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For further information, see CMDT Part 18-15: Pelvic Organ Prolapse

Key Features

  • Uterine prolapse most commonly occurs as a delayed result of childbirth injury to the pelvic floor (particularly the transverse cervical and uterosacral ligaments)

    • Unrepaired obstetric lacerations of the levator musculature and perineal body augment the weakness

    • Attenuation of the pelvic structures with aging can worsen the prolapse

  • Vaginal hernias commonly seen in multiparous women

    • Cystocele

    • Rectocele

    • Enterocele

  • Cystocele is a hernia of the bladder wall into the vagina, causing a soft anterior fullness

  • Cystocele may be accompanied by urethrocele, which is not a hernia but a sagging of the urethra after 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

  • Enterocele is a vaginal vault hernia containing small intestine, usually in the posterior vagina and resulting from a deepening of the pouch of Douglas

  • All three types of hernia may occur in combination

  • Risk factors for pelvic organ prolapse may include

    • Vaginal birth, with injury to pelvic floor

    • Genetic predisposition

    • Advancing age

    • Prior pelvic surgery

    • Connective tissue disorders

    • Increased intra-abdominal pressure associated with obesity or straining associated with chronic constipation or coughing

Clinical Findings

  • Sensation or observation of a bulge or protrusion in the vagina

  • Urinary or fecal incontinence

  • Constipation

  • A sense of incomplete bladder emptying

  • Dyspareunia

Diagnosis

  • Clinical: pelvic examination

  • For uterine prolapse

    • Stage I prolapse: the uterus descends only partway down the vagina

    • Stage II prolapse: the corpus descends to the introitus and the cervix protrudes slightly beyond

    • Stage III prolapse: the entire cervix and uterus protrude beyond the introitus

    • Stage IV prolapse: the vagina is inverted

Treatment

  • Pelvic muscle training (Kegel exercises) is a simple, noninvasive intervention that may improve pelvic function

  • For uterine prolapse, the type of surgery depends on extent of prolapse and the desire for menstruation, pregnancy, and coitus

  • The simplest, most effective procedure is vaginal hysterectomy with repair of the cystocele, rectocele or enterocele as needed

  • If pregnancy is desired, a partial resection of the cervix with plication of the cardinal ligaments can be attempted

  • For older women who do not desire coitus, partial obliteration of the vagina is surgically simple and effective

  • For vaginal hernias, supportive measures include a high-fiber diet and laxatives to improve constipation. Weight reduction in obese patients and limitation of straining and lifting are helpful

  • The only cure for symptomatic cystocele, rectocele, or enterocele is corrective surgery

  • The prognosis after an uncomplicated procedure is good

  • A well-fitted vaginal pessary (eg, inflatable doughnut type, Gellhorn pessary) may reduce uterine prolapse, cystocele, rectocele, or enterocele temporarily and are helpful in women who do not wish surgery or are poor surgical candidates

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