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 or bowel 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

• Most common surgical procedure is vaginal or abdominal hysterectomy with additional attention to restoring apical support after the uterus is removed, with suspension either by vaginal uterosacral, sacrospinous fixation, or by abdominal sacral colpopexy

• For elderly women who do not desire coitus, colpocleisis, the partial obliteration of the vagina, is an effective and straightforward procedure

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