Types of Prolapse 

Urethrocele (urethral hypermobility)

Greek “ourethra”=urethra & “kele”=hernia

 

The urethra, the tube that conveys urine from the bladder, is about 1½ inches in length and is fused to the  distal third of the vagina.  The bladder neck is located at the junction of the bladder and urethra and is the main muscle that provides continence (urinary control).  Descent of the bladder neck and urethra into the roof of the vagina occurs when their support structures become lax.  Detachment of the urethropelvic ligaments from the tendinous arc allow such descent. This causes stress urinary  incontinence, a spurt-like leakage of urine that can occur with any activity that increases abdominal pressure, typically sneezing, coughing, lifting, laughing, running, dancing, aerobics, etc.

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Cystocele (bladder prolapse) Refer to (Figure 9).

Greek “kystis”=bladder & “kele”=hernia

 Descent of the bladder through a weakness in its supporting tissues gives rise to a cystocele, a.k.a.  “dropped bladder,” “prolapsed bladder,” or “bladder hernia.”  A central-defect cystocele occurs when the bladder falls into the roof of the vagina as a result of a  weakness in the perivesical fascia between the top wall of the vagina and the bladder.  A lateral-defect cystocele occurs when the attachment of the bladder to the pelvic side wall weakens (the vesicopelvic fascia becomes detached from the tendinous arc).  The most common defect is a combined central and lateral defect followed by a lateral defect alone, followed by a central defect alone.  As a cystocele progresses, the amount of descent into the roof of the vagina increases.  Cystoceles are graded as follows:

                GRADE 1= mild

                GRADE 2= bladder to vaginal opening (introitus) with strain.

                GRADE 3= bladder outside vaginal opening with strain.  

                GRADE 4= bladder outside vaginal opening at all times.

The symptoms of a cystocele are typically one or more of the following:

  • a bulge or lump protruding from the vagina
  • kinking of the urethra causing obstruction and hence:
    • the need for “manual reduction” (pushing back) of the cystocele in order to urinate
    • obstructive urinary symptoms (a slow, weak steam that stops and starts)
    • irritative urinary symptoms (frequent and urgent urinating)
    • urinary tract infections due to incomplete bladder emptying
    • vaginal pain or painful intercourse

 

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Rectocele (rectal prolapse) Refer to (Figure 10).

Greek “rectum”=straight & “kele”=hernia

 

Ascent of the rectum through a weakness in its supporting tissues gives rise to a rectocele, a.k .a. “dropped rectum” or “prolasped rectum,” or “rectal hernia.” The rectum protrudes through the floor of the vagina because the levator muscles, prerectal fascia, and pararectal fascia have become lax.  As a  rectocele progresses, the amount of ascent into the vaginal floor increases. Essentially, a rectocele is an upside-down cystocele.  Rectoceles are graded as follows:

                GRADE 1= mild

                GRADE 2= rectum to vaginal opening with strain

                GRADE 3= rectum outside vaginal opening with strain

                GRADE 4= rectum outside vaginal opening at all times

 

The symptoms of a rectocele are typically one or more of the following:

  • a bulge or lump protruding from the vagina, especially noticeable during bowel movements
  • kinking of the normally straight rectum creating a relative obstruction and thus:
    • difficulty with bowel movements
    • the need for “splinting” (holding the rectocele down with your fingers) to empty the bowels
    • fecal soiling
    • incomplete emptying of the rectum
    • vaginal pain or painful intercourse

 

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Perineal Floor Relaxation

Usually accompanying a rectocele is perineal muscle laxity, a condition in which the muscles of the perineum (the anatomical region between the vagina and anus) become lax. Weakness in the levator muscles, the bulbcavernosus muscle, the transverse perineal muscles, and the  central tendon occur causing the following anatomical changes:

  • a wide and lax vaginal opening
  • decreased distance between the vagina and anus
  • change in the vaginal angle such that the vagina assumes a more vertical axis as opposed to its normal posterior (downwards) angulation

 Women with perineal relaxation who are sexually active may complain of a very loose or gaping vagina, making intercourse less satisfying for themselves and their partners.

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Enterocele (small intestinal prolapse) Referto (Figure 11).

Greek “enteron”=intestine & “kele”=hernia

 

The peritoneum is the thin sac that contains the abdominal  organs, including the small intestine.  Descent of the peritoneal contents through a weakness in the supporting tissues at the apex of the vagina gives rise to an enterocele, a.k.a. “dropped small intestine,” “small intestine prolapse,” or “small intestine hernia.”  Enteroceles are caused by a weakness or separation of the cardinal and sacro-uterine ligaments.  As an enterocele progresses, the amount of descent into the vagina increases.

 Enteroceles are graded as follows:

                GRADE 1= mild

                GRADE 2= peritoneal sac to vaginal opening with strain

                GRADE 3= peritoneal sac outside vaginal opening with strain

                GRADE 4= peritoneal sac outside vaginal opening at all times

 The symptoms of an enterocele are typically one or more of the following:

  • a bulge or lump protruding through the vagina
  • intestinal cramping due to small intestine trapped within the entrocele
  • vaginal pain or painful intercourse

 There are several types of enteroceles:

  • “pulsion”: from chronically increased abdominal pressure
  • “traction”: when other pelvic organs, such as the uterus, bladder or rectum, cause a pull (traction) on the vaginal vault and peritoneum
  • “iatrogenic”: following a surgical procedure such as hysterectomy

“Simple” enteroceles exist when there is no vaginal vault prolapse; “complex” enteroceles are  associated with vaginal vault and uterine prolapse.

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Vaginal Vault Prolapse

 

The most advanced stage of pelvic relaxation occurs when the support structures of the vagina (cardinal and uterosacral ligaments) are damaged by hysterectomy or other pelvic surgery such that the vaginal vault everts. Vault prolapse, a.k.a. “dropped vaginal vault.” “prolapsed vaginal vault,” or “vaginal vault hernia” is rarely an isolated event, but rather occurs in association with enterocele, cystocele and uterine prolapse.  For illustrative purposes, if the  vagina can be thought of as a “sock,” vaginal vault prolapse is a condition in which the sock is turned inside out. 

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Uterine Prolapse Refer to (Figure 12).

 

Descent of the uterus and cervix because of weakness of their supporting structures (utero-sacral and cardinal  ligaments) results in uterine prolapse, a.k.a. “dropped uterus,” “prolapsed uterus,” or “uterine hernia.” Normally the cervix is located in the deepest third of the vagina.  As uterine prolapse progresses, the amount of descent into the vaginal canal will increase. Uterine prolapse is graded as follows:

                GRADE 1= mild descent of the cervix towards                                      the vaginal opening with strain

                GRADE 2= cervix to vaginal opening with                                              strain

                GRADE 3= cervix outside vaginal opening with strain

               GRADE 4= “procidentia,” complete prolapse in which the cervix and                                                      uterus are outside the vaginal opening at all times

The symptoms of uterine prolapse are typically one or more of the following:

  • bulge or lump protruding from the vagina
  • a sense of “dropping out” and lack of pelvic support
  • urinary symptoms: obstructive voiding symptoms, the need to “manually reduce” (push  back) the uterus in order to initiate voiding, irritative voiding symptoms, incontinence, urinary tract infections
  • kidney obstruction because of descent of bladder and ureters (tubes that drain urine from the kidney to the bladder)
  • vaginal pain with sitting and walking
  • painful intercourse
  • spotting or bloody vaginal discharge

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