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GENERAL CONSIDERATIONS
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Pelvic organ prolapse, including cystocele, rectocele, and enterocele, are vaginal hernias commonly seen in multiparous women. Cystocele is a hernia of the bladder wall into the vagina, causing a soft anterior fullness (eFigure 18–7). Cystocele may be accompanied by urethrocele, which is not a hernia but a sagging of the urethra following its detachment from the pubic symphysis usually during childbirth. Rectocele is a herniation of the terminal rectum into the posterior vagina, causing a collapsible pouch-like fullness (eFigure 18–8). Enterocele is a vaginal vault hernia containing small intestine, usually in the posterior vagina and resulting from a deepening of the pouch of Douglas. Two or all three types of hernia may occur in combination. The cause of pelvic organ prolapse is multifactorial. Risk factors include vaginal birth, genetic predisposition, advancing age, prior pelvic surgery, connective tissue disorders, and increased intra-abdominal pressure associated with obesity or straining associated with chronic constipation or coughing (eFigures 18–7, 18–8, 18–9, 18–10). A woman's lifetime risk of surgery for pelvic organ prolapse is 12–19%.
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The Pelvic Organ Prolapse Quantification (POPQ) system is a commonly used method for classifying pelvic organ prolapse. In this system, the hymen acts as the fixed point of reference, with six defined points for measurement and three other landmarks. POPQ measurements provide a quantitative representation of anterior, apical, and posterior vaginal prolapse relative to the hymen. An alternative staging system, the Baden-Walker system, includes a degree of prolapse relative to the hymen (from 0 to 4) for each prolapsed structure.
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Symptoms of pelvic organ prolapse may include a sensation of a bulge or ...