Normal Anatomy

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.

Cystocele and Urethrocele
Anterior vaginal wall prolapse

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.

Rectocele
Posterior vaginal wall prolapse

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

Uterine Prolapse

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

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

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

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