gynecology and obstetrics
Anterior and Posterior Vaginal Wall Prolapse
Introduction
Anterior and posterior vaginal wall prolapse involve protrusion of an organ into the vaginal canal. Anterior vaginal wall prolapse is commonly referred to as cystocele or urethrocele (when the bladder or urethra is involved). Posterior vaginal wall prolapse is commonly referred to as enterocele (when the small intestine and peritoneum are involved) and rectocele (when the rectum is involved). Symptoms include pelvic or vaginal fullness or pressure, urinary incontinence, urinary retention, and difficulty passing stool. Diagnosis is clinical. Treatment includes conservative management with pelvic muscle exercises, pessaries, and sometimes surgery. Cystocele, urethrocele, enterocele, and rectocele are particularly likely to occur together. Urethrocele is virtually always accompanied by cystocele (cystourethrocele). Cystocele and cystourethrocele commonly develop when the pubocervical vesical fascia is weakened. Enterocele usually occurs after a hysterectomy. Weakness in the pubocervical fascia and rectovaginal fascia allows the apex of the vagina, which contains the peritoneum and small bowel, to descend. Rectocele results from disruption of the levator ani muscles. Risk factorsfor vaginal wall prolapse are Age Obesity Vaginal delivery Chronic straining (eg, due to constipation or heavy lifting) Severityof vaginal wall prolapse can be graded by the Pelvic Organ Prolapse-Quantification (POP-Q) system: Stage 0: No prolapse Stage I: Most distal prolapse is more than 1 cm above the hymen Stage II: Most distal prolapse is between 1 cm above and 1 cm below the hymen Stage III: Most distal prolapse is more than 1 cm below hymen but 2 cm shorter than total vaginal length Stage IV: Complete eversion The POP-Q system is recommended by professional organizations because it is a reliable and reproducible classification system that is based on predefined anatomic landmarks. The Baden-Walker system, which is based on level of protrusion, is sometimes used. However, it is an older classification system that is not reproducible: Grade 0: No prolapse Grade 1: Halfway to the hymen Grade 2 : To the hymen Grade 3 : Halfway past the hymen Grade 4: Maximal possible 