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III) Pelvic Floor Disorders

3) Genital prolapse:

Genital prolapse:

• Uterine prolapse

• Cystocele

• Rectocele

• Enterocele

• Rectal prolapse

Genital prolapse can involve any of the main pelvic organs including the bladder, uterus and cervix, and the bowel. Women suffering from genital prolapse often have associated urinary or anal incontinence, although it is urinary incontinence which is most common. Symptoms are dependent on the specific abnormality, but usually include a feeling of pelvic fullness or discomfort, lower back discomfort or the appearance of a bulge in, or
even out of, the vagina.

Uterine prolapse:

With gross uterine prolapse, the uterus sometimes protrudes completely out of the body. Not only does this cause significant discomfort especially when erect, but also such women usually have to push it back in before they can sit down. Even in lesser degrees of uterine prolapse the feeling of vaginal fullness can be extreme. The lower part of the uterus and cervix often becomes swollen and this, together with continual scratching on clothes, pads and pantiliners, can cause an ulcer to develop, which can bleed or cause a discharge. Although this severe degree of prolapse (called total procidentia) is by no means rare, the more usual degree of uterine prolapse is far more moderate. It would involve the uterus and cervix moving up and down in the vagina (almost like a piston in a sleeve).

Uterine prolapse is the result of damage to the support structures at multiple levels. By now you are familiar with the levator ani muscles and the pelvic fascia as support structures. Uterine support, in addition, involves certain specific ligaments and is dependent on a normal uterine position in the pelvis.

The uterus is usually tilted and bent forwards in such a way that in the erect (standing) position its long axis is lying almost horizontal (level with the ground) and directed forward. In this horizontal position, the shelf of the levator ani muscles and the pelvic fascia support the bulk of its mass. In some women it is bent backwards and, although this is less common, almost the same applies. The uterosacral and cardinal ligaments are specific ligaments attached to the lower part of the uterus and to the pelvic side walls (see illustrations). These ligaments are usually very strong and provide significant support to the uterus.

Damage to the pelvic floor leads to an increased aperture of the opening that the vagina and cervix penetrate, which as we know is the result of weak, wasted or torn levator ani muscles and pelvic fascia. In the setting of stretched or weak uterosacral and cardinal ligaments, it is not surprising that the uterus would simply slide down through this opening. It is really a simple matter of gravity - if the anchors of the uterus fail and the underlying support is weak, the uterus will descend.

As mentioned before, all the pelvic support structures are less rigid and more pliable in pregnancy, which explains to some degree the occurrence of uterine prolapse in the occasional women even during their first pregnancy. Of course, the added weight of the fetus and increased uterine weight are significant co-factors in the development of this problem, but fortunately as the uterus enlarges it reaches a point where it is too large to
move through the pelvis. This solves the problem for the moment, although such women are at higher risk for a reoccurrence during future pregnancies and I would consider them to be at high risk for future genital prolapse after pregnancy.

Cystocele:

A cystocele is an abnormal bulging of the bladder into the vaginal roof (anterior vaginal wall). This is experienced as a bulge in the vagina from the top, which sometimes comes right down to the vaginal entrance and even through the entrance. The anatomical defects are by now familiar. These, not surprisingly, involve torn or fractured pelvic fascial layers, ruptured fascial ligaments, or levator ani muscles weakened by one of the factors discussed earlier. 

Cystoceles are commonly associated with urinary incontinence as a result of bladder neck support deficiency, associated with the injuries that cause the cystocele in the first place and other factors already outlined. Urinary incontinence does not always occur in the setting of a cystocele, so it is sometimes difficult to understand why some patients are totally dry in the presence of an obvious cystocele.

Some very large cystoceles cure the incontinence problem by kinking the urethra by virtue of their extreme prolapse. This could in the long run lead to renal (kidney) problems resulting from recurrent infections, or increased backpressure on the kidneys. Curing these cystoceles sometimes has the unfortunate side effect of unmasking the stress incontinence, so while the patient is cured of her cystocele she is not much better off. It is thus important that this be taken into consideration when surgery is planned for a cystocele.