Vaginal Prolapse

Last updated 20.09.12

 

Definition

-  Prolapse of female internal genitals from normal anatomical position

 

Types

-  Anterior = Cystocoele

-  Posterior

-  Lower = Rectocoele

-  Upper = Enterocoele

-  Apical or Central = Vault Prolapse

-  Uterine prolapse

 

Features

-  50% parous women

-  20% asymptomatic

-  3 layers of support

-  Level I: uterosacral & cardial ligaments

-  Level II: white line (arcus tendineus)

-  Level III: pelvic floor

 

Risk Factors

-  Age

-  Menopause

-  Increased abdominal pressure (chronic cough, constipation..)

-  Caucasian

-  Connective tissue disorder

-  Pregnancy & childbirth

-  Surgery

 

Associated S/S

-  Urinary: voiding difficulty, urgency, UTI

-  May mask stress incontinence (obstruction)

-  Bowel: anal incontinence (rectocoele), digital manual anal evacuation

-  Sexual dysfunction: psychological, should not cause dysparaenuria

-  Lump: most common presenation

-  Rectocoele more obvious on defecation

-  Pain, dragging, heaviness

-  Vaginal bleeding only if ulceration

 

Ix

-  Abdo exam: ascities, mass

-  Speculum: site/type or prolapse

-  Cough: ?incontinence (stress)

-  VE

-  POP-Q assessemnt

 

Mx

-  If asymptomatic nil Mx required

-  Pessary: ring or shelf

-  F/U every 3-6months for R/V

-  Should improve back otherwise ?cause

-  Topical oestrogen

-  Physiotherapy: pelvic floor exercises as prevention

-  No evidence of effect for improving S/S of lump/bulge

-  Improves stress incontinence

-  Surgery

-  If symptomatic or poor QOL

-  Apical repair: vault prolapse

-  Posterior repair: rectoceole

-  Anterior repair: cyctocoele

-  Vaginal hysterectomy

 

 

 

Cystocoele

<Vaginal Prolapse>

 

Features

-  Thinning & stretching of vesico-vaginal fascia

-  Detachment of lateral vaginal wall from white line of pelvis

 

Associated S/S

-  Frequency & urgency

-  Does not cause urge or stres incontinence

-  May coexist with/or latent stress incontinence as obstruction masks S/S

-  If large may cause obstruction & incomplete emptying + S/S worse later in day

-  May cause vesicovaginal fistula or ureteric obstruction

-  Short term voiding difficulties: freq & urge

-  Central Cystocoele: loss of vaginal rugae on exam w thin, shiny epithelium

-  Lateral Cystocoele: rugae retained

 

Mx

-  Surgery: Anterior Repair

-  May unmask stress incontinence

-  Fascial repair +/- with mesh

-  Paravagianl defect repair

 

Cystocoele

 

 

 

Rectocoele

<Vaginal Prolapse>

 

Features

- Weakening or splitting of rectovaginal fascia

- May have transverse defects

- Typically mid third of posterior vaginal wall

- Commonly ass w perineal deficiency

 

Associated S/S

- Difficulty emptying bowels

- May need to digitate

- Decreased coital sensation

- Does not cause faecal incontinence

 

Mx

- Surgery: Posterior Repair

-  Excessive vaginal narrowing: dyspareunia

-  May cause rectovaginal fistula (rare)

-  Fascial repair +/- with mesh

 

Rectocoele

 

 

 

Eterocoele

<Vaginal Prolapse>

 

Features

-  Herniation of rectouterine space

-  Upper third or posterior vaginal wall

-  Lined by peritoneum & contains small bowel

-  Ass w vault & uterine prolapse

 

Associated S/S

-  Dragging aching lower back pain

-  Stretching of vessels in mesentery 

 

Enterocoele

 

 

 

Vault Prolapse

<Vaginal Prolapse>

 

Features

-  Prolapse of upper vagina after hysterectomy

-  Contains small bowel

-  Can result in total vaginal eversion

 

Assoacited S/S

-  Bowel S/S

-  Urethral &/or ureteral obstruction

-  Latent stress incontinence, overflow incontinence

 

Mx

- Apical repair

-  Reattachment of uterosacral ligament

-  Abdominal sacrocolpoplexy (mesh) or vaginal sacrospinous fixation

- Vaginal obliteration (colpocelesis)

-  Rarely done

 

 

References