Category Archive Pregnancy & Mom Care

Protrusion of The Bladder/A cystocele otherwise known as a protrusion of the bladder occurs when the bladder descends into the vagina. The bladder bulges through the anterior wall of the vagina, with which it is anatomically associated. There are multiple underlying causes for the development of cystocele resulting in weakness of the muscles and the connective tissue surrounding the bladder and vagina.[rx]

A cystocele is the most common type of pelvic organ prolapse. Pelvic organ prolapse occurs when the vaginal walls, uterus, or both lose their normal support and prolapse, or bulge, into the vaginal canal or through the vaginal opening. Other nearby pelvic organs, such as the bladder or bowel, may be involved and also drop from their normal position in the body.

Types of Cystocele

Cystocele can be further described as being apical, medial, lateral, or mediolateral.

• The apical cystocele – is located in the upper third of the vagina. The structures involved are the endopelvic fascia and ligaments. The cardinal ligaments and the uterosacral ligaments suspend the upper vaginal-dome. The cystocele in this region of the vagina is thought to be due to a cardinal ligament defect.^[rx][rx]
• Medial cystocele – forms in the mid-vagina and is related to a defect in the suspension provided by to a sagittal suspension system defect in the uterosacral ligaments and pubocervical fascia. The pubocervical fascia may thin or tear and create the cystocele. Aid in diagnosis is the creation of a ‘shiny’ spot on the epithelium of the vagina. This defect can be assessed by MRI.^[ex][rx]
• Lateral cystocele – forms when both the pelvic perineal muscle and its ligamentous–fascial develop a defect. The ligamentous– fascial creates a ‘hammock-like’ suspension and support for the lateral sides of the vagina. Defects in this lateral support system result in a lack of bladder support. Cystocele that develops laterally is associated with an anatomic imbalance between the anterior vaginal wall and the arcus tendinous fasciae pelvis – the essential ligament structure.^[rx][rx]

Causes of Cystocele

Cystoceles result from a weakness of the pelvic-floor support system. The main associated risk factors are obesity, increasing age, and parity. They can also occur due to chronically increased intra-abdominal pressure, collagen abnormality, family history of cystocele, and following pelvic surgery.

• Obesity – Giri et al., in their systematic review, reported that women with BMI >25 had a risk ratio of 1.36 (95% confidence interval) for developing prolapse, while women with BMI >30 had a risk ratio of 1.47 (95% confidence interval).[rx] Another study suggested that in overweight and obese women, the risk of progression of a cystocele increased by 32% and 48%, respectively, compared with participants with normal BMI.[rx] However, few studies have shown that weight loss did not lead to symptoms resolution or regression of the prolapse. In particular, in some of them, weight loss was associated with a borderline worsening of uterine prolapse, indicating that the damage to the pelvic floor is irreversible.[rx][rx]
• Advancing Age – A number of studies have shown a strong link between aging and vaginal prolapse.[rx][rx] It is suggested that age-related changes in pelvic anatomy, innervation, and vasculature cause weakness in pelvic floor strength.[rx] A study of vaginal tissue biopsies discovered that collagen in the vaginal wall changes its structure over time, which might explain the link between aging and cystocele development.[rx]
• Parity and Other Childbirth-related Factors – Vaginal delivery carries a high risk for pelvic floor weakness.[rx] The attenuation of the pelvic floor muscles has been shown to increase with parity. Nygaard et al. showed that the prevalence of pelvic floor disorders increases by 12.8%, 18.4%, 24,6%, and 32.4% for 0, 1, 2, and 3 deliveries, respectively.[rx] Moreover, it was found that forceps delivery plays a critical role in levator ani muscle avulsion.[rx] Mant et al. specifically suggest that the first stage of labor is responsible for developing a vaginal prolapse.[rx]
• Increased Intra-abdominal Pressure – Increased intra-abdominal pressure seems to have a weak correlation with anterior vaginal prolapse. Several studies indicated a correlation between cystocele development and constipation, chronic cough, and obstructive pulmonary disease, which are all associated with chronically increased abdominal pressure.[rx][rx][rx]
• Collagen Abnormality – The predominant type of collagen found in the vaginal wall is type III, designed to be resistant to sudden pressure changes, which is essential in tissues that require elasticity. In women with vaginal prolapse, the amount of collagen III in the vaginal tissue was higher than in healthy women, possibly due to the underlying remodeling.[rx] Women with congenital conditions affecting collagen production, such as Marfan and Ehlers-Danlos syndrome, are predisposed to developing cystocele.[rx][rx] Up to a third of women with Marfans and three-quarters of women with Ehlers-Danols have a history of vaginal wall prolapse.[rx]
• Family History – Even though there are no known specific genes responsible for the development of vaginal prolapse, a review of sixteen studies has revealed that women with pelvic prolapse are highly likely to have a relative suffering from the same condition.[rx]
• Pelvic Surgery – Surgery of the pelvis, especially hysterectomy, causes damage to the endopelvic fascia and nerves. This, in turn, results in a greater risk of vaginal prolapse and herniation of the bladder.[rx]

Risk factors

Risk factors for developing a cystocele are:

Connective tissue disorders predispose women to developing cystocele and another pelvic organ prolapse. The tissues tensile strength of the vaginal wall decreases when the structure of the collagen fibers change and become weaker.^[rx]

Symptoms of Cystocele

The symptoms of a cystocele may include:

• a vaginal bulge
• the feeling that something is falling out of the vagina
• the sensation of pelvic heaviness or fullness
• difficulty starting a urine stream
• a feeling of incomplete urination
• frequent or urgent urination
• fecal incontinence^[rx]
• frequent urinary tract infections
• back and pelvic pain
• fatigue
• painful sexual intercourse^[rx]
• bleeding^[rx]
• A feeling of fullness or pressure in your pelvis and vagina
• In some cases, a bulge of tissue in your vagina that you can see or feel
• Increased pelvic pressure when you strain, cough, bear down or lift
• Problems urinating, including difficulty starting a urine stream, the feeling that you haven’t completely emptied your bladder after urinating, feeling a frequent need to urinate or leaking urine (urinary incontinence)
• A cystocele also called a prolapsed or dropped bladder, is the bulging or dropping of the bladder into the vagina.
• A cystocele occurs when the muscles and supportive tissues between a woman’s bladder and vagina weaken and stretch, letting the bladder sag from its normal position and bulge into the vagina or through the vaginal opening.
• Diagnosing a cystocele requires medical tests and a physical exam of the vagina.
• Cystocele treatment depends on the severity of the cystocele and whether a woman has symptoms.

A bladder that has dropped from its normal position and into the vagina can cause some forms of incontinence and incomplete emptying of the bladder.^[rx]

Diagnosis of Cystocele

The most objective and standard tool for evaluating the severity of the anterior wall prolapse is the POPQ system, which was introduced in 1996. This system is recognized by The American College of Obstetricians and Gynecologists and consists of 4 stages.

• Stage 0 – no prolapse
• Stage 1 – most distal part of prolapse is -1cm (above the level of the hymen)
• Stage 2 – most distal part of prolapse is >= -1cm but <= +1cm (<=1cm above or below the hymenal plane)
• Stage 3 – most outside portion of the prolapse >+1cm but <+(total vaginal length -2)cm (beyond the hymen; protrudes no farther than 2cm less than the total vaginal length)
• Stage 4 – complete eversion of the vagina; most distal portion of the prolapse >= +(total vaginal length -2) cm.[rx]

Three stages are used for patients after removal of the uterus and four if the uterus is present.

Medical history

A health care professional may ask about your

• symptoms, such as bulges or lumps in the vagina, pelvic pressure or heaviness, and urinary incontinence
• pregnancy and childbirth history
• current and past medical problems, including surgeries
• family history
• over-the-counter and prescription medicines
• bowel habits

Diagnosis of anterior prolapse may involve

• A pelvic exam – You may be examined while lying down and possibly while standing up. During the exam, your doctor looks for a tissue bulge in your vagina that indicates pelvic organ prolapse. You’ll likely be asked to bear down as if during a bowel movement to see how much that affects the degree of prolapse. To check the strength of your pelvic floor muscles, you’ll be asked to contact them, as if you’re trying to stop the stream of urine.
• Filling out a questionnaire – You may fill out a form that helps your doctor assess your medical history, the degree of your prolapse, and how much it affects your quality of life. This information also helps guide treatment decisions.
• Bladder and urine tests – If you have significant prolapse, you might be tested to see how well and completely your bladder empties. Your doctor might also run a test on a urine sample to look for signs of a bladder infection if it seems that you’re retaining more urine in your bladder than is normal after urinating.
• Urodynamics – Measures the bladder’s ability to hold and release urine.
• Cystoscopy (cystourethroscopy) – A long tube-like instrument is passed through the urethra to examine the bladder and urinary tract for malformations, blockages, tumors, or stone

Treatment of Cystocele

Non-surgical

Cystocele is often treated by non-surgical means:

• Pessary – This is a removable device inserted into the vagina to support the anterior vaginal wall. Pessaries come in many different shapes and sizes. There are sometimes complications with the use of a pessary.^[rx]
• Pelvic floor muscle therapy – Pelvic floor exercises to strengthen vaginal support can be of benefit. Specialized physical therapy can be prescribed to help strengthen the pelvic floor muscles.^[rx][rx]
• Dietary changes – Ingesting high fiber foods will aid in promoting bowel movements.^[rx]
• Estrogen – intravaginal administration helps to prevent pelvic muscle atrophy^[rx]
• Kegel exercises – (pelvic muscle exercises) can be advised for women with stage 1 or 2 prolapse. It is found that these exercises improve prolapses by 1-2 cm on average. A systematic review and meta-analysis of the effectiveness of Pelvic Floor Muscle Therapy (PFMT) showed that women involved in pelvic muscle training showed better outcomes regarding symptoms and reduction of the size of the prolapse compared to control groups.[rx] Supervised muscle training for at least 12-16 weeks can be considered for such women to measure the improvement.[rx] The exercises should be continued if they are proved to be beneficial for the patient.

• Hormone Replacement Therapy – is not a treatment for cystocele. There is no evidence that estrogen’s topical or systemic use reduces the size of cystocele; the creams or estrogen-containing vaginal pessaries can still be used for women with cystocele for treating signs of vaginal atrophy, which may occur concurrently.[rx] Another study has shown the pre-operative use of topical estrogen creams improve the synthesis of collagen, preventing thinning of the vaginal wall, and reducing the activity of degrading enzymes.[rx]

It is essential to encourage the patient to work on modifiable risk factors, such as a high BMI (>30), smoking, heavy lifting, chronic cough, or constipation.

Surgical Management

Surgical management is the next step for symptomatic women, those who require immediate relief, those who have declined conservative treatment, or for whom the conservative approach has failed to provide benefit. It should be noted that surgical management should follow the completion of the patient’s family as the pelvic support system can be further damaged during labor.

Surgical planning depends on whether the anterior vaginal prolapse is isolated or is combined with apical or posterior vaginal prolapse. A careful examination is required as a part of preoperative planning.

Anterior colporrhaphy

Anterior repair is performed trans-vaginally to repair central vaginal wall defects and to lessen the size of the anterior vaginal wall.

For this procedure, a patient is placed in the lithotomy position and catheterized; a Sims speculum is inserted to achieve a better view of the defect. An Allis forceps are placed at the midline of the anterior wall 1cm proximal to the urethra and two more forceps on each side next to the cervix or the vaginal cuff. Local infiltration with an adrenaline/lidocaine solution is commonly used to achieve hydro-dissection, analgesia, and to minimize intraoperative bleeding. With the use of Metzenbaum scissors, dissection of vaginal mucosa from the underlying vesicovaginal fascia is performed. When the mucosal layer is entirely free, a folding of the muscular layer and adventitia using figure-of-eight sutures is performed. Careful placement of the sutures is crucial in order not to damage the bladder.

2-0 Vicryl or PDS sutures are most often used. After successful plication, the excessive vaginal mucosa is removed, and the wound is closed with absorbable sutures.  The surgeon should be careful not to reduce the diameter of the vagina too much, as later it may cause pain during sexual intercourse. One study has reported the success rate of surgical approach ranging from 63% to 76.5%, depending on the procedure followed.[rx]

Sacral colpopexy

The other way to repair a bladder prolapse is to perform a sacral colpopexy, which is usually done laparoscopically. This procedure aims to place a permanent mesh to the anterior and posterior walls of the vagina and then attach it to the anterior longitudinal ligament below the sacral promontory. The operation can be performed together with anterior colporrhaphy or on its own. The benefit of sacral colpopexy is that it avoids vaginal incisions and scarring, which results in a lower risk of vaginal shortening or dyspareunia. The success rate of this procedure is 60% to 89%.[rx] A randomized trial indicated that laparoscopic sacral colpopexy has a higher success rate and a lower chance of repeat procedure for both anterior and posterior vaginal prolapses.[rx]

In many countries, including the US and the UK, the use of mesh for cystocele repairs has been suspended since 2019, pending an investigation into their use.[rx]

Complication

Post-surgical complications can develop. The complications following surgical treatment of cystocele are:

People Also Reading

Bladder Prolapse – Causes, Symptoms, Treatment Prolapsed Uterine Bladder – Causes, Symptoms, Treatment Protrusion of the small intestines peritoneum and vaginal canal Lateral Cystocele – Causes, Symptoms, Treatment Apical Cystocele – Causes, Symptoms, Treatment Cystocele – Causes, Symptoms, Diagnosis, Treatment Medial Cystocele – Causes, Symptoms, Treatment Enterocele – Causes, Symptoms, Diagnosis, Treatment Cystocele Prolapse – Causes, Symptoms, Treatment Uterine Prolapse – Causes, Symptoms, Treatment Prolapsed Cystocele – Causes, Symptoms, Treatment Prolapse After Childbirth – What To Know, How To Do

Apical cystocele is located in the upper third of the vagina. The structures involved are the endopelvic fascia and ligaments. The cardinal ligaments and the uterosacral ligaments suspend the upper vaginal-dome. The cystocele in this region of the vagina is thought to be due to a cardinal ligament defect.^[rx][rx]

Protrusion of The Bladder/A cystocele otherwise known as a protrusion of the bladder occurs when the bladder descends into the vagina. The bladder bulges through the anterior wall of the vagina, with which it is anatomically associated. There are multiple underlying causes for the development of cystocele resulting in weakness of the muscles and the connective tissue surrounding the bladder and vagina.[rx]

A cystocele is the most common type of pelvic organ prolapse. Pelvic organ prolapse occurs when the vaginal walls, uterus, or both lose their normal support and prolapse, or bulge, into the vaginal canal or through the vaginal opening. Other nearby pelvic organs, such as the bladder or bowel, may be involved and also drop from their normal position in the body.

Types of Cystocele

Cystocele can be further described as being apical, medial, lateral, or mediolateral.

• Apical cystocele is located in the upper third of the vagina. The structures involved are the endopelvic fascia and ligaments. The cardinal ligaments and the uterosacral ligaments suspend the upper vaginal-dome. The cystocele in this region of the vagina is thought to be due to a cardinal ligament defect.^[rx][rx]
• Medial cystocele – forms in the mid-vagina and is related to a defect in the suspension provided by to a sagittal suspension system defect in the uterosacral ligaments and pubocervical fascia. The pubocervical fascia may thin or tear and create the cystocele. Aid in diagnosis is the creation of a ‘shiny’ spot on the epithelium of the vagina. This defect can be assessed by MRI.^[ex][rx]
• Lateral cystocele – forms when both the pelvic perineal muscle and its ligamentous–fascial develop a defect. The ligamentous– fascial creates a ‘hammock-like’ suspension and support for the lateral sides of the vagina. Defects in this lateral support system result in a lack of bladder support. Cystocele that develops laterally is associated with an anatomic imbalance between the anterior vaginal wall and the arcus tendinous fasciae pelvis – the essential ligament structure.^[rx][rx]

Causes of Apical Cystocele

Cystoceles result from a weakness of the pelvic-floor support system. The main associated risk factors are obesity, increasing age, and parity. They can also occur due to chronically increased intra-abdominal pressure, collagen abnormality, family history of cystocele, and following pelvic surgery.

• Obesity – Giri et al., in their systematic review, reported that women with BMI >25 had a risk ratio of 1.36 (95% confidence interval) for developing prolapse, while women with BMI >30 had a risk ratio of 1.47 (95% confidence interval).[rx] Another study suggested that in overweight and obese women, the risk of progression of a cystocele increased by 32% and 48%, respectively, compared with participants with normal BMI.[rx] However, few studies have shown that weight loss did not lead to symptoms resolution or regression of the prolapse. In particular, in some of them, weight loss was associated with a borderline worsening of uterine prolapse, indicating that the damage to the pelvic floor is irreversible.[rx][rx]
• Advancing Age – A number of studies have shown a strong link between aging and vaginal prolapse.[rx][rx] It is suggested that age-related changes in pelvic anatomy, innervation, and vasculature cause weakness in pelvic floor strength.[rx] A study of vaginal tissue biopsies discovered that collagen in the vaginal wall changes its structure over time, which might explain the link between aging and cystocele development.[rx]
• Parity and Other Childbirth-related Factors – Vaginal delivery carries a high risk for pelvic floor weakness.[rx] The attenuation of the pelvic floor muscles has been shown to increase with parity. Nygaard et al. showed that the prevalence of pelvic floor disorders increases by 12.8%, 18.4%, 24,6%, and 32.4% for 0, 1, 2, and 3 deliveries, respectively.[rx] Moreover, it was found that forceps delivery plays a critical role in levator ani muscle avulsion.[rx] Mant et al. specifically suggest that the first stage of labor is responsible for developing a vaginal prolapse.[rx]
• Increased Intra-abdominal Pressure – Increased intra-abdominal pressure seems to have a weak correlation with anterior vaginal prolapse. Several studies indicated a correlation between cystocele development and constipation, chronic cough, and obstructive pulmonary disease, which are all associated with chronically increased abdominal pressure.[rx][rx][rx]
• Collagen Abnormality – The predominant type of collagen found in the vaginal wall is type III, designed to be resistant to sudden pressure changes, which is essential in tissues that require elasticity. In women with vaginal prolapse, the amount of collagen III in the vaginal tissue was higher than in healthy women, possibly due to the underlying remodeling.[rx] Women with congenital conditions affecting collagen production, such as Marfan and Ehlers-Danlos syndrome, are predisposed to developing cystocele.[rx][rx] Up to a third of women with Marfans and three-quarters of women with Ehlers-Danols have a history of vaginal wall prolapse.[rx]
• Family History – Even though there are no known specific genes responsible for the development of vaginal prolapse, a review of sixteen studies has revealed that women with pelvic prolapse are highly likely to have a relative suffering from the same condition.[rx]
• Pelvic Surgery – Surgery of the pelvis, especially hysterectomy, causes damage to the endopelvic fascia and nerves. This, in turn, results in a greater risk of vaginal prolapse and herniation of the bladder.[rx]

Risk factors

Risk factors for developing a cystocele are:

Connective tissue disorders predispose women to developing cystocele and another pelvic organ prolapse. The tissues tensile strength of the vaginal wall decreases when the structure of the collagen fibers change and become weaker.^[rx]

Symptoms of Apical Cystocele 

The symptoms of a cystocele may include:

• a vaginal bulge
• the feeling that something is falling out of the vagina
• the sensation of pelvic heaviness or fullness
• difficulty starting a urine stream
• a feeling of incomplete urination
• frequent or urgent urination
• fecal incontinence^[rx]
• frequent urinary tract infections
• back and pelvic pain
• fatigue
• painful sexual intercourse^[rx]
• bleeding^[rx]
• A feeling of fullness or pressure in your pelvis and vagina
• In some cases, a bulge of tissue in your vagina that you can see or feel
• Increased pelvic pressure when you strain, cough, bear down or lift
• Problems urinating, including difficulty starting a urine stream, the feeling that you haven’t completely emptied your bladder after urinating, feeling a frequent need to urinate or leaking urine (urinary incontinence)
• A cystocele also called a prolapsed or dropped bladder, is the bulging or dropping of the bladder into the vagina.
• A cystocele occurs when the muscles and supportive tissues between a woman’s bladder and vagina weaken and stretch, letting the bladder sag from its normal position and bulge into the vagina or through the vaginal opening.
• Diagnosing a cystocele requires medical tests and a physical exam of the vagina.
• Cystocele treatment depends on the severity of the cystocele and whether a woman has symptoms.

A bladder that has dropped from its normal position and into the vagina can cause some forms of incontinence and incomplete emptying of the bladder.^[rx]

Diagnosis of Apical Cystocele

The most objective and standard tool for evaluating the severity of the anterior wall prolapse is the POPQ system, which was introduced in 1996. This system is recognized by The American College of Obstetricians and Gynecologists and consists of 4 stages.

• Stage 0 – no prolapse
• Stage 1 – most distal part of prolapse is -1cm (above the level of the hymen)
• Stage 2 – most distal part of prolapse is >= -1cm but <= +1cm (<=1cm above or below the hymenal plane)
• Stage 3 – most outside portion of the prolapse >+1cm but <+(total vaginal length -2)cm (beyond the hymen; protrudes no farther than 2cm less than the total vaginal length)
• Stage 4 – complete eversion of the vagina; most distal portion of the prolapse >= +(total vaginal length -2) cm.[rx]

Three stages are used for patients after removal of the uterus and four if the uterus is present.

Medical history

A health care professional may ask about your

• symptoms, such as bulges or lumps in the vagina, pelvic pressure or heaviness, and urinary incontinence
• pregnancy and childbirth history
• current and past medical problems, including surgeries
• family history
• over-the-counter and prescription medicines
• bowel habits

Diagnosis of anterior prolapse may involve

• A pelvic exam – You may be examined while lying down and possibly while standing up. During the exam, your doctor looks for a tissue bulge in your vagina that indicates pelvic organ prolapse. You’ll likely be asked to bear down as if during a bowel movement to see how much that affects the degree of prolapse. To check the strength of your pelvic floor muscles, you’ll be asked to contact them, as if you’re trying to stop the stream of urine.
• Filling out a questionnaire – You may fill out a form that helps your doctor assess your medical history, the degree of your prolapse, and how much it affects your quality of life. This information also helps guide treatment decisions.
• Bladder and urine tests – If you have significant prolapse, you might be tested to see how well and completely your bladder empties. Your doctor might also run a test on a urine sample to look for signs of a bladder infection if it seems that you’re retaining more urine in your bladder than is normal after urinating.
• Urodynamics – Measures the bladder’s ability to hold and release urine.
• Cystoscopy (cystourethroscopy) – A long tube-like instrument is passed through the urethra to examine the bladder and urinary tract for malformations, blockages, tumors, or stone

Treatment of Apical Cystocele

Non-surgical

Cystocele is often treated by non-surgical means:

• Pessary – This is a removable device inserted into the vagina to support the anterior vaginal wall. Pessaries come in many different shapes and sizes. There are sometimes complications with the use of a pessary.^[rx]
• Pelvic floor muscle therapy – Pelvic floor exercises to strengthen vaginal support can be of benefit. Specialized physical therapy can be prescribed to help strengthen the pelvic floor muscles.^[rx][rx]
• Dietary changes – Ingesting high fiber foods will aid in promoting bowel movements.^[rx]
• Estrogen – intravaginal administration helps to prevent pelvic muscle atrophy^[rx]
• Kegel exercises – (pelvic muscle exercises) can be advised for women with stage 1 or 2 prolapse. It is found that these exercises improve prolapses by 1-2 cm on average. A systematic review and meta-analysis of the effectiveness of Pelvic Floor Muscle Therapy (PFMT) showed that women involved in pelvic muscle training showed better outcomes regarding symptoms and reduction of the size of the prolapse compared to control groups.[rx] Supervised muscle training for at least 12-16 weeks can be considered for such women to measure the improvement.[rx] The exercises should be continued if they are proved to be beneficial for the patient.

• Hormone Replacement Therapy – is not a treatment for cystocele. There is no evidence that estrogen’s topical or systemic use reduces the size of cystocele; the creams or estrogen-containing vaginal pessaries can still be used for women with cystocele for treating signs of vaginal atrophy, which may occur concurrently.[rx] Another study has shown the pre-operative use of topical estrogen creams improve the synthesis of collagen, preventing thinning of the vaginal wall, and reducing the activity of degrading enzymes.[rx]

It is essential to encourage the patient to work on modifiable risk factors, such as a high BMI (>30), smoking, heavy lifting, chronic cough, or constipation.

Surgical Management

Surgical management is the next step for symptomatic women, those who require immediate relief, those who have declined conservative treatment, or for whom the conservative approach has failed to provide benefit. It should be noted that surgical management should follow the completion of the patient’s family as the pelvic support system can be further damaged during labor.

Surgical planning depends on whether the anterior vaginal prolapse is isolated or is combined with apical or posterior vaginal prolapse. A careful examination is required as a part of preoperative planning.

Anterior colporrhaphy

Anterior repair is performed trans-vaginally to repair central vaginal wall defects and to lessen the size of the anterior vaginal wall.

For this procedure, a patient is placed in the lithotomy position and catheterized; a Sims speculum is inserted to achieve a better view of the defect. An Allis forceps are placed at the midline of the anterior wall 1cm proximal to the urethra and two more forceps on each side next to the cervix or the vaginal cuff. Local infiltration with an adrenaline/lidocaine solution is commonly used to achieve hydro-dissection, analgesia, and to minimize intraoperative bleeding. With the use of Metzenbaum scissors, dissection of vaginal mucosa from the underlying vesicovaginal fascia is performed. When the mucosal layer is entirely free, a folding of the muscular layer and adventitia using figure-of-eight sutures is performed. Careful placement of the sutures is crucial in order not to damage the bladder.

2-0 Vicryl or PDS sutures are most often used. After successful plication, the excessive vaginal mucosa is removed, and the wound is closed with absorbable sutures.  The surgeon should be careful not to reduce the diameter of the vagina too much, as later it may cause pain during sexual intercourse. One study has reported the success rate of surgical approach ranging from 63% to 76.5%, depending on the procedure followed.[rx]

Sacral colpopexy

The other way to repair a bladder prolapse is to perform a sacral colpopexy, which is usually done laparoscopically. This procedure aims to place a permanent mesh to the anterior and posterior walls of the vagina and then attach it to the anterior longitudinal ligament below the sacral promontory. The operation can be performed together with anterior colporrhaphy or on its own. The benefit of sacral colpopexy is that it avoids vaginal incisions and scarring, which results in a lower risk of vaginal shortening or dyspareunia. The success rate of this procedure is 60% to 89%.[rx] A randomized trial indicated that laparoscopic sacral colpopexy has a higher success rate and a lower chance of repeat procedure for both anterior and posterior vaginal prolapses.[rx]

In many countries, including the US and the UK, the use of mesh for cystocele repairs has been suspended since 2019, pending an investigation into their use.[rx]

Complication

Post-surgical complications can develop. The complications following surgical treatment of cystocele are:

People Also Reading

Lateral Cystocele – Causes, Symptoms, Treatment Cystocele – Causes, Symptoms, Diagnosis, Treatment Medial Cystocele – Causes, Symptoms, Treatment Cystocele Prolapse – Causes, Symptoms, Treatment Prolapsed Cystocele – Causes, Symptoms, Treatment Enterocele – Causes, Symptoms, Diagnosis, Treatment Protrusion of The Bladder – Causes, Symptoms, Treatment Prolapsed Uterine Bladder – Causes, Symptoms, Treatment Bladder Prolapse – Causes, Symptoms, Treatment Uterine Prolapse – Causes, Symptoms, Treatment Sigmoidocele – Causes, Symptoms, Treatment Prolapsed Rectocele – Causes, Symptoms, Treatment

Medial Cystocele forms in the mid-vagina and is related to a defect in the suspension provided by to a sagittal suspension system defect in the uterosacral ligaments and pubocervical fascia. The pubocervical fascia may thin or tear and create the cystocele. Aid in diagnosis is the creation of a ‘shiny’ spot on the epithelium of the vagina. This defect can be assessed by MRI.^[ex][rx]

A cystocele otherwise known as a protrusion of the bladder occurs when the bladder descends into the vagina. The bladder bulges through the anterior wall of the vagina, with which it is anatomically associated. There are multiple underlying causes for the development of cystocele resulting in weakness of the muscles and the connective tissue surrounding the bladder and vagina.[rx]

A cystocele is the most common type of pelvic organ prolapse. Pelvic organ prolapse occurs when the vaginal walls, uterus, or both lose their normal support and prolapse, or bulge, into the vaginal canal or through the vaginal opening. Other nearby pelvic organs, such as the bladder or bowel, may be involved and also drop from their normal position in the body.

Types of Cystocele

Cystocele can be further described as being apical, medial, lateral, or mediolateral.

• Apical cystocele is located in the upper third of the vagina. The structures involved are the endopelvic fascia and ligaments. The cardinal ligaments and the uterosacral ligaments suspend the upper vaginal-dome. The cystocele in this region of the vagina is thought to be due to a cardinal ligament defect.^[rx][rx]
• Medial cystocele – forms in the mid-vagina and is related to a defect in the suspension provided by to a sagittal suspension system defect in the uterosacral ligaments and pubocervical fascia. The pubocervical fascia may thin or tear and create the cystocele. Aid in diagnosis is the creation of a ‘shiny’ spot on the epithelium of the vagina. This defect can be assessed by MRI.^[ex][rx]
• Lateral cystocele – forms when both the pelvic perineal muscle and its ligamentous–fascial develop a defect. The ligamentous– fascial creates a ‘hammock-like’ suspension and support for the lateral sides of the vagina. Defects in this lateral support system result in a lack of bladder support. Cystocele that develops laterally is associated with an anatomic imbalance between the anterior vaginal wall and the arcus tendinous fasciae pelvis – the essential ligament structure.^[rx][rx]

Causes of Medial Cystocele

Cystoceles result from a weakness of the pelvic-floor support system. The main associated risk factors are obesity, increasing age, and parity. They can also occur due to chronically increased intra-abdominal pressure, collagen abnormality, family history of cystocele, and following pelvic surgery.

• Obesity – Giri et al., in their systematic review, reported that women with BMI >25 had a risk ratio of 1.36 (95% confidence interval) for developing prolapse, while women with BMI >30 had a risk ratio of 1.47 (95% confidence interval).[rx] Another study suggested that in overweight and obese women, the risk of progression of a cystocele increased by 32% and 48%, respectively, compared with participants with normal BMI.[rx] However, few studies have shown that weight loss did not lead to symptoms resolution or regression of the prolapse. In particular, in some of them, weight loss was associated with a borderline worsening of uterine prolapse, indicating that the damage to the pelvic floor is irreversible.[rx][rx]
• Advancing Age – A number of studies have shown a strong link between aging and vaginal prolapse.[rx][rx] It is suggested that age-related changes in pelvic anatomy, innervation, and vasculature cause weakness in pelvic floor strength.[rx] A study of vaginal tissue biopsies discovered that collagen in the vaginal wall changes its structure over time, which might explain the link between aging and cystocele development.[rx]
• Parity and Other Childbirth-related Factors – Vaginal delivery carries a high risk for pelvic floor weakness.[rx] The attenuation of the pelvic floor muscles has been shown to increase with parity. Nygaard et al. showed that the prevalence of pelvic floor disorders increases by 12.8%, 18.4%, 24,6%, and 32.4% for 0, 1, 2, and 3 deliveries, respectively.[rx] Moreover, it was found that forceps delivery plays a critical role in levator ani muscle avulsion.[rx] Mant et al. specifically suggest that the first stage of labor is responsible for developing a vaginal prolapse.[rx]
• Increased Intra-abdominal Pressure – Increased intra-abdominal pressure seems to have a weak correlation with anterior vaginal prolapse. Several studies indicated a correlation between cystocele development and constipation, chronic cough, and obstructive pulmonary disease, which are all associated with chronically increased abdominal pressure.[rx][rx][rx]
• Collagen Abnormality – The predominant type of collagen found in the vaginal wall is type III, designed to be resistant to sudden pressure changes, which is essential in tissues that require elasticity. In women with vaginal prolapse, the amount of collagen III in the vaginal tissue was higher than in healthy women, possibly due to the underlying remodeling.[rx] Women with congenital conditions affecting collagen production, such as Marfan and Ehlers-Danlos syndrome, are predisposed to developing cystocele.[rx][rx] Up to a third of women with Marfans and three-quarters of women with Ehlers-Danols have a history of vaginal wall prolapse.[rx]
• Family History – Even though there are no known specific genes responsible for the development of vaginal prolapse, a review of sixteen studies has revealed that women with pelvic prolapse are highly likely to have a relative suffering from the same condition.[rx]
• Pelvic Surgery – Surgery of the pelvis, especially hysterectomy, causes damage to the endopelvic fascia and nerves. This, in turn, results in a greater risk of vaginal prolapse and herniation of the bladder.[rx]

Risk factors

Risk factors for developing a cystocele are:

Connective tissue disorders predispose women to developing cystocele and another pelvic organ prolapse. The tissues tensile strength of the vaginal wall decreases when the structure of the collagen fibers change and become weaker.^[rx]

Symptoms of Medial Cystocele

The symptoms of a cystocele may include:

• a vaginal bulge
• the feeling that something is falling out of the vagina
• the sensation of pelvic heaviness or fullness
• difficulty starting a urine stream
• a feeling of incomplete urination
• frequent or urgent urination
• fecal incontinence^[rx]
• frequent urinary tract infections
• back and pelvic pain
• fatigue
• painful sexual intercourse^[rx]
• bleeding^[rx]
• A feeling of fullness or pressure in your pelvis and vagina
• In some cases, a bulge of tissue in your vagina that you can see or feel
• Increased pelvic pressure when you strain, cough, bear down or lift
• Problems urinating, including difficulty starting a urine stream, the feeling that you haven’t completely emptied your bladder after urinating, feeling a frequent need to urinate or leaking urine (urinary incontinence)
• A cystocele also called a prolapsed or dropped bladder, is the bulging or dropping of the bladder into the vagina.
• A cystocele occurs when the muscles and supportive tissues between a woman’s bladder and vagina weaken and stretch, letting the bladder sag from its normal position and bulge into the vagina or through the vaginal opening.
• Diagnosing a cystocele requires medical tests and a physical exam of the vagina.
• Cystocele treatment depends on the severity of the cystocele and whether a woman has symptoms.

A bladder that has dropped from its normal position and into the vagina can cause some forms of incontinence and incomplete emptying of the bladder.^[rx]

Diagnosis of Medial Cystocele

The most objective and standard tool for evaluating the severity of the anterior wall prolapse is the POPQ system, which was introduced in 1996. This system is recognized by The American College of Obstetricians and Gynecologists and consists of 4 stages.

• Stage 0 – no prolapse
• Stage 1 – most distal part of prolapse is -1cm (above the level of the hymen)
• Stage 2 – most distal part of prolapse is >= -1cm but <= +1cm (<=1cm above or below the hymenal plane)
• Stage 3 – most outside portion of the prolapse >+1cm but <+(total vaginal length -2)cm (beyond the hymen; protrudes no farther than 2cm less than the total vaginal length)
• Stage 4 – complete eversion of the vagina; most distal portion of the prolapse >= +(total vaginal length -2) cm.[rx]

Three stages are used for patients after removal of the uterus and four if the uterus is present.

Medical history

A health care professional may ask about your

• symptoms, such as bulges or lumps in the vagina, pelvic pressure or heaviness, and urinary incontinence
• pregnancy and childbirth history
• current and past medical problems, including surgeries
• family history
• over-the-counter and prescription medicines
• bowel habits

Diagnosis of anterior prolapse may involve

• A pelvic exam – You may be examined while lying down and possibly while standing up. During the exam, your doctor looks for a tissue bulge in your vagina that indicates pelvic organ prolapse. You’ll likely be asked to bear down as if during a bowel movement to see how much that affects the degree of prolapse. To check the strength of your pelvic floor muscles, you’ll be asked to contact them, as if you’re trying to stop the stream of urine.
• Filling out a questionnaire – You may fill out a form that helps your doctor assess your medical history, the degree of your prolapse, and how much it affects your quality of life. This information also helps guide treatment decisions.
• Bladder and urine tests – If you have significant prolapse, you might be tested to see how well and completely your bladder empties. Your doctor might also run a test on a urine sample to look for signs of a bladder infection if it seems that you’re retaining more urine in your bladder than is normal after urinating.
• Urodynamics – Measures the bladder’s ability to hold and release urine.
• Cystoscopy (cystourethroscopy) – A long tube-like instrument is passed through the urethra to examine the bladder and urinary tract for malformations, blockages, tumors, or stone

Treatment of Medial Cystocele

Non-surgical

Cystocele is often treated by non-surgical means:

• Pessary – This is a removable device inserted into the vagina to support the anterior vaginal wall. Pessaries come in many different shapes and sizes. There are sometimes complications with the use of a pessary.^[rx]
• Pelvic floor muscle therapy – Pelvic floor exercises to strengthen vaginal support can be of benefit. Specialized physical therapy can be prescribed to help strengthen the pelvic floor muscles.^[rx][rx]
• Dietary changes – Ingesting high fiber foods will aid in promoting bowel movements.^[rx]
• Estrogen – intravaginal administration helps to prevent pelvic muscle atrophy^[rx]
• Kegel exercises – (pelvic muscle exercises) can be advised for women with stage 1 or 2 prolapse. It is found that these exercises improve prolapses by 1-2 cm on average. A systematic review and meta-analysis of the effectiveness of Pelvic Floor Muscle Therapy (PFMT) showed that women involved in pelvic muscle training showed better outcomes regarding symptoms and reduction of the size of the prolapse compared to control groups.[rx] Supervised muscle training for at least 12-16 weeks can be considered for such women to measure the improvement.[rx] The exercises should be continued if they are proved to be beneficial for the patient.

• Hormone Replacement Therapy – is not a treatment for cystocele. There is no evidence that estrogen’s topical or systemic use reduces the size of cystocele; the creams or estrogen-containing vaginal pessaries can still be used for women with cystocele for treating signs of vaginal atrophy, which may occur concurrently.[rx] Another study has shown the pre-operative use of topical estrogen creams improve the synthesis of collagen, preventing thinning of the vaginal wall, and reducing the activity of degrading enzymes.[rx]

It is essential to encourage the patient to work on modifiable risk factors, such as a high BMI (>30), smoking, heavy lifting, chronic cough, or constipation.

Surgical Management

Surgical management is the next step for symptomatic women, those who require immediate relief, those who have declined conservative treatment, or for whom the conservative approach has failed to provide benefit. It should be noted that surgical management should follow the completion of the patient’s family as the pelvic support system can be further damaged during labor.

Surgical planning depends on whether the anterior vaginal prolapse is isolated or is combined with apical or posterior vaginal prolapse. A careful examination is required as a part of preoperative planning.

Anterior colporrhaphy

Anterior repair is performed trans-vaginally to repair central vaginal wall defects and to lessen the size of the anterior vaginal wall.

For this procedure, a patient is placed in the lithotomy position and catheterized; a Sims speculum is inserted to achieve a better view of the defect. An Allis forceps are placed at the midline of the anterior wall 1cm proximal to the urethra and two more forceps on each side next to the cervix or the vaginal cuff. Local infiltration with an adrenaline/lidocaine solution is commonly used to achieve hydro-dissection, analgesia, and to minimize intraoperative bleeding. With the use of Metzenbaum scissors, dissection of vaginal mucosa from the underlying vesicovaginal fascia is performed. When the mucosal layer is entirely free, a folding of the muscular layer and adventitia using figure-of-eight sutures is performed. Careful placement of the sutures is crucial in order not to damage the bladder.

2-0 Vicryl or PDS sutures are most often used. After successful plication, the excessive vaginal mucosa is removed, and the wound is closed with absorbable sutures.  The surgeon should be careful not to reduce the diameter of the vagina too much, as later it may cause pain during sexual intercourse. One study has reported the success rate of surgical approach ranging from 63% to 76.5%, depending on the procedure followed.[rx]

Sacral colpopexy

The other way to repair a bladder prolapse is to perform a sacral colpopexy, which is usually done laparoscopically. This procedure aims to place a permanent mesh to the anterior and posterior walls of the vagina and then attach it to the anterior longitudinal ligament below the sacral promontory. The operation can be performed together with anterior colporrhaphy or on its own. The benefit of sacral colpopexy is that it avoids vaginal incisions and scarring, which results in a lower risk of vaginal shortening or dyspareunia. The success rate of this procedure is 60% to 89%.[rx] A randomized trial indicated that laparoscopic sacral colpopexy has a higher success rate and a lower chance of repeat procedure for both anterior and posterior vaginal prolapses.[rx]

In many countries, including the US and the UK, the use of mesh for cystocele repairs has been suspended since 2019, pending an investigation into their use.[rx]

Complication

Post-surgical complications can develop. The complications following surgical treatment of cystocele are:

People Also Reading

Lateral Cystocele – Causes, Symptoms, Treatment Apical Cystocele – Causes, Symptoms, Treatment Cystocele – Causes, Symptoms, Diagnosis, Treatment Cystocele Prolapse – Causes, Symptoms, Treatment Prolapsed Cystocele – Causes, Symptoms, Treatment Protrusion of The Bladder – Causes, Symptoms, Treatment Enterocele – Causes, Symptoms, Diagnosis, Treatment Prolapsed Uterine Bladder – Causes, Symptoms, Treatment Bladder Prolapse – Causes, Symptoms, Treatment Uterine Prolapse – Causes, Symptoms, Treatment Prolapse After Childbirth – What To Know, How To Do Vaginal Vault Prolapse – Causes, Symptoms, Treatment

Lateral Cystocele forms when both the pelvic perineal muscle and its ligamentous–fascial develop a defect. The ligamentous– fascial creates a ‘hammock-like’ suspension and support for the lateral sides of the vagina. Defects in this lateral support system result in a lack of bladder support. Cystocele that develops laterally is associated with an anatomic imbalance between the anterior vaginal wall and the arcus tendinous fasciae pelvis – the essential ligament structure.^[rx][rx]

A cystocele otherwise known as a protrusion of the bladder occurs when the bladder descends into the vagina. The bladder bulges through the anterior wall of the vagina, with which it is anatomically associated. There are multiple underlying causes for the development of cystocele resulting in weakness of the muscles and the connective tissue surrounding the bladder and vagina.[rx]

A cystocele is the most common type of pelvic organ prolapse. Pelvic organ prolapse occurs when the vaginal walls, uterus, or both lose their normal support and prolapse, or bulge, into the vaginal canal or through the vaginal opening. Other nearby pelvic organs, such as the bladder or bowel, may be involved and also drop from their normal position in the body.

Types of Cystocele

Cystocele can be further described as being apical, medial, lateral, or mediolateral.

• Apical cystocele is located in the upper third of the vagina. The structures involved are the endopelvic fascia and ligaments. The cardinal ligaments and the uterosacral ligaments suspend the upper vaginal-dome. The cystocele in this region of the vagina is thought to be due to a cardinal ligament defect.^[rx][rx]
• Medial cystocele – forms in the mid-vagina and is related to a defect in the suspension provided by to a sagittal suspension system defect in the uterosacral ligaments and pubocervical fascia. The pubocervical fascia may thin or tear and create the cystocele. Aid in diagnosis is the creation of a ‘shiny’ spot on the epithelium of the vagina. This defect can be assessed by MRI.^[ex][rx]
• Lateral cystocele – forms when both the pelvic perineal muscle and its ligamentous–fascial develop a defect. The ligamentous– fascial creates a ‘hammock-like’ suspension and support for the lateral sides of the vagina. Defects in this lateral support system result in a lack of bladder support. Cystocele that develops laterally is associated with an anatomic imbalance between the anterior vaginal wall and the arcus tendinous fasciae pelvis – the essential ligament structure.^[rx][rx]

Causes of Lateral Cystocele

Cystoceles result from a weakness of the pelvic-floor support system. The main associated risk factors are obesity, increasing age, and parity. They can also occur due to chronically increased intra-abdominal pressure, collagen abnormality, family history of cystocele, and following pelvic surgery.

• Obesity – Giri et al., in their systematic review, reported that women with BMI >25 had a risk ratio of 1.36 (95% confidence interval) for developing prolapse, while women with BMI >30 had a risk ratio of 1.47 (95% confidence interval).[rx] Another study suggested that in overweight and obese women, the risk of progression of a cystocele increased by 32% and 48%, respectively, compared with participants with normal BMI.[rx] However, few studies have shown that weight loss did not lead to symptoms resolution or regression of the prolapse. In particular, in some of them, weight loss was associated with a borderline worsening of uterine prolapse, indicating that the damage to the pelvic floor is irreversible.[rx][rx]
• Advancing Age – A number of studies have shown a strong link between aging and vaginal prolapse.[rx][rx] It is suggested that age-related changes in pelvic anatomy, innervation, and vasculature cause weakness in pelvic floor strength.[rx] A study of vaginal tissue biopsies discovered that collagen in the vaginal wall changes its structure over time, which might explain the link between aging and cystocele development.[rx]
• Parity and Other Childbirth-related Factors – Vaginal delivery carries a high risk for pelvic floor weakness.[rx] The attenuation of the pelvic floor muscles has been shown to increase with parity. Nygaard et al. showed that the prevalence of pelvic floor disorders increases by 12.8%, 18.4%, 24,6%, and 32.4% for 0, 1, 2, and 3 deliveries, respectively.[rx] Moreover, it was found that forceps delivery plays a critical role in levator ani muscle avulsion.[rx] Mant et al. specifically suggest that the first stage of labor is responsible for developing a vaginal prolapse.[rx]
• Increased Intra-abdominal Pressure – Increased intra-abdominal pressure seems to have a weak correlation with anterior vaginal prolapse. Several studies indicated a correlation between cystocele development and constipation, chronic cough, and obstructive pulmonary disease, which are all associated with chronically increased abdominal pressure.[rx][rx][rx]
• Collagen Abnormality – The predominant type of collagen found in the vaginal wall is type III, designed to be resistant to sudden pressure changes, which is essential in tissues that require elasticity. In women with vaginal prolapse, the amount of collagen III in the vaginal tissue was higher than in healthy women, possibly due to the underlying remodeling.[rx] Women with congenital conditions affecting collagen production, such as Marfan and Ehlers-Danlos syndrome, are predisposed to developing cystocele.[rx][rx] Up to a third of women with Marfans and three-quarters of women with Ehlers-Danols have a history of vaginal wall prolapse.[rx]
• Family History – Even though there are no known specific genes responsible for the development of vaginal prolapse, a review of sixteen studies has revealed that women with pelvic prolapse are highly likely to have a relative suffering from the same condition.[rx]
• Pelvic Surgery – Surgery of the pelvis, especially hysterectomy, causes damage to the endopelvic fascia and nerves. This, in turn, results in a greater risk of vaginal prolapse and herniation of the bladder.[rx]

Risk factors

Risk factors for developing a cystocele are:

Connective tissue disorders predispose women to developing cystocele and another pelvic organ prolapse. The tissues tensile strength of the vaginal wall decreases when the structure of the collagen fibers change and become weaker.^[rx]

Symptoms of Lateral Cystocele

The symptoms of a cystocele may include:

• a vaginal bulge
• the feeling that something is falling out of the vagina
• the sensation of pelvic heaviness or fullness
• difficulty starting a urine stream
• a feeling of incomplete urination
• frequent or urgent urination
• fecal incontinence^[rx]
• frequent urinary tract infections
• back and pelvic pain
• fatigue
• painful sexual intercourse^[rx]
• bleeding^[rx]
• A feeling of fullness or pressure in your pelvis and vagina
• In some cases, a bulge of tissue in your vagina that you can see or feel
• Increased pelvic pressure when you strain, cough, bear down or lift
• Problems urinating, including difficulty starting a urine stream, the feeling that you haven’t completely emptied your bladder after urinating, feeling a frequent need to urinate or leaking urine (urinary incontinence)
• A cystocele also called a prolapsed or dropped bladder, is the bulging or dropping of the bladder into the vagina.
• A cystocele occurs when the muscles and supportive tissues between a woman’s bladder and vagina weaken and stretch, letting the bladder sag from its normal position and bulge into the vagina or through the vaginal opening.
• Diagnosing a cystocele requires medical tests and a physical exam of the vagina.
• Cystocele treatment depends on the severity of the cystocele and whether a woman has symptoms.

A bladder that has dropped from its normal position and into the vagina can cause some forms of incontinence and incomplete emptying of the bladder.^[rx]

Diagnosis of Lateral Cystocele

The most objective and standard tool for evaluating the severity of the anterior wall prolapse is the POPQ system, which was introduced in 1996. This system is recognized by The American College of Obstetricians and Gynecologists and consists of 4 stages.

• Stage 0 – no prolapse
• Stage 1 – most distal part of prolapse is -1cm (above the level of the hymen)
• Stage 2 – most distal part of prolapse is >= -1cm but <= +1cm (<=1cm above or below the hymenal plane)
• Stage 3 – most outside portion of the prolapse >+1cm but <+(total vaginal length -2)cm (beyond the hymen; protrudes no farther than 2cm less than the total vaginal length)
• Stage 4 – complete eversion of the vagina; most distal portion of the prolapse >= +(total vaginal length -2) cm.[rx]

Three stages are used for patients after removal of the uterus and four if the uterus is present.

Medical history

A health care professional may ask about your

• symptoms, such as bulges or lumps in the vagina, pelvic pressure or heaviness, and urinary incontinence
• pregnancy and childbirth history
• current and past medical problems, including surgeries
• family history
• over-the-counter and prescription medicines
• bowel habits

Diagnosis of anterior prolapse may involve

• A pelvic exam – You may be examined while lying down and possibly while standing up. During the exam, your doctor looks for a tissue bulge in your vagina that indicates pelvic organ prolapse. You’ll likely be asked to bear down as if during a bowel movement to see how much that affects the degree of prolapse. To check the strength of your pelvic floor muscles, you’ll be asked to contact them, as if you’re trying to stop the stream of urine.
• Filling out a questionnaire – You may fill out a form that helps your doctor assess your medical history, the degree of your prolapse, and how much it affects your quality of life. This information also helps guide treatment decisions.
• Bladder and urine tests – If you have significant prolapse, you might be tested to see how well and completely your bladder empties. Your doctor might also run a test on a urine sample to look for signs of a bladder infection if it seems that you’re retaining more urine in your bladder than is normal after urinating.
• Urodynamics – Measures the bladder’s ability to hold and release urine.
• Cystoscopy (cystourethroscopy) – A long tube-like instrument is passed through the urethra to examine the bladder and urinary tract for malformations, blockages, tumors, or stone

Treatment of Lateral Cystocele

Non-surgical

Cystocele is often treated by non-surgical means:

• Pessary – This is a removable device inserted into the vagina to support the anterior vaginal wall. Pessaries come in many different shapes and sizes. There are sometimes complications with the use of a pessary.^[rx]
• Pelvic floor muscle therapy – Pelvic floor exercises to strengthen vaginal support can be of benefit. Specialized physical therapy can be prescribed to help strengthen the pelvic floor muscles.^[rx][rx]
• Dietary changes – Ingesting high fiber foods will aid in promoting bowel movements.^[rx]
• Estrogen – intravaginal administration helps to prevent pelvic muscle atrophy^[rx]
• Kegel exercises – (pelvic muscle exercises) can be advised for women with stage 1 or 2 prolapse. It is found that these exercises improve prolapses by 1-2 cm on average. A systematic review and meta-analysis of the effectiveness of Pelvic Floor Muscle Therapy (PFMT) showed that women involved in pelvic muscle training showed better outcomes regarding symptoms and reduction of the size of the prolapse compared to control groups.[rx] Supervised muscle training for at least 12-16 weeks can be considered for such women to measure the improvement.[rx] The exercises should be continued if they are proved to be beneficial for the patient.

• Hormone Replacement Therapy – is not a treatment for cystocele. There is no evidence that estrogen’s topical or systemic use reduces the size of cystocele; the creams or estrogen-containing vaginal pessaries can still be used for women with cystocele for treating signs of vaginal atrophy, which may occur concurrently.[rx] Another study has shown the pre-operative use of topical estrogen creams improve the synthesis of collagen, preventing thinning of the vaginal wall, and reducing the activity of degrading enzymes.[rx]

It is essential to encourage the patient to work on modifiable risk factors, such as a high BMI (>30), smoking, heavy lifting, chronic cough, or constipation.

Surgical Management

Surgical management is the next step for symptomatic women, those who require immediate relief, those who have declined conservative treatment, or for whom the conservative approach has failed to provide benefit. It should be noted that surgical management should follow the completion of the patient’s family as the pelvic support system can be further damaged during labor.

Surgical planning depends on whether the anterior vaginal prolapse is isolated or is combined with apical or posterior vaginal prolapse. A careful examination is required as a part of preoperative planning.

Anterior colporrhaphy

Anterior repair is performed trans-vaginally to repair central vaginal wall defects and to lessen the size of the anterior vaginal wall.

For this procedure, a patient is placed in the lithotomy position and catheterized; a Sims speculum is inserted to achieve a better view of the defect. An Allis forceps are placed at the midline of the anterior wall 1cm proximal to the urethra and two more forceps on each side next to the cervix or the vaginal cuff. Local infiltration with an adrenaline/lidocaine solution is commonly used to achieve hydro-dissection, analgesia, and to minimize intraoperative bleeding. With the use of Metzenbaum scissors, dissection of vaginal mucosa from the underlying vesicovaginal fascia is performed. When the mucosal layer is entirely free, a folding of the muscular layer and adventitia using figure-of-eight sutures is performed. Careful placement of the sutures is crucial in order not to damage the bladder.

2-0 Vicryl or PDS sutures are most often used. After successful plication, the excessive vaginal mucosa is removed, and the wound is closed with absorbable sutures.  The surgeon should be careful not to reduce the diameter of the vagina too much, as later it may cause pain during sexual intercourse. One study has reported the success rate of surgical approach ranging from 63% to 76.5%, depending on the procedure followed.[rx]

Sacral colpopexy

The other way to repair a bladder prolapse is to perform a sacral colpopexy, which is usually done laparoscopically. This procedure aims to place a permanent mesh to the anterior and posterior walls of the vagina and then attach it to the anterior longitudinal ligament below the sacral promontory. The operation can be performed together with anterior colporrhaphy or on its own. The benefit of sacral colpopexy is that it avoids vaginal incisions and scarring, which results in a lower risk of vaginal shortening or dyspareunia. The success rate of this procedure is 60% to 89%.[rx] A randomized trial indicated that laparoscopic sacral colpopexy has a higher success rate and a lower chance of repeat procedure for both anterior and posterior vaginal prolapses.[rx]

In many countries, including the US and the UK, the use of mesh for cystocele repairs has been suspended since 2019, pending an investigation into their use.[rx]

Complication

Post-surgical complications can develop. The complications following surgical treatment of cystocele are:

People Also Reading

Apical Cystocele – Causes, Symptoms, Treatment Cystocele – Causes, Symptoms, Diagnosis, Treatment Medial Cystocele – Causes, Symptoms, Treatment Cystocele Prolapse – Causes, Symptoms, Treatment Prolapsed Cystocele – Causes, Symptoms, Treatment Enterocele – Causes, Symptoms, Diagnosis, Treatment Protrusion of The Bladder – Causes, Symptoms, Treatment Prolapsed Uterine Bladder – Causes, Symptoms, Treatment Bladder Prolapse – Causes, Symptoms, Treatment Uterine Prolapse – Causes, Symptoms, Treatment Prolapsed Rectocele – Causes, Symptoms, Treatment Prolapse Urethrocele – Causes, Symptoms, Treatment

An enterocele is a protrusion of the small intestines and peritoneum into the vaginal canal. It may be treated transvaginally or by laparoscopy. An enterocele may also obstruct the rectum, leading to symptoms of obstructed defecation.^[rx] Enteroceles can form after treatment for gynecological cancers.^[rx]

An enterocele is a pelvic hernia formed from the separation of endopelvic fascia, associated with the posterior or anterior vaginal fornix, and most commonly located in the posterior superior vaginal segment. Rectal prolapse is a debilitating condition in which the mucosa of the rectum protrudes circumferentially from the anus. Surgical repair is the recommended treatment for rectal prolapse, and though there are many different surgical options, there is no consensus on which approach is best. We present a case of anterior rectal prolapse due to enterocele which was treated by correction of enterocele with a vaginal approach and propose some clinical features and diagnostic techniques that may distinguish this entity from traditional rectal prolapse.

Causes of Enterocele

When the support system which holds pelvic organs in place become distressed, stretched, or torn, it allows pelvic organs to shift into new positions, thus causing a prolapse. Damage to these support systems can be caused by a number of different factors such as:

• Childbirth – Vaginal delivery causes stress on pelvic organs and support structures. Risk increases with number and size of children delivered vaginally.
• Surgery, such as a hysterectomy, or radiation treatment in the pelvic area.
• Menopause – A woman’s ovaries stop producing hormones that regulate her monthly cycle. The hormone estrogen, which helps keep pelvic muscles strong, is in lower supply.
• Extreme physical activity or lifting of heavy objects.
• Being overweight
• Chronic constipation
• Chronic cough (as seen in smokers or asthmatics)
• Genetic or hereditary factors – One person’s pelvic support system may be naturally weaker than another’s.

This shows the bladder which has herniated, or “dropped” into the vagina.

Risk factors

Factors that increase your risk of developing small bowel prolapse include:

• Pregnancy and childbirth – Vaginal delivery of one or more children contributes to the weakening of your pelvic floor support structures, increasing your risk of prolapse. The more pregnancies you have, the greater your risk of developing any type of pelvic organ prolapse. Women who have only cesarean deliveries are less likely to develop prolapse.
• Age – Small bowel prolapse and other types of pelvic organ prolapse occur more often with increasing age. As you get older, you tend to lose muscle mass and muscle strength — in your pelvic muscles as well as other muscles.
• Pelvic surgery – Removal of your uterus (hysterectomy) or surgical procedures to treat incontinence may increase your risk of developing small bowel prolapse.
• Increased abdominal pressure – Being overweight increases pressure inside your abdomen, which increases your risk of developing small bowel prolapse. Other factors that increase pressure include ongoing (chronic) cough and straining during bowel movements.
• Smoking – Smoking is associated with developing prolapse because smokers frequently cough, increasing abdominal pressure.
• Race – For unknown reasons, Hispanic and white women are at higher risk of developing pelvic organ prolapse.
• Connective tissue disorders – You may be genetically prone to prolapse due to weaker connective tissues in your pelvic area, making you naturally more susceptible to small bowel prolapse and other types of pelvic organ prolapse.

Symptoms of Enterocele

In many cases a woman will feel no symptoms from prolapse and will find out about it only during an normal pelvic exam.

In cases where symptoms do occur, the following are most common:

• A feeling of fullness, heaviness or pain in the pelvic area. Often this feeling gets worse as the day goes on or gets worse after standing, lifting or coughing.
• Lower back pain.
• Bulging in the vagina.
• Leakage of urine.
• Frequent bladder infections.
• Problems with sexual intercourse.
• Problems inserting tampons.
• A feeling of pelvic fullness, pressure or pain. The discomfort is often worse at the end of the day or with heavy lifting.
• Low back pain that improves when lying down
• A soft bulge of tissue in the vagina that increases in size with standing or with activity, and decreases in size when lying down.
• Vaginal discomfort and painful intercourse (dyspareunia)

Diagnosis of Enterocele

Often a physical exam is all that is needed to diagnose prolapse. If additional information is needed, a number of tests may be done that measure how well each of the pelvic organs is working.

Medical history

A health care professional may ask about your

• symptoms, such as bulges or lumps in the vagina, pelvic pressure or heaviness, and urinary incontinence
• pregnancy and childbirth history
• current and past medical problems, including surgeries
• family history
• over-the-counter and prescription medicines
• bowel habits

Diagnosis of anterior prolapse may involve

• A pelvic exam – You may be examined while lying down and possibly while standing up. During the exam, your doctor looks for a tissue bulge in your vagina that indicates pelvic organ prolapse. You’ll likely be asked to bear down as if during a bowel movement to see how much that affects the degree of prolapse. To check the strength of your pelvic floor muscles, you’ll be asked to contact them, as if you’re trying to stop the stream of urine.
• Filling out a questionnaire – You may fill out a form that helps your doctor assess your medical history, the degree of your prolapse, and how much it affects your quality of life. This information also helps guide treatment decisions.
• Bladder and urine tests – If you have significant prolapse, you might be tested to see how well and completely your bladder empties. Your doctor might also run a test on a urine sample to look for signs of a bladder infection if it seems that you’re retaining more urine in your bladder than is normal after urinating.
• Urodynamics – Measures the bladder’s ability to hold and release urine.
• Cystoscopy (cystourethroscopy) – A long tube-like instrument is passed through the urethra to examine the bladder and urinary tract for malformations, blockages, tumors, or stone

Treatment of Enterocele

• Hysterectomy – Surgical removal of the uterus in cases of severe uterine prolapse.
• Uterine suspension – Putting the uterus back in its normal position, either by connecting support tissue to the lower part of the uterus, or by using a mesh material that forms a sling to hold it in place.
• Kegel exercises – Tightening and relaxing the muscles used to control the flow of urine in order to strengthen the muscles that support the pelvic organs.
• Taking the hormone estrogen – Helps prevent further weakening of pelvic support muscles but has a number of possible negative side effects.
• Vaginal pessary – A removable rubber or plastic device inserted into the vagina to provide support in the area of the prolapse. Pessaries are most often used when the patient wants to avoid surgery or has medical problems that make surgery too risky.

Surgery

A surgeon can perform surgery to repair the prolapse through the vagina or abdomen, with or without robotic assistance. During the procedure, your surgeon moves the prolapsed small bowel back into place and tightens the connective tissue of your pelvic floor. Sometimes, small portions of synthetic mesh may be used to help support weakened tissues.

Prevention

You may be able to lower your chances of small bowel prolapse with these strategies:

• Maintain a healthy weight. If you’re overweight, losing some weight can decrease the pressure inside your abdomen.
• Prevent constipation. Eat high-fiber foods, drink plenty of fluids and exercise regularly to help prevent having to strain during bowel movements.
• Treat a chronic cough. Constant coughing increases abdominal pressure. See your doctor to ask about treatment if you have an ongoing (chronic) cough.
• Quit smoking. Smoking contributes to chronic coughing.
• Avoid heavy lifting. Lifting heavy objects increases abdominal pressure.

Pelvic organ prolapse is strongly linked to labor and vaginal delivery. So you may want to delay surgical repair of a rectocele or enterocele until you have finished having children.

Surgical repair may relieve some, but not all, of the problems caused by a rectocele or enterocele.

• If pelvic pain, low back pain, or pain with intercourse is present before surgery, the pain may still occur after surgery.
• Symptoms of constipation may return following surgery.
• The success rate is lower if you have had previous pelvic surgery or radiation therapy to the pelvis.

You can control many of the activities that contributed to your rectocele or enterocele or made it worse. After surgery:

• Avoid smoking.
• Stay at a healthy weight for your height.
• Avoid constipation.
• Avoid activities that put strain on the lower pelvic muscles, such as heavy lifting or long periods of standing.

References

People Also Reading

Enterocele Prolapse – Causes, Symptoms, Treatment Prolapsed Enterocele – Causes, Symptoms, Treatment Sigmoidocele – Causes, Symptoms, Treatment Pouch of Douglas Descent – Symptoms, Treatment Prolapse After Childbirth – What To Know, How To Do Rectal Prolapse – Causes, Symptoms, Diagnosis, Treatment Vaginal Prolapse – Causes, Symptoms, Diagnosis, Treatment Procidentia – Causes, Symptoms, Diagnosis, Treatment Uterine Prolapse at a Young Age Cystocele – Causes, Symptoms, Diagnosis, Treatment Bladder Prolapse – Causes, Symptoms, Treatment Prolapsed Uterine Bladder – Causes, Symptoms, Treatment

Protrusion of the small intestines peritoneum and vaginal canal/An enterocele is a protrusion of the small intestines and peritoneum into the vaginal canal. It may be treated transvaginally or by laparoscopy. An enterocele may also obstruct the rectum, leading to symptoms of obstructed defecation.^[rx] Enteroceles can form after treatment for gynecological cancers.^[rx]

An enterocele is a pelvic hernia formed from the separation of endopelvic fascia, associated with the posterior or anterior vaginal fornix, and most commonly located in the posterior superior vaginal segment. Rectal prolapse is a debilitating condition in which the mucosa of the rectum protrudes circumferentially from the anus. Surgical repair is the recommended treatment for rectal prolapse, and though there are many different surgical options, there is no consensus on which approach is best. We present a case of anterior rectal prolapse due to enterocele which was treated by correction of enterocele with a vaginal approach and propose some clinical features and diagnostic techniques that may distinguish this entity from traditional rectal prolapse.

Causes of Enterocele

When the support system which holds pelvic organs in place become distressed, stretched, or torn, it allows pelvic organs to shift into new positions, thus causing a prolapse. Damage to these support systems can be caused by a number of different factors such as:

• Childbirth – Vaginal delivery causes stress on pelvic organs and support structures. Risk increases with number and size of children delivered vaginally.
• Surgery, such as a hysterectomy, or radiation treatment in the pelvic area.
• Menopause – A woman’s ovaries stop producing hormones that regulate her monthly cycle. The hormone estrogen, which helps keep pelvic muscles strong, is in lower supply.
• Extreme physical activity or lifting of heavy objects.
• Being overweight
• Chronic constipation
• Chronic cough (as seen in smokers or asthmatics)
• Genetic or hereditary factors – One person’s pelvic support system may be naturally weaker than another’s.

This shows the bladder which has herniated, or “dropped” into the vagina.

Risk factors

Factors that increase your risk of developing small bowel prolapse include:

• Pregnancy and childbirth – Vaginal delivery of one or more children contributes to the weakening of your pelvic floor support structures, increasing your risk of prolapse. The more pregnancies you have, the greater your risk of developing any type of pelvic organ prolapse. Women who have only cesarean deliveries are less likely to develop prolapse.
• Age – Small bowel prolapse and other types of pelvic organ prolapse occur more often with increasing age. As you get older, you tend to lose muscle mass and muscle strength — in your pelvic muscles as well as other muscles.
• Pelvic surgery – Removal of your uterus (hysterectomy) or surgical procedures to treat incontinence may increase your risk of developing small bowel prolapse.
• Increased abdominal pressure – Being overweight increases pressure inside your abdomen, which increases your risk of developing small bowel prolapse. Other factors that increase pressure include ongoing (chronic) cough and straining during bowel movements.
• Smoking – Smoking is associated with developing prolapse because smokers frequently cough, increasing abdominal pressure.
• Race – For unknown reasons, Hispanic and white women are at higher risk of developing pelvic organ prolapse.
• Connective tissue disorders – You may be genetically prone to prolapse due to weaker connective tissues in your pelvic area, making you naturally more susceptible to small bowel prolapse and other types of pelvic organ prolapse.

Symptoms of Enterocele

In many cases a woman will feel no symptoms from prolapse and will find out about it only during an normal pelvic exam.

In cases where symptoms do occur, the following are most common:

• A feeling of fullness, heaviness or pain in the pelvic area. Often this feeling gets worse as the day goes on or gets worse after standing, lifting or coughing.
• Lower back pain.
• Bulging in the vagina.
• Leakage of urine.
• Frequent bladder infections.
• Problems with sexual intercourse.
• Problems inserting tampons.
• A feeling of pelvic fullness, pressure or pain. The discomfort is often worse at the end of the day or with heavy lifting.
• Low back pain that improves when lying down
• A soft bulge of tissue in the vagina that increases in size with standing or with activity, and decreases in size when lying down.
• Vaginal discomfort and painful intercourse (dyspareunia)

Diagnosis of Enterocele

Often a physical exam is all that is needed to diagnose prolapse. If additional information is needed, a number of tests may be done that measure how well each of the pelvic organs is working.

Medical history

A health care professional may ask about your

• symptoms, such as bulges or lumps in the vagina, pelvic pressure or heaviness, and urinary incontinence
• pregnancy and childbirth history
• current and past medical problems, including surgeries
• family history
• over-the-counter and prescription medicines
• bowel habits

Diagnosis of anterior prolapse may involve

• A pelvic exam – You may be examined while lying down and possibly while standing up. During the exam, your doctor looks for a tissue bulge in your vagina that indicates pelvic organ prolapse. You’ll likely be asked to bear down as if during a bowel movement to see how much that affects the degree of prolapse. To check the strength of your pelvic floor muscles, you’ll be asked to contact them, as if you’re trying to stop the stream of urine.
• Filling out a questionnaire – You may fill out a form that helps your doctor assess your medical history, the degree of your prolapse, and how much it affects your quality of life. This information also helps guide treatment decisions.
• Bladder and urine tests – If you have significant prolapse, you might be tested to see how well and completely your bladder empties. Your doctor might also run a test on a urine sample to look for signs of a bladder infection if it seems that you’re retaining more urine in your bladder than is normal after urinating.
• Urodynamics – Measures the bladder’s ability to hold and release urine.
• Cystoscopy (cystourethroscopy) – A long tube-like instrument is passed through the urethra to examine the bladder and urinary tract for malformations, blockages, tumors, or stone

Treatment of Enterocele

• Hysterectomy – Surgical removal of the uterus in cases of severe uterine prolapse.
• Uterine suspension – Putting the uterus back in its normal position, either by connecting support tissue to the lower part of the uterus, or by using a mesh material that forms a sling to hold it in place.
• Kegel exercises – Tightening and relaxing the muscles used to control the flow of urine in order to strengthen the muscles that support the pelvic organs.
• Taking the hormone estrogen – Helps prevent further weakening of pelvic support muscles but has a number of possible negative side effects.
• Vaginal pessary – A removable rubber or plastic device inserted into the vagina to provide support in the area of the prolapse. Pessaries are most often used when the patient wants to avoid surgery or has medical problems that make surgery too risky.

Surgery

A surgeon can perform surgery to repair the prolapse through the vagina or abdomen, with or without robotic assistance. During the procedure, your surgeon moves the prolapsed small bowel back into place and tightens the connective tissue of your pelvic floor. Sometimes, small portions of synthetic mesh may be used to help support weakened tissues.

Prevention

You may be able to lower your chances of small bowel prolapse with these strategies:

• Maintain a healthy weight. If you’re overweight, losing some weight can decrease the pressure inside your abdomen.
• Prevent constipation. Eat high-fiber foods, drink plenty of fluids and exercise regularly to help prevent having to strain during bowel movements.
• Treat a chronic cough. Constant coughing increases abdominal pressure. See your doctor to ask about treatment if you have an ongoing (chronic) cough.
• Quit smoking. Smoking contributes to chronic coughing.
• Avoid heavy lifting. Lifting heavy objects increases abdominal pressure.

Pelvic organ prolapse is strongly linked to labor and vaginal delivery. So you may want to delay surgical repair of a rectocele or enterocele until you have finished having children.

Surgical repair may relieve some, but not all, of the problems caused by a rectocele or enterocele.

• If pelvic pain, low back pain, or pain with intercourse is present before surgery, the pain may still occur after surgery.
• Symptoms of constipation may return following surgery.
• The success rate is lower if you have had previous pelvic surgery or radiation therapy to the pelvis.

You can control many of the activities that contributed to your rectocele or enterocele or made it worse. After surgery:

• Avoid smoking.
• Stay at a healthy weight for your height.
• Avoid constipation.
• Avoid activities that put strain on the lower pelvic muscles, such as heavy lifting or long periods of standing.

References

People Also Reading

Prolapse After Childbirth – What To Know, How To Do What Is a Vaginal Prolapse Repair Surgery? Your Sex Life After a Vaginal Prolapse Exercise and Vaginal Discomfort – What To Do, Not To Do Protrusion of The Bladder – Causes, Symptoms, Treatment Vaginal Vault Prolapse – Causes, Symptoms, Treatment Uterine Prolapse at a Young Age Enterocele – Causes, Symptoms, Diagnosis, Treatment Vaginal Prolapse – Causes, Symptoms, Diagnosis, Treatment Sigmoidocele – Causes, Symptoms, Treatment Pouch of Douglas Descent – Symptoms, Treatment Posterior Vaginal Prolapse – Causes, Symptoms, Treatment

or

A small rectocele may not cause any symptoms, especially if it bulges less than 2 centimeters (less than 1 inch) into the vagina. However, larger rectoceles can trigger a variety of rectal and vaginal complaints, including:

• A bulge of tissue protruding through the vaginal opening
• Constipation
• Difficulty having a bowel movement
• Pain or discomfort during sexual intercourse
• A feeling that the rectum has not emptied completely after a bowel movement
• A sensation of rectal pressure
• Rectal pain
• Difficulty controlling the passage of stool or gas from the rectum
• Low back pain that is relieved by lying down. In many women, this back pain may worsen as the day goes on and is more severe in the evening.

Transperineal Repairs

For a perineal approach, the patient is placed in the prone jackknife position and a U-shape incision is created [rx]. A high dissection is undertaken to reach the vaginal cupola after which a trapezoid, L-shaped strip of the posterior redundant vaginal wall is resected. Reconstruction is effected by a running suture of 3–0 polyglactin, and the space between the rectal and vaginal walls is closed and a levator plication is then executed by placing two to three single sutures. The skin is then completely closed; combined procedures for hemorrhoidectomies and/or fissures can be undertaken.

Transanal Repair

He felt that the prolapsed anterior rectal mucosa was a source of defecation difficulties that aggravated hemorrhoidal disease despite correction of the posterior vaginal wall and rectovaginal musculofascial layer. His procedure was performed in the lithotomy position. The redundant rectal mucosa was grasped and pulled outward until taut. A two-layer suture closure was performed underlying the rectal mucosa, including hemorrhoid. The anterior rectal mucosa was then removed. The formation of scar at the suture line added to support.

Posterior Colporrhaphy Technique

Posterior colporrhaphy is commonly performed in conjunction with a perineoplasty to address a rectocele or relaxed perineum and widened genital hiatus. Preoperatively, the severity of the rectocele is assessed, as well as the desired final vaginal caliber. Allis clamps are placed on the inner labia minora/hymen remnants bilaterally and then approximated in the midline. The resultant vagina should loosely admit two to three fingers. A triangular incision over the perineal body is made between the Allis clamps, and sharp dissection is then performed to separate the posterior vaginal epithelium from the underlying rectovaginal fascia.

Site-Specific Fascial Defect Repair Technique

Discrete tears or breaks in the rectovaginal fascia or rectovaginal septum have been described and may contribute to the formation of rectoceles.^[rx]The intent of the site-specific fascial defect repair of rectoceles is to identify the fascial tears and reapproximate the edges. The surgical dissection is similar to the traditional posterior colporrhaphy whereby the vaginal mucosa is dissected off the underlying rectovaginal fascia to the lateral border of the levator muscles.

Laparoscopic Rectocele Repair Technique

Laparoscopic rectocele repair involves opening the rectovaginal space and dissecting inferiorly to the perineal body. The perineal body is sutured to the rectovaginal septum and rectovaginal fascial defects are identified and closed. The advantages are reported to be better visualization, and more rapid recovery, with decreased pain and hospitalization. Disadvantages include difficulty with laparoscopic suturing, increased operating time/expense, and extended time necessary to master the laparoscopic surgical techniques.^[rx]

References

People Also Reading

Enterocele – Causes, Symptoms, Diagnosis, Treatment Sigmoidocele – Causes, Symptoms, Treatment Rectal Prolapse – Causes, Symptoms, Diagnosis, Treatment Pouch of Douglas Descent – Symptoms, Treatment Vaginal Prolapse – Causes, Symptoms, Diagnosis, Treatment Prolapse After Childbirth – What To Know, How To Do Procidentia – Causes, Symptoms, Diagnosis, Treatment Posterior Vaginal Prolapse – Causes, Symptoms, Treatment Cystocele – Causes, Symptoms, Diagnosis, Treatment Prolapsed Rectocele – Causes, Symptoms, Treatment Prolapsed Rectal – Causes, Symptoms, Treatment Enterocele Prolapse – Causes, Symptoms, Treatment

or

A small rectocele may not cause any symptoms, especially if it bulges less than 2 centimeters (less than 1 inch) into the vagina. However, larger rectoceles can trigger a variety of rectal and vaginal complaints, including:

• A bulge of tissue protruding through the vaginal opening
• Constipation
• Difficulty having a bowel movement
• Pain or discomfort during sexual intercourse
• A feeling that the rectum has not emptied completely after a bowel movement
• A sensation of rectal pressure
• Rectal pain
• Difficulty controlling the passage of stool or gas from the rectum
• Low back pain that is relieved by lying down. In many women, this back pain may worsen as the day goes on and is more severe in the evening.

Transperineal Repairs

For a perineal approach, the patient is placed in the prone jackknife position and a U-shape incision is created [rx]. A high dissection is undertaken to reach the vaginal cupola after which a trapezoid, L-shaped strip of the posterior redundant vaginal wall is resected. Reconstruction is effected by a running suture of 3–0 polyglactin, and the space between the rectal and vaginal walls is closed and a levator plication is then executed by placing two to three single sutures. The skin is then completely closed; combined procedures for hemorrhoidectomies and/or fissures can be undertaken.

Transanal Repair

He felt that the prolapsed anterior rectal mucosa was a source of defecation difficulties that aggravated hemorrhoidal disease despite correction of the posterior vaginal wall and rectovaginal musculofascial layer. His procedure was performed in the lithotomy position. The redundant rectal mucosa was grasped and pulled outward until taut. A two-layer suture closure was performed underlying the rectal mucosa, including hemorrhoid. The anterior rectal mucosa was then removed. The formation of scar at the suture line added to support.

Posterior Colporrhaphy Technique

Posterior colporrhaphy is commonly performed in conjunction with a perineoplasty to address a rectocele or relaxed perineum and widened genital hiatus. Preoperatively, the severity of the rectocele is assessed, as well as the desired final vaginal caliber. Allis clamps are placed on the inner labia minora/hymen remnants bilaterally and then approximated in the midline. The resultant vagina should loosely admit two to three fingers. A triangular incision over the perineal body is made between the Allis clamps, and sharp dissection is then performed to separate the posterior vaginal epithelium from the underlying rectovaginal fascia.

Site-Specific Fascial Defect Repair Technique

Discrete tears or breaks in the rectovaginal fascia or rectovaginal septum have been described and may contribute to the formation of rectoceles.^[rx]The intent of the site-specific fascial defect repair of rectoceles is to identify the fascial tears and reapproximate the edges. The surgical dissection is similar to the traditional posterior colporrhaphy whereby the vaginal mucosa is dissected off the underlying rectovaginal fascia to the lateral border of the levator muscles.

Laparoscopic Rectocele Repair Technique

Laparoscopic rectocele repair involves opening the rectovaginal space and dissecting inferiorly to the perineal body. The perineal body is sutured to the rectovaginal septum and rectovaginal fascial defects are identified and closed. The advantages are reported to be better visualization, and more rapid recovery, with decreased pain and hospitalization. Disadvantages include difficulty with laparoscopic suturing, increased operating time/expense, and extended time necessary to master the laparoscopic surgical techniques.^[rx]

References

People Also Reading

Vaginal Vault Prolapse – Causes, Symptoms, Treatment Vaginal Prolapse – Causes, Symptoms, Diagnosis, Treatment What Is a Vaginal Prolapse Repair Surgery? Your Sex Life After a Vaginal Prolapse Prolapse After Childbirth – What To Know, How To Do Rectal Prolapse – Causes, Symptoms, Diagnosis, Treatment Enterocele Prolapse – Causes, Symptoms, Treatment Prolapse Urethrocele – Causes, Symptoms, Treatment Bladder Prolapse – Causes, Symptoms, Treatment Rectocele Prolapse – Causes, Symptoms, Treatment Uterine Prolapse – Causes, Symptoms, Treatment Uterine Prolapse at a Young Age

Sigmoidocele is an uncommon accompaniment of pelvic prolapse. It is difficult to detect a sigmoidocele during clinical pelvic examination, and as a consequence, a sigmoidocele may be unexpectedly encountered during vaginal repair of pelvic prolapse. The author has discovered and repaired a sigmoidocele during vaginal surgery in 4 patients with either complete procidentia or vaginal vault eversion. The procedure involves a modification of the bilateral sacrospinous vaginal vault fixation using two additional sutures to suspend the sigmoid colon from the sacrospinous ligament. Clinical and functional results have been excellent. This is the first description of a vaginal approach to the repair of a sigmoidocele.

Sigmoidocele (also known as Pouch of Douglas descent) refers to a condition where the sigmoid colon descends (prolapses) into the lower pelvic cavity. ^[rx] This can obstruct the rectum and cause symptoms of obstructed defecation.^[rx]

Many women may notice a bulge in their vagina. They may also notice dragging or a feeling of pressure particularly towards the end of the day or if they have been on their feet for a few hours.

As the bulge gets bigger sometimes it can be more difficult to completely empty their bowels. This is because the bulge presses on the front of the rectum. Sometimes the bulging gives the sensation that there is still more bowel movement to pass even though the lower bowel is empty.

It is important to make sure that it is the enterocele or sigmoidocele that is causing the bowel problem. Most women will require some form of endoscopic examination of the bowel either by flexible sigmoidoscopy or colonoscopy to ensure that it is otherwise healthy.

The most useful test for the enterocele or sigmoidocele itself is a videoproctogram. or MRI program. These tests should confirm that there is a bulge and that it is causing an obstruction to defaecation. It is also useful to ensure that there are not any other areas of prolapse such as an internal prolapse or a rectocele which would require treatment at the same time.

Most women will also have tests of their sphincter muscle function (anorectal physiology) and an endoanal ultrasound scan to look for any damage to the muscle.

If symptoms are minimal then no surgical treatment may be necessary. Keeping the stools soft and avoiding straining should help to prevent the enterocele or sigmoidocele getting larger. Sometimes glycerine suppositories or small enemas will help emptying.

For most women who have an enterocele or sigmoidocele that is causing pressure symptoms or problems with bowel emptying, a repair is recommended. The type of repair will depend on whether there is any other pelvic floor weakness or prolapse. An operation to repair an enterocele through the vagina may be performed in conjunction with a gynecologist. Sometimes a ventral mesh rectopexy may be considered particularly if internal rectal prolapse co-exists.

References

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Pouch of Douglas Descent – Symptoms, Treatment Bifid Tongue – Causes, Symptoms, Treatment Cleft Tongue Syndrome – Causes, Symptoms, Treatment Glossoschissis – Causes, Symptoms, Treatment Cervical/Cervix Stenosis – Causes, Symptoms, Treatment Vaginal Vault Prolapse – Causes, Symptoms, Treatment Endometrial Metaplasias – Causes, Symptoms, Treatment Urethrocele – Causes, Symptoms, Treatment Uterine Prolapse – Causes, Symptoms, Treatment Chondroid Metaplasia – Causes, Symptoms, Treatment Hematometra – Causes, Symptoms, Treatment Fibrolipoma – Causes, Symptoms, Diagnosis, Treatment

Pouch of Douglas Descent/Sigmoidocele is an uncommon accompaniment of pelvic prolapse. It is difficult to detect a sigmoidocele during clinical pelvic examination, and as a consequence, a sigmoidocele may be unexpectedly encountered during vaginal repair of pelvic prolapse. The author has discovered and repaired a sigmoidocele during vaginal surgery in 4 patients with either complete procidentia or vaginal vault eversion. The procedure involves a modification of the bilateral sacrospinous vaginal vault fixation using two additional sutures to suspend the sigmoid colon from the sacrospinous ligament. Clinical and functional results have been excellent. This is the first description of a vaginal approach to the repair of a sigmoidocele.

Sigmoidocele (also known as Pouch of Douglas descent) refers to a condition where the sigmoid colon descends (prolapses) into the lower pelvic cavity. ^[rx] This can obstruct the rectum and cause symptoms of obstructed defecation.^[rx]

Many women may notice a bulge in their vagina. They may also notice dragging or a feeling of pressure particularly towards the end of the day or if they have been on their feet for a few hours.

As the bulge gets bigger sometimes it can be more difficult to completely empty their bowels. This is because the bulge presses on the front of the rectum. Sometimes the bulging gives the sensation that there is still more bowel movement to pass even though the lower bowel is empty.

It is important to make sure that it is the enterocele or sigmoidocele that is causing the bowel problem. Most women will require some form of endoscopic examination of the bowel either by flexible sigmoidoscopy or colonoscopy to ensure that it is otherwise healthy.

The most useful test for the enterocele or sigmoidocele itself is a videoproctogram. or MRI program. These tests should confirm that there is a bulge and that it is causing an obstruction to defaecation. It is also useful to ensure that there are not any other areas of prolapse such as an internal prolapse or a rectocele which would require treatment at the same time.

Most women will also have tests of their sphincter muscle function (anorectal physiology) and an endoanal ultrasound scan to look for any damage to the muscle.

If symptoms are minimal then no surgical treatment may be necessary. Keeping the stools soft and avoiding straining should help to prevent the enterocele or sigmoidocele from getting larger. Sometimes glycerine suppositories or small enemas will help to empty.

For most women who have an enterocele or sigmoidocele that is causing pressure symptoms or problems with bowel emptying, a repair is recommended. The type of repair will depend on whether there is any other pelvic floor weakness or prolapse. An operation to repair an enterocele through the vagina may be performed in conjunction with a gynecologist. Sometimes a ventral mesh rectopexy may be considered particularly if internal rectal prolapse co-exists.

References

People Also Reading

Sigmoidocele – Causes, Symptoms, Treatment Bifid Tongue – Causes, Symptoms, Treatment Cleft Tongue Syndrome – Causes, Symptoms, Treatment Glossoschissis – Causes, Symptoms, Treatment Cervical/Cervix Stenosis – Causes, Symptoms, Treatment Vaginal Vault Prolapse – Causes, Symptoms, Treatment Endometrial Metaplasias – Causes, Symptoms, Treatment Urethrocele – Causes, Symptoms, Treatment Uterine Prolapse – Causes, Symptoms, Treatment Chondroid Metaplasia – Causes, Symptoms, Treatment Hematometra – Causes, Symptoms, Treatment Fibrolipoma – Causes, Symptoms, Diagnosis, Treatment

Urethrocele is a condition in which the urethra shifts from its original position and starts pressing against the vagina. It is one of the different types of prolapse that affects the female organ, along with cystoceles, enteroceles, and rectoceles. This condition is mainly triggered by the weakening of the tissues and muscle fibers that are responsible for holding the urethra in place, which is usually caused by pelvic damage due to childbirth or injury, but it can also be congenital in some rare cases. Urethrocele can sometimes be asymptomatic, allowing patients to live normally without needing treatment. However, it can also cause troublesome symptoms, such as incontinence, in which case it can be treated with continuous exercise or surgery.

A ureterocele is defined as cystic dilatation of terminal ureter with associated tissue defect in the urinary bladder, bladder neck, or even extending into the posterior urethra. It is usually associated with variable degrees of bladder muscle defect and renal parenchymal abnormality.

A urethrocele is the prolapse of the female urethra into the vagina. The weakening of the tissues that hold the urethra in place may cause it to protrude into the vagina.^[rx][rx] Urethroceles often occur with cystoceles (involving the urinary bladder as well as the urethra).^[rx] In this case, the term used is cystourethrocele.^[rx][rx]

A ureterocele is a congenital abnormality with cystic dilatation of the lower part of the ureter, often associated with other anomalies like a stenotic ureteric orifice or a duplicated system along with other clinical sequelae. They could lead to various effects with regard to obstruction, reflux, continence, and renal function [^rx]. Ureteroceles may be intravesical (orthotopic) or extravesical (ectopic) [^rx].

Types

Urethral prolapse is classified by the severity of the protrusion:

• The first-degree prolapse means the urethra is mildly pushing against the vaginal walls or slightly dropped toward the urethral opening.
• Second-degree prolapse typically means the urethra extends to the vaginal or urethral opening, or the vaginal walls have collapsed somewhat.
• Third-degree prolapse means the organs bulge outside of the vaginal or urethral opening.

What Are the Stages of a Urethrocele Prolapse?

As with most female pelvic organ prolapses, a urethrocele prolapse can occur in varying degrees of severity:

• Stage 1 – The urethra begins to press down against the upper wall of the vagina and protrudes into it only to a slight degree. Symptoms can be mild or even unnoticeable.
• Stage 2 – The urethra has prolapsed, or dropped down, far enough into the vagina that it reaches the opening of the vagina but is not visible. Symptoms will be moderately uncomfortable or inconvenient.
• Stage 3 – The urethra has prolapsed down far enough that it protrudes outside of the vaginal opening. Symptoms will be severe, and the urethra will be visible from the outside of the body.

Causes of Urethrocele

Urethroceles can often result as a result of damage to the supporting structures of the pelvic floor. Urethroceles can form after treatment for gynecological cancers.^[rx] Urethroceles are often caused by childbirth, the movement of the baby through the vagina causing damage to the surrounding tissues.^[rx] When they occur in women who have never had children, they may be the result of a congenital weakness in the tissues of the pelvic floor.^[rx]

Each one of these factors increases your risk of experiencing a urethrocele, or other type or pelvic organ prolapse, as they all result in weakened pelvic floor muscles:

• Pregnancy – This is in part due to the extra weight that the baby adds to the pelvic area, which can weaken the pelvic floor muscles. It is also thought to be caused by pregnancy hormones allowing vaginal tissues to stretch beyond their rebound limits. Multiple pregnancies will further increase your risk.
• Childbirth – Again, around 50% of women who give birth vaginally will experience some level of prolapse. A large baby or a difficult birth where you’ve had to push a lot or forceps were used may increase your risk. More than one birth also increases your risk of experiencing a vaginal prolapse.
• Menopause – The change in hormones you experience during this time of your life, particularly the drop in estrogen, can cause your pelvic floor muscles to weaken. Effects can be worsened by the general loss of muscle tone associated with aging.
• Hysterectomy – A hysterectomy is the complete removal of the uterus and cervix. This surgery removes some of the strength of the pelvic area as the uterus is no longer there as support.
• Bodyweight – Being overweight or obese can increase your chances of suffering a pelvic organ prolapse due to the weight on your pelvic area.
• Constipation – Continued straining to pass a stool will put extra pressure on the pelvic floor, and could cause it to weaken.
• Persistent coughing – Constant heavy coughing can add pressure to the pelvic floor. If you smoke and have a persistent smokers cough or if you have a lung condition that results in a cough, such as asthma or bronchitis, then you could be at a higher risk.
• Heavy lifting – Repetitive heavy lifting, and lifting incorrectly, increases the pressure put on the pelvic floor.
• Strenuous activity – Heavy, high impact exercise such as running or plyometric training (jump training) can cause the pelvic floor muscles to weaken.
• Previous pelvic surgeries – A previous vaginal prolapse surgery can weaken the pelvic floor muscles, and is likely to be part of the cause of any future pelvic organ prolapses.
• Pelvic conditions – Heavy fibroids or a tumour somewhere in your pelvis can add weight to the area and weaken the pelvic floor muscles.

Symptoms of Urethrocele

There are often no symptoms associated with a urethrocele.^[rx] When present, symptoms include stress incontinence, increased urinary frequency, and urinary retention (difficulty in emptying the bladder).^[rx][rx] Pain during sexual intercourse may also occur.^[rx]

• vaginal or vulvar irritation
• a feeling of fullness or pressure in the pelvic and vaginal area
• aching discomfort in the pelvic area
• urinary problems, such as stress incontinence, being unable to empty the bladder, and frequent urination
• painful sex
• organs bulging out of the vaginal or urethral opening

In the early stages of a urethrocele prolapse you may have no symptoms at all and it therefore may only be diagnosed during a routine examination, such as a smear test. But it is also possible to experience any or all of the following symptoms severely:

• a feeling of pressure inside the vagina, especially when sitting down
• a dragging feeling inside the vagina, and/or feeling that something is going to fall out
• noticeable red tissue protruding from the vagina
• discomfort or pain during sex
• persistent or frequent urinary tract infections (cystitis)
• urinary stress incontinence – the inability to hold in urine when you cough, sneeze, laugh, exercise or lift heavy objects
• urinary incontinence – a complete inability to hold in urine
• a frequent need to urinate
• an urgent need to urinate
• difficulty passing urine and completely emptying your bladder

Diagnosis of Urethrocele

• Voiding-cystourethrography (VCUG) – We performed VCUG in 14 patients and VUR was diagnosed in 4 (33%). One patient had Grade 1 and three patients had Grade 2 VUR. VCUG revealed ureterocele in four patients, and one patient was misdiagnosed as ‘bladder diverticulum. Four patients showed normal images in VCUG.
• Ultrasonography (US) – Ureterocele was defined by the US as showing a cystic lesion in the urinary bladder in 13 out of 17 patients. Dilated distal ureters were revealed by the US in 2 patients. Duplex systems were diagnosed in 5, and dilated urinary systems with varying degrees were detected in 15 patients. Ureterocele was incorrectly diagnosed with the US as ‘bladder diverticulum’ in one patient.
• Intravenous urography (IVU) – IVU showed ureterocele in 8 of the 12 patients. Duplex systems were found in 5 patients. Nine patients had dilated urinary systems. Remarkable upper pole dysfunction was shown in one patient by this method. The patient was treated by endoscopic incision.
• Ureterocele-urinary system interaction – In general, 15 out of 19 patients were ascertained as having varying degrees of dilated urinary systems-either unilateral or bilateral-depending on the radiological diagnostic methods.
• Dimercaptosuccinic acid scintigraphy (DMSA) – Ipsilaterally localized renal scarring and non-functioning upper pole images were taken in 7 of the 13 patients.
• Computed tomography – and MAG ₃ scintigraphy were used in one of our patients for differential diagnosis of hydronephrotic mass and obstruction.
• Cystoscopy – was used for complementary diagnostic reasons in patients who underwent open surgery and for all patients who were endoscopically treated.

Treatment of Urethrocele

Nonsurgical treatment

• Pessaries – These silicone devices sit in the vaginal canal and help maintain its structure. Pessaries come in many sizes and shapes. Your doctor will place it in your vaginal canal. It’s an easy, noninvasive option, so doctors often recommend trying a pessary before other treatments.
• Topical hormones – Estrogen creams can supply some of the missing hormones to the weakened tissues to help bolster their strength.
• Pelvic floor exercises – Pelvic floor exercises, also called Kegel exercises, help you tone the organs in your pelvis. Imagine you’re trying to hold an object in place with your vaginal canal, and tightly contract for 1 to 2 seconds. Then relax for 10 seconds. Repeat this 10 times, and do this several times a day.
• Kegel exercises – These are also known as pelvic floor exercises. You can do them quickly and easily, at any time of day as no one will know you’re doing them. They help to strengthen the pelvic floor muscles. You can make them even more effective by using a Kegel8 Ultra 20 Pelvic Toner.
• Maintain your weight – Making sure you stick to a healthy weight will put less pressure on your pelvic floor muscles, giving you more chance of keeping them strong.
• Avoiding constipation – Eating a high fiber diet of fruits, vegetables, and wholegrain cereals will help your bowels stay regular, as will drinking plenty of water.
• Lift heavyweights (and children) safely – Lifting correctly will make all the difference to not only your back but your pelvic area too. The National Health Service (NHS) suggest holding the load close to your waist and avoid bending your back.
• Avoid too much high impact exercise – High impact exercises are great for overall health. But if you’re worried about a prolapse, then gentler, lower impact exercise like swimming will be better.
• Treat that cough – Persistent heavy coughing can cause a weakening in the pelvic floor muscles that may not become apparent straight away. Get medical help for a cough that lasts longer than a week.
• Good posture  – Make sure you have good posture, especially when seated – walk tall and sit tall with no slouching and adopt the BBC, Bum to the Back of the Chair, method.
• Lifestyle changes – Maintain a healthy weight and avoid constipation, heavy lifting, and prolonged coughing. Obesity can weaken muscles, so losing weight is a good way to help reduce pressure. Likewise, treating any underlying medical conditions that might be impacting your pelvic floor muscles will help eliminate stress. Try to avoid lifting heavy objects too. The strain can cause organs to prolapse.
• Wearing a vaginal pessary – A vaginal pessary will support even severe pelvic organ prolapses. It’s a small, usually silicone, device that is placed inside the vagina to help support the vaginal wall and prevent other pelvic organs from collapsing further into it. Different shapes and sizes of vaginal pessaries suit different shapes and sizes of women. Your doctor can help you find the right one and help you change the pessary every four to six months. This is commonly the favored treatment for those unable to undergo surgery due to medical conditions or those wishing to have children in the future.
• Estrogen cream – Oestrogen cream should be applied 2-3 times a day for a course of two weeks, directly to the prolapsed urethra. This treatment is not recommended if bleeding is occurring. In postmenopausal women, you may be prescribed a long term course of treatment following a urethrocele surgery.
• Antibiotics – The use of topical antibiotics is prescribed for complex situations and those where the infection is present. This treatment is not recommended if bleeding is occurring.
• Sitz bath – These hot saltwater baths can be purchased relativity cheaply. Used once or twice a day, they can reduce the discomfort for mild urethrocele prolapses.

In the circumstance of non-surgical treatments not fully relieving your symptoms and they remain severe, you may be advised to have a surgical intervention for your urethrocele prolapse. The surgery may be completed in conjunction with others, to repair all prolapses you are experiencing at once:

• Surgery – Surgery is usually the last resort and is used for women with severe urethral prolapses. The aim of the surgery is to remove tissue that is no longer functional and restore strength in the urethra. During surgery, usually through the vagina, but sometimes through the abdomen, your surgeon will lift the urethra back into place and remove part of the mucosa (mucous membrane) that covers the urethra. They will usually also add a few deep dissolvable surgical stitches to the vaginal wall to help strengthen it. It is important to note that surgery is unable to repair the pelvic floor muscles. You will need to perform pelvic floor exercises after your recovery to prevent the prolapse from returning.

How Can I Prevent a Urethrocele?

No matter how old (or young) you are, it’s never too early or too late to take your pelvic floor muscles into account. Keeping them strong means you’re less likely to experience a pelvic organ prolapse of any kind:

• Kegel exercises – These are also known as pelvic floor exercises. You can do them quickly and easily, at any time of day as no one will know you’re doing them. They help to strengthen the pelvic floor muscles. You can make them even more effective by using a Kegel8 Ultra 20 Pelvic Toner.
• Maintain your weight – Making sure you stick to a healthy weight will put less pressure on your pelvic floor muscles, giving you more chance of keeping them strong. The National Institute for Heath and Care Excellence (NICE) recommends keeping your BMI under 30.
• Avoiding constipation – Eating a high fiber diet of fruits, vegetables, and wholegrain cereals will help your bowels stay regular, as will drinking plenty of water.
• Lift heavyweights (and children) safely – Lifting correctly will make all the difference to not only your back but your pelvic area too. The National Health Service (NHS) suggest holding the load close to your waist and avoid bending your back.
• Avoid too much high impact exercise – High impact exercises are great for overall health. But if you’re worried about a prolapse, then gentler, lower impact exercise like swimming will be better.
• Treat that cough – Persistent heavy coughing can cause a weakening in the pelvic floor muscles that may not become apparent straight away. Get medical help for a cough that lasts longer than a week.
• Good posture – Make sure you have good posture, especially when seated – walk tall and sit tall with no slouching and adopt the BBC, Bum to the Back of the Chair, method.

Even if you’re young, of a healthy weight, and have no plans to have a baby any time soon, these steps are still worth taking as preventative measures.

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