Vaginal Prolapse Relaxation

Types of vaginal prolapse:

• Cystocele
• Urethrocele
• Rectocele
• Uterine Prolapse
• Vaginal vault
• Enterocele

Normal Anatomy - Imageswill open in a new window
It is easier to understand uterine and vaginal wall relaxation (prolapse) if one has a working knowledge of normal anatomy. The support system of the uterus, urethra, bladder and to some degree the rectum is the vagina, specifically the "fascia". The vagina is a fibromuscular tube (fascia) covered with vaginal epithelium (skin). It is this fascia which is responsible for the integrity and vaginal wall strength. The fascia is the support system of the vagina. This fascia is elevated and suspended and attached to muscles and ligaments of the pelvis. A simple analogy to the vaginal wall, skin and peripheral attachment is the floor you may be standing upon. The integrity, strength or support (fascia) of the floor is the concrete or wood and the carpet (skin or epithelium) on the support is the vaginal epithelium (vagina skin). The vaginal epithelium (skin) very little support function and primarily acts as a covering. 

The floor you are standing, like the fascia, is a complete piece of material which supports anything that sits or stands upon it. The floor, as does the fascia, must be attached to something to give it a point of attachment and further strength. Peripherally the floor is attached to the walls and foundation of the house. Likewise the vagina is attached to certain ligaments and muscles so it remains supportive. 

Anterior vaginal wall prolapse (cystocele and urethrocele) - Imageswill open in a new window
The anterior vaginal wall supports the bladder and the urethra. The anterior vaginal wall supportive layer is called the pubocervical fascia. It is named based upon its two ends of attachment. It is attached distally to the pubic bone area and proximally to the cervix if the uterus has not been removed. The pubocervical fascia is also attached laterally (on both sides) to the pelvic floor muscles specifically the obturator internus muscle. As long as this vaginal wall stays in place the bladder and urethra will stay in its normal anatomical position. 
Patients with cystocele or cystourethrocele may experience: 

• Pelvic/vaginal pressure 
• Dyspareunia (painful intercourse) 
• Dragging or drawing vaginal sensation 
• Urinary incontinence
• Difficulty emptying bladder 
• Repositioning body to empty bladder 

When there is break in the pubocervical fascia there is a loss of support of the urethra and/or bladder resulting in: 

• Cystocele: Loss of support at the level of the bladder. "bladder drop" 
• Urethrocele: Loss of support at the level of the urethra. Can be diagnosed by doing a Q-tip test and often coexists with stress urinary incontinence.
• Cystourethrocele: Loss of support of both the urethra and bladder. These two conditions most commonly coexist. 

To better understand the lack of bladder and urethra support, we need to appreciate the support of those organs by viewing them from an aerial view (i.e. looking downwards on the vagina). Normal support shows the pubocervical fascia (support system of the anterior vaginal wall attached to the arcus tendineus (a tough canvas-like material overlying the muscles) on the pelvic side wall. 

If there is a break in the pubocervical fascia anywhere throughout its length or at its attachment to the arcus tendineus it will result in a lack of support of the bladder or urethra. A break in the pubocervical fascia (support system) can be in the middle of the fascia (midline defect), apically (where anterior vaginal wall meets the cervix) or laterally (paravaginal defect). Surgical correction of cystocele and urethrocele depend upon the specific area of break: 

• Midline defects - site specific repair or anterior repair (colporrhaphy) 
• Paravaginal defects - paravaginal repair (MOST COMMON) 
• Transverse defects - site specific repair 

Example of a midline (central) defect: Picture yourself standing in the middle of a room, on a wooden floor which is covered with carpet. Suddenly someone cuts a hole in the wooden floor directly beneath you, leaving the carpet intact. Your feet and body would begin to sag into the hole, but you would not fall through because of the support of the carpet. 

This is an example of a midline defect - the bladder falls into the hole or defect of the pubocervical fascia (i.e.. wooden floor). Now the bladder's only support, in this specific area, is the vaginal skin (carpet). The problem or defect here is not the entire floor, it is only the hole in the floor which is directly beneath you. Therefore this is the area or portion of the pubocervical fascia (i.e. wooden floor) which needs to be repaired. 

The surgical repair of this defect can be found under "Anterior Repair".

Example of paravaginal or lateral defect: (MOST COMMON DEFECT) If you were standing on a floor and someone took a saw and cut the attachment of the floor to its wall on each side, the floor would begin to sag. The wooden floor is completely intact without any central or midline defects. Therefore, the problem is not the integrity of the floor directly beneath you, but its attachment to the walls on each side of the room. 

Posterior vaginal wall prolapse (rectocele) - Imageswill open in a new window
The supportive layer of the posterior vaginal wall is called the rectovaginal septum or rectovaginal fascia. It is attached distally to the perineal body, laterally to the levator ani muscle and proximally to the cervix (if uterus is present). When a break in the rectovaginal septum is present the rectal wall will come into contact with the vaginal skin and create a bulge on the posterior bottom side of the vagina. The bulge will usually increase in size with bearing down (Valsalva maneuver) especially when having a bowel movement. Patients with a rectocele may experience: 

• Vaginal pressure/discomfort 
• Protrusion coming from the posterior vaginal wall 
• Difficulty evacuating rectum 
• Dyspareunia (painful intercourse) 
• Repositioning of body during bowel movements

For surgical treatment information see "Posterior Repair"

Uterine Prolapse - Imageswill open in a new window
The uterosacral ligaments primarily support the upper 20% of the vagina (apex) and the uterus. When the uterosacral ligaments break the uterus begins to descend into the vagina. Further uterine descension pulls the rest of the vagina down resulting in apical tears of the anterior (pubocervical) fascia and posterior (rectovaginal) fascia from its points of lateral attachment. Anterior vaginal wall lateral tears are called paravaginal defects and results in cystourethrocele. Continued uterine and vaginal prolapse can result in a complete uterine and vaginal prolapse such that the uterus falls outside the vaginal opening and the vagina falls inside out. 

Vaginal Vault Prolapse - Imageswill open in a new window
Vaginal vault prolapse usually refers to an apical vaginal relaxation in an individual who no longer has a uterus (post hysterectomy). As the apex of the vagina continues to descend it pulls the rest of the vagina down resulting in apical tears of the anterior and posterior fascia from its lateral points of attachment. Continued descent of the vaginal apex may result in complete eversion of the vagina. Complete eversion of the vagina means that the once highest point in the vagina is now the lowest point hanging out of the vagina.

Enterocele - Imageswill open in a new window
Enterocele occur primarily in patients who have had their uterus removed (hysterectomy). The anterior vaginal wall (pubocervical) fascia and posterior vaginal wall (rectovaginal) fascia separate and intestines can push directly against the vaginal skin. The herniation at the apex of the vagina is known as an enterocele.

Patients with a large enterocele, vaginal vault prolapse and uterine/vaginal prolapse may experience: 

• Pelvic or vaginal pressure 
• Difficulty evacuating rectum
• Difficulty emptying bladder
• Dyspareunia (painful intercourse) 
• Lower back pain/discomfort 
• Increasing pain/discomfort with prolonged standing 
• Decreased pain/discomfort upon lying down 
• Pain increases as day progresses

References:

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