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

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Disclosures

Medscape General Medicine. 1998;1(3) 

In This Article

Clinical Evaluation to Identify Areas of Vaginal Weakness

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. Additionally, the patient may need to strain or maintain the upright position for a sufficient period to allow all areas of prolapse to be manifested.

In some cases, a cystocele or rectocele may be seen when the patient quickly bears down; however, if this maneuver is not maintained long enough, then an enterocele or a moderate degree of vault prolapse may not be appreciated. These provocative maneuvers should reliably reproduce the prolapse and stress incontinence experienced by the patient under normal circumstances. Therefore, the examination should identify the specific areas that are deficient in support, what degree of prolapse is present, and possible etiologies for the lack of support.

Method of Evaluation

The pelvic exam is performed using the lower blade of a Graves speculum. The speculum is placed on the posterior wall of the vagina, and the anterior wall is evaluated for mucosal atrophy, loss of vaginal rugae, loss of central or lateral support consistent with a cystocele, and urethral support. Any abnormalities of the urethra should be noted, such as a diverticulum, caruncle, or unsuspected urethral hypersuspension. The degree of enlargement of a cystocele with straining should be noted. A cotton swab placed in the urethra can help in crudely assessing urethral hypermobility. A change greater than 30 to 35 degrees is considered "abnormal." Some women who have greater than 35 degrees' rotation do not leak urine, whereas others who have minimal rotation are severely incontinent.[5]

Urinary leakage should also be evaluated with the patient straining maximally. If the patient does not leak urine during the straining maneuver but has significant prolapse, the prolapse should be temporarily reduced with a vaginal pack maintained in place with the speculum tip in contact with the vaginal apex while the patient again strains maximally.

We have been impressed with the number of patients in whom we cannot demonstrate urinary leakage until the prolapse is reduced. We and others have not found the Marshall or Bonney test of supporting the bladder neck with fingers or other instruments as reliable a method of predicting who will respond favorably to an incontinence procedure.[6] Lastly, the inability to demonstrate leakage in the supine position is not unusual, and placing the patient upright to evaluate leakage is more physiologic.

In all patients with an intact uterus, mobility with straining should be assessed, and any abnormalities of the cervix should be evaluated with a Pap smear. A history of unexplained uterine bleeding usually requires an endometrial biopsy. A cervix that has moved from a normal position down to the level of the hymen is considered hypermobile and is likely to progress farther after an incontinence procedure is performed, possibly leading to a hysterectomy and a dissatisfied patient at a later date.

The posterior vaginal wall is examined similarly by placing the lower blade of the Graves speculum against the anterior vaginal wall. In the post-hysterectomy patient, descent of the vaginal apex with the patient straining indicates a lack of vaginal vault support. In most cases, an enterocele coexists with vault prolapse. A bulging of the posterior vaginal wall may be an enterocele or a rectocele. Descent of the posterior vaginal wall near the apex indicates a probable enterocele. Descent of the vaginal wall at the level of the hymen or below usually indicates a rectocele.

Confirmation of these defects can often be made by placing one finger in the rectum and another on the posterior wall of the vagina. Thickening or pulsation of the rectovaginal wall when the patient strains is indicative of an enterocele. If this maneuver is inconclusive, perform the examination with the patient standing.

A rectocele can be diagnosed by evaluating the structural integrity of the distal rectovaginal septum. Fascial weakness in the distal rectovaginal septum would allow a rectocele to occur. Lastly, the perineal body, which lies between the vagina and anus, should be evaluated for structural integrity. A lax perineal body is usually manifested by a very large vaginal opening.

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