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Pelvic Floor Prolapse, Cystocele, and Rectocele
Overview
Pelvic floor prolapse is the relaxation of pelvic floor muscles of a female such that pelvic organs can descend down into and possibly out of the vaginal vault. Prolapse of the bladder through the anterior wall of the vagina is a cystocele. Prolapse of the rectum through the posterior vaginal wall is a rectocele. Prolapse of small bowel through the posterior vaginal wall is an enterocele. Prolapse of the uterus is called uterine prolapse.
The uterus, ovaries, bowel, bladder, and rectum are suspended in the female pelvis on tendinous cords (ligaments) similar to bungee cords hanging from the pelvic bones. These ligaments and the pelvic floor muscles keep these pelvic organs in place and prevent these organs from descending down and out through the vagina. These ligaments and the pelvic muscles wear out over time and as a result the pelvic organs can descend down through the vagina (descensus). Along with time and age other risk factors for descensus include a history of pregnancy, deliveries, pelvic surgery (especially hysterectomy), and pelvic radiation.
Pelvic descensus unto itself does not necessarily pose a health problem. In fact, mild descensus is extremely common and asymptomatic and needs no intervention. As prolapse progresses and the uterus, bladder, rectum, or bowel drops further down the vaginal canal the prolapse becomes visible and can cause a sense of pressure or even pain. In severe cases the entire uterus and large portions of bowel or bladder drop out of the vagina and this can even lead to a surgical emergency when prolapse becomes symptomatic and surgical treatment may be merited. If surgical evaluation is considered evaluation in the office might include: detailed pelvic exam, cystoscopy (telescopic examination of the bladder), and urodynamics (a functional study of the bladder). For surgical repair of prolapse/descensus there are three types of surgical repairs: transvaginal suture plication, transvaginal mesh kit repairs, and transabdominal suspension. We highly recommend transabdominal suspension by robotically-assisted Laparoscopic technique as our surgical treatment of choice.
Transvaginal suture plication has historically been the most common type of repair for prolapse. This type of repair is also called an anterior vaginal repair for cystocele and a posterior vaginal repair for rectocele or enterocele. This type of repair fails almost 100% of the time because it relies on suturing together the same muscles and ligaments that failed in the first place.
The transvaginal mesh kit repairs use synthetic mesh to support the vaginal from the bony pelvis and pelvic ligaments. This type of repair has more durable success than simple suture plication but the mesh lies just under the vaginal mucosa which risks erosion. Because of the risk of erosion the FDA released consumer warnings about these repair kits.
At USA Delaware our recommended approach to treating pelvic descensus is robotic sacrocolpopexy. This is an abdominal suspension without the need for an incision. With robotic laparoscopic sacrocolpexy 5 small port sites are used to apply a synthetic mesh to the vagina and suture it up to the bony sacrum. This approach offers a long-term solution for all forms of desenscus. For further details see our patient brief on Robotic Sacrocolpopexy.
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