Pelvic Organ Prolapse: Cystocele, Rectocele or Enterocele

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

Sensation or observation of a bulge or protrusion in the vagina

Urinary or fecal incontinence

Constipation

A sense of incomplete bladder emptying

Dyspareunia

Clinical: pelvic examination

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