Rectocele/Cystocele

It is a displacement and herniation of one or more of the pelvic organs downward from their normal positions.

Causes of Genital Organ Prolapse

There are many causes of pelvic relaxation. Age, menopausal status, pregnancy, vaginal birth, obesity, chronic cough, chronic constipation, genetic factors, previous hysterectomy, and occupations involving heavy lifting are common.

30% of patients with prolapsing pelvic organs also have a family history of prolapse. Especially in the white race, prolapse due to low collagen content can be more common. Prolapse after difficult childbirth, giving birth to large babies and childbirths requiring intervention cause tears and stretch marks in the endopelvic fascia and may result in sagging in the genitals. Chronic constipation and cough can increase this damage. Nerve injury of the pelvic floor muscle is also a factor.

Pelvic Organ Prolapse Frequency

One in 9 women undergoes operation at least once for pelvic relaxation and/or stress incontinence.

Symptoms of Pelvic Organ Prolapse

The patient presents with the feeling of mass in the vagina, which is most common. Sagging structures can create a feeling of pressure in the vagina. Sagging can be aggravated while walking and standing. There may be an unwanted noise (queefing) during sexual intercourse.

Urinary incontinence may occur in 40% of patients with sagging. While urinating, it may be necessary to push the bladder by hand and support it. Urine may remain in the sagged part of the bladder precluding complete evacuation. Pressure ulcers and irritation may be seen over time, since the mucous membrane of the sagging organs is exposed to outside.

Type of Prolapse in Genital Organs

Clinical classification is made according to the organ that sags or appears to be sagged.

The main displaced bodies include bladder, urethra, uterus and rectum. Pelvic relaxation is described with reference to the vagina.

Diagnosis of Pelvic Organ Prolapse

The diagnosis is based on vaginal examination findings.

Rectal examination may be useful to distinguish enterocele from rectocele. Examination may also be performed with the patient standing.

Treatment

In mild cases that do not show symptoms, treatment may not be required.

Pessaries can be used in the non-surgical approach.

The main treatment is surgery. Pelvic floor weaknesses are repaired.

Vaginal hysterectomy is performed in patients who is over 40 years of age and do not have a desire for child, if there is also a sagging of the uterus.

Manchester-Fothergill operation can be performed in young patients.

The shortening of round ligaments and fixing it to the anterior abdominal wall, that is, classical uteropia does not offer good results.

In uterine descensus and vaginal cuff prolapse, sacrospinous ligament fixation, retro peritoneal abdominal uterosacropexia, sacral colpopexy surgeries have been performed in recent years.

In elderly patients who cannot undergo hysterectomy, the vaginal mucosa is removed and the vagina is closed completely with Le Fort operation.

Cystocele

A cystocele is also known as a dropped or fallen bladder Cystosele is sometimes accompanied by various urinary complaints and sometimes urinary incontinence. In the upper wall of the vagina, there may be a lump bulging outwards. With cyctocele, there may be an increase in mobility of the bladder neck. In advanced forms, there may be urine remaining in the bladder after urination. Sometimes patients try to urinate by supporting their bladder with hand. The treatment is surgery.

Cystocele Diagnosis

We diagnose cystocele by telling the patient strain during vaginal exam. If there is urinary incontinence, urodynamic testing may be requested. The degree of prolapse can also be seen with ultrasound.

Cystocele Surgery Techniques

Often anterior colporaphy is performed. In addition, the following operations can also be performed.

  • Paraurethral tissue is suspended on the pubic symphysis through retropubic colposuspension (Marshall Marchetti Krantz -MMK- procedure).
  • Burch colposuspension (suspending paravaginal tissues to cooper ligament) can be done.
  • Paravaginal defect repair (lateral vaginal walls are suspended on the archus tendinus).

These techniques lift the lower urinary tract towards the retzius cavity.

  • Needle procedure (Pereyra and Stamey procedure).
  • Paravaginal repair.
  • If there is intrinsic urethral sphincter dysfunction, sling procedure, artificial injections and periurethral bulking injections are performed in addition to the anterior colpography.

Urethrocele

A urethrocele is the sagging of the lower wall of the urethra (small tube that carries urine from the bladder to outside the body during urination). The lower 1/3 of the urethra is estrogen-dependent. Sagging in the urethra can be observed especially during menopause. Painful urination, burning in the urine, ulceration in the urinary exit area may occur.

Cystourethrocele

A cystourethrocele is the sagging of the lower wall of the bladder and urethra.

Rectocele

A rectocele is the bulging of the upper wall of the rectum towards the vagina. A herniation in the anal canal occurs due to the weakening and separation of the pelvic floor muscles called levator ani. This may happen especially after difficult births. Sometimes this herniation towards the vagina becomes more pronounced during the defecation and can cause constipation.

Surgery Techniques for Rectocele

Posterior colpography

Colpoperineorrhaphy operations are performed.

Enterocele

An enterecole is the sagging of the lower part of the abdominal cavity, (also called pouch of Douglas) into the vagina. In this type of prolapse, small intestines bulge towards the vagina. Rectal examination may be required to distinguish from rectocele.

Moschcowitz procedure; A series of circular sutures are placed in the abdomen for narrowing the cul-de-sac. Halban operation; sutures are placed sagittally to obliterate the cul-de-sac.

McCall culdoplasty; The sacro uterine ligaments are brought closer.

Uterine Prolapse

Descensus uteri: A Descensus uterus is the downward displacement of the uterus.

Cervical elongation with descensus uteri: The increase in the length of the cervix with the displacement of the uterus downwards.

Partial uterine prolapse: It is the part of the uterus that comes out of the vagina.

Complete uterine prolapse: The entire uterus comes out of the vagina.

Depending on the patient’s preferences (either removal of the uterus and suspension of the related ligaments or the suspension of womb and ligaments without removing the uterus), surgery is recommended which can be performed via vaginal or laparoscopic route.


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