What is Urodynamic Testing?

TYPES OF PROLAPSE?

The normal female pelvis in sagital view from front to back contains the pubic bone, the bladder, the vaginal and uterus, and rectum as illustrated in Figure A.

Figure A. Normal pelvic anatomy in the sagital plane. Used with permission. Source: The Merck Manual of Geriatrics, 3^rd Edition, edited by Mark H. Beers and Robert Berkow. Copyright 2000 by Merck & Co., Inc., Whitehouse Station, NJ.

A cystocele occurs when connective tissue supports between your bladder and vagina break and allows the bladder to “herniate” into the vagina. This is the most common type of prolapse. Cystocele is old terminology for what we now recognize as “anterior vaginal wall support defects”. Mild anterior vaginal wall defects may cause no symptoms at all. As the cystocele becomes more pronounced, it may kink or partially block the urethra. You may then experience a slow urine stream, or feel like you are not completely emptying your bladder when you urinate.

Rectocele occurs when the connective tissue supports between your rectum and vagina break, allowing the rectum to “herniated” into the vagina. Rectocele is old terminology for what we now recognize as “posterior vaginal wall support defects”. Mild posterior vaginal wall support defects may cause no symptoms. As the size of the rectocele increases, you may have difficulty having a bowel movement and have to “stent” or put your finger into your vagina or push in the skin between your vagina and rectum to get the stool to come out. As previously mentioned, loss of stool during intercourse may occur when the rectocele is pushed back where it should be, and trapped stool located just inside the opening to the rectum comes out.

Cystoceles and rectoceles can frequently occur at the same time as illustrated in Figure B. Poor support for the vaginal apex is the most likely cause of coexisting cystoceles and rectoceles.

Figure B. Co-existent cystocele and rectocele in the sagital plane. Used with permission.Source: The Merck Manual of Geriatrics, 3^rd Edition, edited by Mark H. Beers and Robert Berkow. Copyright 2000 by Merck & Co., Inc., Whitehouse Station, NJ.

Rectal prolapse is not the same as a rectocele. Rectal prolapse occurs when the rectum descends out of the anus (opening where stool comes out).

Enterocele occurs when the connective tissue supports at the top of the vagina break, allowing the small intestine to “herniate” into the vagina. Because the tissue supports at the top of the vagina break, an enterocele may also herniated toward the front of the vagina as an anterior vaginal wall support defect. An anterior enterocele is commonly mistaken for a cystocele on examination and can be the cause of early surgical failures after traditional surgical repairs. A rectal enterocele occurs when the connective tissue supports of the rectum break allowing the small intestine to “herniate” into the rectum, protruding out of the anus. In this case, a rectal enterocele can be often confused with rectal prolapse on examination.

Enteroceles often coexist with vaginal vault prolapse and occasionally coexist with rectoceles. The symptoms may be similar to rectocele and include low back pain or pelvic pressure.

Figure C. Enterocele with Vaginal Vault Prolapse, post-hysterectomy in the sagital plane. Used with permission. Source: The Merck Manual of Geriatrics, 3^rd Edition, edited by Mark H. Beers and Robert Berkow. Copyright 2000 by Merck & Co., Inc., Whitehouse Station, NJ.

Uterine prolapse occurs when the connective tissue supports for the uterus break and the uterus “herniates”. Symptoms may be a combination of those experienced with cystocele and rectocele.

The vaginal vault is the top of the vagina and is normally held in place by the connective tissue supports of the uterus. When the uterus is removed (hysterectomy), the vaginal vault can fall in on itself (like a sock pushed inside out) if the connective tissue supports of the uterus are not reattached to the vaginal vault. When the supports of the vagina break, vaginal vault prolapse can occur. This happens in about 15% of women who have had a hysterectomy for uterine prolapse, and in about 1% of the women who have had a hysterectomy for other reasons.

Figure D. Uterine prolapse in the sagital plane. Note the co-existent rectocele, cystocele, and enterocele. Used with permission. Source: The Merck Manual of Geriatrics, 3^rd Edition, edited by Mark H. Beers and Robert Berkow. Copyright 2000 by Merck & Co., Inc., Whitehouse Station, NJ.

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