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GENERAL CONSIDERATIONS

Pelvic organ prolapses, including cystocele, rectocele, and enterocele, are vaginal hernias commonly seen in multiparous women. Cystocele is a hernia of the bladder wall into the vagina, causing a soft anterior fullness (eFigure 18–7). Cystocele may be accompanied by urethrocele, which is not a hernia but a sagging of the urethra following its detachment from the pubic symphysis during childbirth. Rectocele is a herniation of the terminal rectum into the posterior vagina, causing a collapsible pouch-like fullness (eFigure 18–8). Enterocele is a vaginal vault hernia containing small intestine, usually in the posterior vagina and resulting from a deepening of the pouch of Douglas. Two or all three types of hernia may occur in combination. Risk factors may include vaginal birth, genetic predisposition, advancing age, prior pelvic surgery, connective tissue disorders, and increased intra-abdominal pressure associated with obesity or straining associated with chronic constipation or coughing (eFigures 18–7, 18–8, 18–9). A woman's lifetime risk of surgery for pelvic organ prolapse is 12–19%.

eFigure 18–7.

Cystocele. (Reproduced, with permission, from DeCherney AH, Pernoll ML [editors]. Current Obstetrics & Gynecology Diagnosis & Treatment, 8th ed. Originally published by Appleton & Lange. Copyright © 1994 by The McGraw-Hill Companies, Inc.)

eFigure 18–8.

Rectocele. (Reproduced, with permission, from DeCherney AH, Pernoll ML [editors]. Current Obstetrics & Gynecology Diagnosis & Treatment, 8th ed. Originally published by Appleton & Lange. Copyright © 1994 by The McGraw-Hill Companies, Inc.)

eFigure 18–9.

Enterocele and prolapsed uterus. (Reproduced, with permission, from DeCherney AH, Pernoll ML [editors]. Current Obstetrics & Gynecology Diagnosis & Treatment, 8th ed. Originally published by Appleton & Lange. Copyright © 1994 by The McGraw-Hill Companies, Inc.)

CLASSIFICATION

The Pelvic Organ Prolapse Quantification (POPQ) system is the preferred method for classifying pelvic organ prolapse. In this system, the hymen acts as the fixed point of reference, with six defined points for measurement and three other landmarks. The terminology does not assign a specific label to the prolapsing part of the vagina, recognizing that the organ above the prolapse often cannot be determined by physical examination. An alternative staging system, the Baden-Walker system, includes a degree of prolapse relative to the hymen (from 0 to 4) for each prolapsed structure.

CLINICAL FINDINGS

Symptoms of pelvic organ prolapse may include a sensation of a bulge or protrusion in the vagina, urinary or fecal incontinence, constipation, sense of incomplete bladder emptying, and dyspareunia. The cause of pelvic organ prolapse, including prolapse of the uterus (eFigure 18–10), vaginal apex, and anterior or posterior vaginal walls, is likely multifactorial.

eFigure 18–10.

Prolapse of ...

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