Pelvic Organ Prolapse: Cystocele, Rectocele, Enterocele

PELVIC ORGAN PROLAPSE: CYSTOCELE, RECTOCELE, ENTEROCELE

Time and gravity can put strain on the ligaments and structures that make up the female pelvis. Childbirth can result in tears of the levator sling musculature, resulting in structural weakness. Hormone deficiency also may play a role.

Cystocele is a downward displacement of the bladder towardthe vaginal orifice (Fig. 47-3) resulting from damage to the anterior vaginal support structures. 

It usually results from injury and strain during childbirth. The condition usually appears some years later when genital atrophy associated with aging occurs, but younger, multiparous, premenopausal women may also be affected.

Rectocele and perineal lacerations may affect the muscles and tissues of the pelvic floor and may occur during childbirth. Be-cause of muscle tears below the vagina, the rectum may pouch upward, thereby pushing the posterior wall of the vagina forward. This structural abnormality is called a rectocele. Sometimes the lacerations may completely sever the fibers of the anal sphincter (complete tear). An enterocele is a protrusion of the intestinal wall into the vagina. Prolapse (if complete prolapse occurs, it may also be referred to as procidentia) results from a weakening of the support structures of the uterus itself; the cervix drops and may protrude from the vagina.

Clinical Manifestations

Because a cystocele causes the anterior vaginal wall to bulge downward, the patient may report a sense of pelvic pressure, fa-tigue, and urinary problems such as incontinence, frequency, and urgency. Back pain and pelvic pain may occur as well. The symp-toms of rectocele resemble those of cystocele, with one exception: instead of urinary symptoms, the patient may experience rectal pressure. Constipation, uncontrollable gas, and fecal incontinence may occur in patients with complete tears. Prolapse can result in feelings of pressure and ulcerations and bleeding. Dyspareunia may occur with these disorders.

Medical Management

Kegel exercises, which involve contracting or tightening the vaginal muscles, are prescribed to help strengthen these weakened muscles. The exercises are more effective in the early stages of a cystocele. Kegel exercises are easy to do and are recommended for all women, including those with strong pelvic floor muscles (Chart 47-4).

Pessaries can be used to avoid surgery. This device is inserted into the vagina and positioned to keep an organ, such as the bladder, uterus, or intestine, properly aligned when a cystocele, rectocele, or prolapse has occurred. Pessaries are usually ring-shaped or doughnut-shaped and are made of various materials, such as rubber or plastic (Fig. 47-4). Rubber pessaries must be avoided in women with latex allergy. The size and type of pessary are selected and fitted by a gynecologic health care provider. The patient should have the pessary removed, examined, and cleaned by her health care provider at prescribed intervals. At this checkup, vaginal walls are examined for pressure points or signs of irritation. Normally, the patient experiences no pain, discom-fort, or discharge with a pessary, but if chronic irritation occurs, alternative measures may be needed.

SURGICAL MANAGEMENT

In many cases, surgery helps to correct structural abnormalities. The procedure to repair the anterior vaginal wall is called anterior colporrhaphy, repair of a rectocele is called a posterior colporrha-phy, and repair of perineal lacerations is called a perineorrhaphy. These repairs are frequently performed laparoscopically, resulting in short hospital stays and good outcomes. A laparoscope is in-serted through a small abdominal incision, the pelvis is visualized, and surgical repairs are performed.