Cystocele, Rectocele, and Vaginal Prolapse - Assignment Example

Cystocele, Rectocele, and Vaginal Prolapse Introduction and Etiology: All these three conditions are parts of a single disorder in the elderly women. This disorder is linked to loss of supports of the uterus and weakness of the pelvic floor. Cystocele is a condition characterized by hernia of the bladder trigone following weakness of the vaginal and pubocervical fascia. The bladder base descends and later a bladder pouch is formed that may contain residual urine increasing the risk of a urinary tract infection and other symptoms of initiating and controlling urinary stream while micturating. Rectocoele is a condition where a prolapse of the lower part of the posterior vaginal wall occurs due to weakness or divarication of the levator ani; the rectum bulges into the vagina, and the patient may have problems with passage of stool. Vaginal prolapse on the other hand resembles a hernia for there is protrusion of part of the abdominal or pelvic contents through an aperture in the supporting structures. Protrusion takes place between the two levatores ani and, in more severe cases, through the orifice of the vagina when vaginal prolapse occurs (Hamilton-Fairley, D., 2004). Signs and Symptoms: The commonest complaints are feeling of fullness of the vagina, a lump coming down, a dragging sensation or bearing down in the back or lower abdomen, vaginal discharge due to congestion of the cervix, an ulcer of the ectocervix or cervical ectropion, and a bloodstained discharge may occur if there is ulceration. Difficulty with coitus may be experienced if the cervix protrudes or is greatly elongated. Urinary symptoms include frequency of micturition. This is common and is often daytime only. Nocturnal frequency may be present if there is added cystitis. Some patients may have urgency of micturition due to weakness of the bladder sphincter mechanism and urge incontinence may occur in some cases. There may be difficulty in emptying the bladder completely and the woman may find she has to push the prolapse up with a finger to complete the act of micturition. Complete retention of urine may follow urethral overstretch. This may be associated with stress incontinence. Many women with prolapse complain of constipation, and this may be due to difficulty in emptying the rectum completely because it bulges into the vagina. Others notice discomfort on sitting on a firm surface; the vaginal wall over the rectocoele can bulge down between the labia. With age, the labia become atrophic and less protective and the prolapsed vagina is exposed to trauma when sitting on hard surfaces (Hamilton-Fairley, D., 2004). A cystourethrocoele is usually obvious and the distance from the introitus to the bulge can be measured using a special ruler. The woman is asked to cough and any leakage of urine and/or descent of the cervix is noted. As the speculum is withdrawn any posterior vaginal wall prolapse can be noted. Where there is a complaint of stress incontinence, examination is best made with some urine in the bladder; the urethra and bladder neck may then be supported with two fingers to demonstrate that this maneuver controls the incontinence (Hamilton-Fairley, D., 2004). Diagnostic and Therapeutic Procedures: Stress incontinence must be distinguished from other causes of incontinence of urine such as urge incontinence and incontinence due to neurological disease. General examination should include fitness for surgery. Abdominal examination should be performed to exclude an intra-abdominal mass. Manual pelvic examination or ultrasound should exclude a pelvic mass and delineate the size of the uterus and ovaries if present. If prolapse is not evident, even with a Valsalva manoeuvre, the patient should be examined in the upright position. It is important to reproduce the symptoms and signs with which the patient presents. If a woman has significant urinary symptoms, urodynamics may help define the cause of the symptoms, which will enable the gynaecologist to give some prognosis for treatment. Hence, if urodynamics indicate obstructed voiding there is a good prognosis for surgical repair of the cystocoele resolving the voiding dysfunction while if the urodynamics suggest the bladder is atonic the prognosis is less favourable. If urodynamics indicate that the bladder is overactive then it is unlikely that surgery will improve the urinary symptoms. An anterior rectocoele may result in obstructed defaecation. Rectal mucosal prolapse may also result in obstructed defaecation and will not be apparent on vaginal examination. Proctography can give some insight into factors which may be contributing to difficulty with defecation. Magnetic resonance imaging has been used as a research tool to try to identify prolapse not clinically evident. It has not been proved to aid or improve treatment outcome to date (Smith, ARB, 2007). Current Trends: Some women elect for non-surgical treatment of their prolapse either because the prognosis offered for treatment is not sufficiently attractive, they are unfit for surgery, they wish to delay surgical treatment for other reasons. Conservative treatment may involve lifestyle advice, pelvic floor physiotherapy, and vaginal pessary. Many surgeons perform vaginal hysterectomy when operating for prolapse, an operation of choice when prolapse is combined with menorrhagia or where there are small uterine fibroids. Vaginal hysterectomy is preferred in cases of uterine procidentia. The best results from operations for repair depend on the degree of descent of the various components of the genital tract together with the judgment and expertise of the surgeon. Anterior colporrhaphy and posterior colpoperineorrhaphy are also offered as management of such patients. These operations are designed to restore the support to the vagina from the levator ani and muscles of the perineum (Smith, ARB, 2007). Currently, women with urinary symptoms and vaginal prolapse should all undergo urodynamic investigation prior to deciding on surgical treatment. This is undertaken for the following reasons. If genuine stress incontinence is demonstrated, vaginal surgery is not the treatment of choice. If the patient has detrusor instability vaginal surgery may make it worse, and there is an increased risk of postoperative urinary retention and/or infection. New surgical techniques for uterovaginal prolapse have been introduced. These include sacrospinous fixation where the uterosacral ligaments are fixed to the sacrospinous ligament via the vaginal or abdominal route (Maher C, Baessler K, Glazener CMA, Adams EJ & Hagen S, 2004). Reference List Hamilton-Fairley, D. (2004). Pelvic Floor Disorders. Lecture Notes Obstetrics and Gynaecology. Blackwell Publishing. USA Pages 284-299. Smith, ARB, (2007) Pelvic floor dysfunction I: uterovaginal prolapse in Edmonds, DK (eds). Dewhurst's Textbook of Obstetrics & Gynaecology, 2007. Blackwell Publishing. USA. Page 496. Maher C, Baessler K, Glazener CMA, Adams EJ & Hagen S (2004) Surgical management of pelvic organ prolapse in women (Review). Cochrane Collaboration 2005 4, CD004014. Read More