Anterior Vaginal Wall Prolapse (Cystocele and Urethrocele)
Vaginal Prolapse Relaxation (continued)
To better understand the lack of bladder and urethra support, we need to appreciate the support of those organs by viewing them from an aerial view (i.e. looking downwards on the vagina). Normal support shows the pubocervical fascia (support system of the anterior vaginal wall attached to the arcus tendineus (a tough canvas-like material overlying the muscles) on the pelvic side wall.
Prolapse Relaxation Figure: Anterior Vagina Normal Support – (aerial view) The bladder and urethra sit on the pubocervical fascia. The pubocervical fascia is attached laterally to the arcus tendineus on both sides..
Normal 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.
If there is a break in the pubocervical fascia anywhere throughout its length or at its attachment to the arcus tendineus it will result in a lack of support of the bladder or urethra. A break in the pubocervical fascia (support system) can be in the middle of the fascia (midline defect), apically (where anterior vaginal wall meets the cervix) or laterally (paravaginal defect). Surgical correction of cystocele and urethrocele depend upon the specific area of break:
- Midline defects – site specific repair or anterior repair (colporrhaphy)
- Paravaginal defects – paravaginal repair (MOST COMMON)
- Transverse defects – site specific repair
Example of a midline (central) defect: Picture yourself standing in the middle of a room, on a wooden floor which is covered with carpet. Suddenly someone cuts a hole in the wooden floor directly beneath you, leaving the carpet intact. Your feet and body would begin to sag into the hole, but you would not fall through because of the support of the carpet.
This is an example of a midline defect - the bladder falls into the hole or defect of the pubocervical fascia (i.e. wooden floor). Now the bladder's only support, in this specific area, is the vaginal skin (carpet). The problem or defect here is not the entire floor, it is only the hole in the floor which is directly beneath you. Therefore this is the area or portion of the pubocervical fascia (i.e. wooden floor) which needs to be repaired.
The surgical repair of this defect can be seen under "Anterior Repair"
Cystocele (Midline Defect) – Vaginal View – here the skin has been pulled back to demonstrate the hole or defect in the pubocervical fascia (supportive layer). The defect in the supportive layer allows the bladder to come in direct contact with the vaginal skin resulting in a cystocele.
Cystocele midline or central defect – (side view) - This patient has a cystocele due to a midline or central defect on the pubocervical fascia (support system). Now the bladder is sagging in the area lacking fascia. To repair this area an anterior repair should be performed to specifically correct the pubocervical fascia defect.
Example of paravaginal or lateral defect: (MOST COMMON DEFECT) If you were standing on a floor and someone took a saw and cut the attachment of the floor to its wall on each side, the floor would begin to sag. The wooden floor is completely intact without any central or midline defects. Therefore, the problem is not the integrity of the floor directly beneath you, but its attachment to the walls on each side of the room.
Paravaginal (lateral) defect – resulting in a cystocele (aerial view)
Normal Anterior Vaginal Wall – (aerial view)
The surgical repair of this defect can be seen under Laparoscopic Paravaginal Repair.