Pelvic Support Disorders

(Pelvic Relaxation Disorders)

Hernia-like protrusions into the vagina by the bladder, rectum, or uterus, caused by weakness of pelvic ligaments, connective tissue, and muscles.

Because women today are living longer, pelvic support disorders are becoming a greater gynecologic health issue. A woman has about an 11% lifetime risk of undergoing surgery for pelvic support disorders and incontinence. Causes of pelvic support disorders are most likely multifactorial; risk factors include trauma during childbirth, increased abdominal pressure secondary to obesity, chronic coughing or straining at stool, estrogen deficiency, and intrinsic connective tissue weakness.

The more common pelvic support disorders include rectoceles, enteroceles, cystoceles, or a combination of these defects. Standardized terminology based on clearly defined anatomic reference points has been developed to permit quantitative, reproducible descriptions of the degree of severity of pelvic support disorders; this terminology facilitates communication between physicians and enables the progression of these conditions to be accurately followed.

A rectocele is a protrusion of the rectum into the vaginal lumen resulting from weakness in the muscular wall of the rectum and the perirectal fascia (see Figure 118-1).

An enterocele is a herniation of the peritoneum and small bowel and is the only true hernia among the pelvic support disorders. Most enteroceles occur downward between the uterosacral ligaments and the rectovaginal space.

A cystocele is a herniation of the urinary bladder through the anterior vaginal wall (see Figure 118-1). Cystoceles usually occur when the pubocervical connective tissue weakens or detaches from its lateral or superior connecting points.

Uterine prolapse is generally the result of poor cardinal or uterosacral ligament support. Typically, uterine prolapse is classified as first degree when the cervix descends below the level of the ischial spine, second degree when the cervix descends to but not through the introitus, and third degree when the cervix descends through the introitus.

Procidentia, which involves prolapse of the uterus and vagina, and total vaginal vault prolapse, which can occur after hysterectomy, represent eversion of the entire vagina (see Figure 118-2).

Symptoms and Signs

Heaviness or pressure in the vaginal area is the most common symptom. A mass may protrude at the introitus. These symptoms almost always occur when the patient is upright; they rarely occur when the patient is supine.

A patient with a rectocele may have difficulty passing stool; manual manipulation may be needed for complete defecation. A patient with an enterocele may experience pelvic fullness, pressure, or pain and lower back pain; the hernia may be palpable in the vagina, particularly on rectovaginal examination. A patient with a cystocele may develop stress or overflow urinary incontinence, incomplete bladder emptying, or a urinary tract infection.

A patient with uterine prolapse may have lower back or sacral pain while standing, although many patients are asymptomatic. A patient with procidentia may experience lower back pain, sacral pain, discomfort when walking (secondary to the protruding "mass"), and bleeding (secondary to ulceration of the cervix and vaginal mucosa). A patient with total vaginal vault prolapse may experience pain, especially when sitting. Third-degree uterine prolapse or total vaginal vault prolapse may lead to ulceration of the vaginal mucosa and bladder or rectal dysfunction (eg, difficulty voiding, chronic residual urine) that is often worse after prolonged standing and is presumably due to urethral kinking, and at least two thirds develop stress incontinence when the prolapse is reduced. In some patients, urethral kinking is protective, because it stops urine from leaking when the anterior vagina and bladder protrude.

Diagnosis

Pelvic support disorders are diagnosed by pelvic examination; use of a Sims' speculum facilitates this examination.

Severe prolapse is obvious when the patient is in the dorsolithotomy position. Less severe prolapse may be detected using a Valsalva maneuver, which often reveals a widening of the genital hiatus and an evident rectocele or cystocele. Bimanual examination, including rectovaginal examination, is helpful in palpating a rectocele.

An enterocele is also diagnosed by pelvic examination; the patient performs a Valsalva maneuver while standing, which usually causes the prolapsing small intestine to bulge downward (see Figure 118-3). An enterocele may be visually indistinguishable from a rectocele.

If uterine prolapse or total vaginal vault prolapse is suspected, anal sphincter tone and the bulbocavernosus reflex should be assessed. Additional tests include residual urine measurement, urinalysis, urine culture and sensitivity, bladder fill testing, and stress testing with the prolapse reduced. Most patients with severe urinary leakage or symptoms and signs of complex bladder dysfunction should undergo full urodynamic evaluation. Ureteral obstruction and subsequent renal damage are uncommon but should be sought if the patient has an enlarged uterus or a pelvic mass.

Treatment

Nonsurgical treatment: Nonsurgical treatment includes pelvic muscle (Kegel's) exercises to strengthen the pelvic floor and perineal body for mild cases of rectocele, cystocele, or uterine prolapse; a pessary may help in more severe cases. Pessaries are particularly useful for patients in whom surgery is contraindicated. These devices are made of silicone, plastic, or rubber and have multiple shapes and sizes (see Figure 118-4). Pessary choice is determined by the amount of pelvic relaxation, the degree of uterine prolapse, the size of the genital hiatus, and the ease of pessary insertion. Teaching and clinical follow-up are important to ensure that the patient properly inserts and removes the pessary. A patient who plans to leave the pessary in place requires periodic follow-up for removal and cleaning of the pessary and inspection of the vagina. The health of the vaginal tissue is optimized with the use of topical estrogen vaginal cream (if the patient is not taking oral hormone replacement therapy), which helps thicken the vaginal epithelium and prevents ulceration.

Surgical treatment: Rectoceles are best treated through a vaginal approach with dissection of the rectovaginal space to expose and repair the defect in the rectal wall or pararectal fascia. Enteroceles and cystoceles may be approached transabdominally or transvaginally. Enteroceles are repaired by dissecting and excising the enterocele sac. Cystoceles are repaired by dissecting the vesicovaginal space and plicating the pubocervical fascia to correct its attenuation.

For uterine prolapse, procidentia, or total vaginal vault prolapse, the upper vagina is sutured to a stable structure within the pelvis. Large defects, such as vaginal vault prolapse and procidentia, are best managed by surgeons experienced in repairing these problems.

During surgery, all pelvic support defects should be corrected. Minimal defects that are not repaired are likely to worsen. Any lower urinary tract problems (notably stress incontinence) should also be treated.