Atlanta Center for Laparoscopic Urogynecology
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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.
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"
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.
The surgical repair of this defect can be seen under Laparoscopic Paravaginal Repair.