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For further information, see CMDT Part 18-07: Pelvic Organ Prolapse

Key Features

  • 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

Treatment

  • Supportive measures

    • High-fiber diet and laxatives to improve constipation

    • Weight reduction in obese patients

    • Limitation of straining and lifting are helpful

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

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

  • Pessaries, which may reduce a cystocele, rectocele, or enterocele, are helpful in women who do not wish to undergo surgery or who are poor surgical candidates

  • 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

  • Uterine suspension with sacrospinous cervicocolpopexy may be an effective approach in older women who wish to avoid hysterectomy but preserve coital function

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