, and the patient's age and comorbidities. Surgery may include one (or a combination) of the following procedures

  • Anterior or posterior colporrhaphy (vaginal repair)

  • Vaginal apex suspension or repair

  • Perineorrhaphy (surgical shortening and tightening of the perineum)

  • Colpocleisis (closure of the vagina after removal of the uterus or with the uterus in place [Le Fort procedure])

Surgical repair of the vagina is usually deferred, if possible, until future childbearing is no longer desired because subsequent vaginal delivery may disrupt the repair. After surgery, patients should avoid heavy lifting for at least 6 weeks.

After surgery to repair a cystocele or cystourethrocele, a urethral catheter may be used for < 24 hours.

Key Points

  • Urethrocele is virtually always accompanied by cystocele, and cystocele, urethrocele, enterocele, and rectocele are likely to occur together.

  • Risk factors for vaginal organ prolapse are age, obesity, and vaginal delivery.

  • 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.

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