Pelvic Organ Prolapse: Cystocele, Rectocele or Enterocele

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