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Vaginal Prolapse Relaxation (continued)

Anterior Vaginal Wall Prolapse (Cystocele and Urethrocele)

The anterior vaginal wall supports the bladder and the urethra. The anterior vaginal wall supportive layer is called the pubocervical fascia. Anterior vaginal wall is named based upon its two ends of attachment. Anterior vaginal wall is attached distally to the pubic bone area and proximally to the cervix if the uterus has not been removed. The pubocervical fascia is also attached laterally (on both sides) to the pelvic floor muscles specifically the obturator internus muscle. As long as this vaginal wall stays in place the bladder and urethra will stay in its normal anatomical position.
Patients with cystocele or cystourethrocele may experience:

	Pelvic/Vaginal pressure
	Dyspareunia (painful intercourse)
	Dragging or drawing vaginal sensation
	Urinary incontinence
	Difficulty emptying bladder
	Repositioning body to empty bladder

When there is break in the pubocervical fascia there is a loss of support of the urethra and/or bladder resulting in:

Cystocele: Loss of support at the level of the bladder. "bladder drop"

Cystourethrocele: Loss of support of both the urethra and bladder. These two conditions most commonly coexist.

Urethrocele: Loss of support at the level of the urethra. Can be diagnosed by doing a Q-tip test and often coexists with stress urinary incontinence.

Prolapse Relaxation Figure: 1 Vaginal and Uterine Support (side view) - Note the upper pubocervical fascia supports the bladder and urethra, the lower rectovaginal fascia supports the rectum. Specifically the rectovaginal fascia keeps the rectum from protruding into the vagina. Both of the pubocervical and rectovaginal fascia attach to the uterus which in turn attaches to the uterosacral ligaments. There is a continuous supportive structure (fascia) from the opening of the vagina to the uterosacral ligaments.	Prolapse Relaxation Figure: 2 Normal support - as seen on vagina inspection.
Prolapse Relaxation Figure: 3 Cystourethrocele - is a combined "cystocele" and "urethrocele" in other words there is a loss of support for the whole anterior vaginal wall. The main supportive layer known as the pubocervical fascia is no longer supporting the bladder or urethra appropriately.	Prolapse Relaxation Figure: 4 Cystourethrocele - as seen on vagina inspection.