Pelvic Prolapse: Diagnosing and Treating Cystoceles, Rectoceles, and Enteroceles

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Disclosures

Medscape General Medicine. 1998;1(3) 

In This Article

Abstract and Introduction

Abstract

The current generation of women is maintaining a healthier and more active lifestyle into an older age. Treatable conditions such as stress urinary incontinence and pelvic prolapse detract from this active lifestyle. In many cases, an improved quality of life can be maintained by treating pelvic prolapse conditions with relatively minor surgical procedures. Optimal treatment requires a knowledge of pelvic floor anatomy, an understanding of the various pelvic floor defects, and experience in selecting the appropriate procedure. The unequivocal diagnosis of pelvic prolapse conditions can only be made on physical examination. Each section of the vagina -- anterior, posterior, lateral, and apex -- must be inspected and evaluated separately to define the true nature and degree of prolapse. The examination should be performed with a moderate amount of urine in the bladder, and the patient must strain forcefully during the procedure. In some cases, this requires that the patient stand or sit upright during part of the examination to allow all areas of prolapse to become manifest. When the proper procedures are performed, excellent long-term results can be anticipated. The successful treatment of cystoceles requires an evaluation for both lateral and central defects, as inadequate treatment of either defect will lead to recurrences. The treatment of rectoceles is more controversial: Most clinicians would repair symptomatic rectoceles, but many choose not to treat asymptomatic rectoceles because there is little documented benefit to justify the risk of postoperative dyspareunia. Small asymptomatic enteroceles may be treated with a pessary; however, large symptomatic enteroceles usually require surgery.

Introduction

Although pelvic prolapse conditions have plagued women for thousands of years, safe and effective treatments for these conditions were not developed until the 19th century. Even today, pelvic prolapse conditions are among the most difficult to diagnose and treat. A thorough understanding of pelvic anatomy and pathophysiology, plus experience in selecting appropriate surgical techniques, is required to effectively treat pelvic prolapse with minimal morbidity and treatment failure.

Pelvic prolapse conditions -- including cystocele, rectocele, enterocele, and uterine and vaginal vault prolapse -- result from weakness or damage to the normal pelvic-support systems. The most commonly implicated etiologies are childbearing and removal of the uterus. Other contributing causes include connective tissue defects, prolonged heavy physical labor, and postmenopausal atrophy.[1,2]

A thorough history and physical exam should be done to diagnose all areas of pelvic prolapse. The surgical treatment then should be individualized to correct each pelvic prolapse defect or combination of defects.

In this article, we examine the pathophysiology of pelvic prolapse, as well as the diagnosis and treatment of cystoceles, rectoceles, and enteroceles. The second article in our discussion of "Pelvic Prolapse" is "Diagnosing and Treating Uterine and Vaginal Vault Prolapse" and we focus on versus herniations of the vaginal vault or apex, such as enterocele or uterine prolapse.

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