Prolapse of the anterior vaginal wall may affect the urethra (urethrocele), and the bladder (cystocele, Fig. 21.6). On examination, the urethra and bladder can be seen to descend and bulge into the anterior vaginal wall and, in severe cases, will be visible at or beyond the introitus of the vagina. An urethrocele is the result of damage to level III (anterior) support, i.e. the pubourethral ligaments. Cystoceles usually result due to a loss of level II support and usually due to a midline defect in pubovesicocervical fascia. A rectocele is formed by a combination of factors: a herniation of the rectum through a defect in the rectovaginal fascia as well as a lateral detachment of the level II support from the ATFP. This can usually be seen as a visible bulge of the rectum through the posterior vaginal wall. It is often associated with a deficiency and laxity of the perineum. This is the classical level III defect (posterior) affecting the perineal body.

An enterocele is formed by a prolapse of the small bowel through the rectouterine pouch, i.e. the pouch of Douglas, through the upper part of the vaginal vault (Fig. 21.6). The condition may occur in isolation, but usually occurs in association with uterine prolapse. An enterocele may also occur following hysterectomy when there is inadequate support of the vaginal vault. This represents damage to level I support.

Uterine prolapse

Descent of the uterus, which occurs when level I support is deficient, may occur in isolation from vaginal wall prolapse but more commonly occurs in conjunction with it. First-degree prolapse of the uterus often occurs in association with retroversion of the uterus and descent of the cervix within the vagina. If the cervix descends to the vaginal introitus, the prolapse is defined as second degree. The term procidentia is applied to where the cervix and the body of the uterus and the vagina walls protrude through the introitus. The word actually means ‘prolapse’ or ‘falling’ but is generally reserved for the description of total or third-degree prolapse (Fig. 21.7).

Symptoms and signs

Symptoms generally depend on the severity and site of the prolapse (Table 21.1).

There are some symptoms that are common to all forms of prolapse; these include:

Symptoms are often multiple and related to the nature of prolapse. It is important to note that the symptoms (and signs) of prolapse are worse at the end of the day. It is, therefore, of some value, to schedule examination of patients that have typical symptoms of prolapse without its obvious signs a little later in the day.

This system was developed in an effort to introduce more objectivity into the quantification of pelvic organ prolapse. For example, measurements in centimetres are used instead of subjective grades. Nine specific measurements are recorded as indicated in Figure 21.9.

Pathogenesis

Prolapse may be:

Management

The management of prolapse can be conservative or surgical.

Conservative treatment

Many women have minor degrees of uterovaginal prolapse, which are asymptomatic. If the recognition of the prolapse is a coincidental finding, the woman should be advised against any surgical treatment.

Minor degrees of prolapse are common after childbirth and should be treated by pelvic floor exercises or the use of a pessary. Operative intervention is deferred for at least 6 months after delivery, as the tissues remain vascular and may undergo further spontaneous improvement.

Hormone replacement therapy may be used preoperatively to prepare the tissues, but by itself is of limited benefit in alleviating symptoms.

Where short-term support is required or the general health of the woman makes operative treatment potentially dangerous, then both vaginal wall and uterine prolapse can be treated by using vaginal pessaries. It is, however, necessary to have some pelvic floor support if a pessary is to be retained.

The most widely used pessaries (Fig. 21.10) are:

• Ring pessary: This pessary consists of a malleable plastic ring, which may vary in diameter from 60–105 mm. The pessary is inserted in the posterior fornix and behind the pubic symphysis. Distension of the vaginal walls tends to support the vaginal wall prolapse.

• Hodge pessary: This is a rigid, elongated, curved ovoid which is inserted in a similar way to the ring pessary and is principally useful in uterine retroversion.

• Gelhorn pessary: This pessary is shaped like a collar stud and is used in the treatment of severe degrees of prolapse.

• Shelf pessary: This is shaped like a coat hook and is used mainly in the treatment of uterine or vaginal vault prolapse.

The main problem with long-term use of pessaries is ulceration of the vaginal vault and rarely a fistula may form, usually between the bladder and the vagina, if the pessary is ‘neglected’ or ‘forgotten’. Pessaries should be replaced every 4–6 months and the vagina should be examined for any signs of ulceration. In postmenopausal women it is considered good practice to prescribe vaginal oestrogen creams/tablets to prevent ulceration.

Surgical treatment

The surgical management of uterovaginal prolapse has seen many changes in recent years. There is an increasing use of graft material and tissue anchors for increasing durability of the prolapse repair. Thus prolapse repairs can be classified into fascial repairs and graft augmented repairs.

Fascial repairs

Classically surgical treatment of a cystocele is by anterior colporrhaphy (Fig. 21.11). The operation consists of dissection of the prolapsed viscus (the urinary bladder) off the vaginal flaps, buttressing the pubovesicocervical fascia with durable delayed absorbable sutures and closure of the vaginal skin. Current practice does not include excision of ‘excess vaginal skin’ as the vagina is expected to remodel and the perceived laxity all but disappears in 6–8 weeks’ time.

Rectocele is repaired by again dissecting the prolapsing viscus (in this case the rectum) off the overlying vaginal skin and effecting a robust repair by apposing the torn ends of the rectovaginal fascia together with delayed absorbable sutures. Sometimes it is possible to identify the tears in the fascia and often a reattachment of the torn ends suffices. Not uncommonly a rectocele is accompanied by a deficient perineal body where the perineal muscles are attenuated or retracted laterally with the patient complaining of ‘vaginal laxity’ or sexual dysfunction. Intravaginal perineoplasty is the operation designed to treat these symptoms and involves lateral dissection to identify the retracted ends of the perineal muscles, apposing these in the midline and suturing the apposed muscles to the apex of the incision. This procedure helps recreate the perineal body, reduces the size of the genital hiatus thus improving vaginal tone and also corrects the vaginal axis. This operation is an improvement on the perineorraphy where the perineal skin is first incised and later excised but still fails to achieve the objectives stated above.

Where there is an enterocele, the procedure of choice is a McCall’s culdoplasty. This involves the placement of delayed absorbable sutures through the cut ends of the uterosacral ligaments and the intervening peritoneum hitching these successively to the vaginal vault. The aim of this operation is not just to treat the enterocele, but also to prevent occurrence of vault prolapse.

The treatment of choice for uterine prolapse depends on the woman’s preference for retaining her reproductive potential. If her family is complete then a vaginal hysterectomy usually with repair of the prolapsed vaginal walls is the preferred approach. If preservation of reproductive function is required, then the uterus can be conserved by simply excising the elongated cervix that is fashioned to an appropriate length with suturing of the cardinal ligaments in front of the cervical stump. This procedure is known as a Manchester or Fothergill repair. The vaginal skin is then sutured into the cervical stump using circumferential sutures. Additionally the operating surgeon may elect to suspend the cervix by means of sutures taken through the sacrospinous ligament called sacrospinous cervicopexy/hysteropexy.

A similar procedure may be employed to treat vault prolapse occurring after hysterectomy; the procedure is then called sacrospinous colpopexy (colpos Gk: vagina).

Graft repairs

The earliest repairs using mesh have been to treat vault prolapse (Fig 21.12). The prolapsed vaginal vault is treated by suspending the vaginal vault from the anterior longitudinal ligament of the sacrum using a synthetic mesh. This procedure is known as sacrocolpopexy – a procedure that can be performed laparoscopically or through a laparotomy. More recently ‘needle driven mesh kits’ have become available to treat vaginal prolapse. The first of these kits was called the PERIGEE™ used to suspend the prolapsed bladder from one ATFP to its opposite member thus recreating the hammock like arrangement that existed in the pelvis prior to the occurrence of the prolapse. A similar device called the APOGEE™ is available to treat large enteroceles and vault prolapses. More recently newer versions called the Anterior and Posterior Elevate™ have been developed to treat anterior, middle and posterior compartment disorders that are safer to use and employ mesh that is more bio-compatible. These new devices require specialized instruction and training prior to use.

Complications

Repairs whether fascial or otherwise can result in injury to the viscus being treated, i.e. bladder, small intestines, rectum or anal canal. The sigmoid colon or the ureters may additionally be injured when a McCalls’ culdoplasty is performed. The new needle driven devices are known to be rarely associated with damage to the deeper vessels in the pelvis and with more common occurrence of vaginal mesh exposure. Primary, reactionary and secondary hemorrhage may all occur with all of these procedures as may infection. The immediate complications of vaginal hysterectomy includes haemorrhage, haematoma formation, infection and less commonly, urinary retention. The long-term complications are dyspareunia and reduced vaginal capacity especially if vaginal skin is inappropriately excised. Fascial repairs especially of the anterior compartment may recur in about a third of cases. Posterior compartment fascial repairs perform better with only 20% recurrence. Inadequate support to the vaginal apex may result in recurrence of the prolapse of the vaginal vault. Mesh repairs are more robust with lower rates of recurrence.

Common disorders of bladder function

The common symptoms of bladder dysfunction include:

Diagnosis

The diagnosis is initially indicated by the history. Continuous loss of urine indicates a fistula, but not all fistulas leak urine continuously. The fistulous communication usually occurs between the bladder and vagina, vesicovaginal fistula, and the ureter and vagina, ureterovaginal fistula. Fistula formation results from:

There are other types of fistula with communications between bowel and urinary tract and between bowel and vagina, but these are less common.

Rectovaginal fistulas have a similar pathogenesis, with the additional factor of perineal breakdown after a third-degree tear.

Urinary fistulas are localized by:

The differential diagnosis between stress and urge incontinence is more difficult and is often unsatisfactory. Adequate preoperative assessment is important if the correct operation is to be employed or if surgery is to be avoided. It is important to assess patients with a validated patient questionnaire (the Modified Bristol Female Lower Urinary Tract Symptoms Questionnaire is a good example) with a 3-day urinary diary and a pad test. These help the clinician gain an insight into how the symptoms of urinary incontinence affect the patient on a day-to-day basis. The bladder and urethra are assessed in the laboratory by urodynamics. This procedure usually involves three basic steps:

1. Uroflowmetry: The patient is asked to pass urine into a specially designed toilet that measures voided volume, maximal and average urinary flow rates. Flow rates of >15 mL/sec are considered acceptable and it is expected that a normal bladder will completely empty itself. Flow rates of <15 mL/sec are indicative of voiding dysfunction and in the female often indicate a ‘functional obstruction’ rather than an anatomic one. Occasionally a powerful detrusor may cause the bladder to contract against a closed internal urethral meatus resulting in dysfunctional voiding, a condition termed ‘detrusor–sphincter dyssynergia’.

2. The cystometrogram (Fig 21.13): Pressure is measured intravesically and intravaginally or less commonly intrarectally, because intravaginal pressure represents intra-abdominal pressure and is subtracted from the intravesical pressure to give a measure of detrusor pressure. The volume of fluid in the bladder at which the first desire to void occurs is usually about 150 mL. A strong desire to void occurs at 400 mL in the normal bladder. High detrusor pressure at a lower volume reflects an abnormally sensitive bladder associated with chronic infection. There should be no detrusor contraction during filling, and any contraction that occurs under these circumstances indicates detrusor instability. An underactive detrusor shows no contraction on complete filling and indicates an abnormality of neurological control. The average bladder has a capacity of 250–550 mL, but capacity is a poor index of bladder function. Thus, cystometry is a useful method for assessing detrusor muscle function or detrusor instability, which may result in urge incontinence.

    In the presence of urethral incompetence, there is low resting urethral pressure, no voluntary increase in urethral pressure, inability to stop midstream, decreased pressure transmission to the abdominal urethra and large volumes in the frequency/volume measurements. There is not always a clear-cut demarcation between the two conditions, as there may be a mixture of both stress and urge incontinence. Nevertheless, it is important to differentiate between the predominant influence of bladder neck weakness and stress incontinence, and detrusor instability and urge incontinence.

3. Urethral pressure profile: This is performed at the very end of the cystometry and measures the pressure within the mid-urethra, in particular the maximum urethral closure pressure (MUCP). This is of value in predicting the likelihood of surgical success after an anti-incontinence procedure. Pressures <20 cm of H₂O are predictive of poorer outcomes.

In some units an endoscopic view of the bladder called ‘cystoscopy’ and an ultrasound scan of the pelvic floor are the additional procedures performed in the evaluation of the incontinent woman.

In the developed world, most urinary tract fistulas result from surgical trauma. The commonest fistulas are vesicovaginal or ureterovaginal and result from surgical trauma at the time of hysterectomy, or sometimes following caesarean section.

A vesicovaginal fistula will usually become apparent in the first postoperative week. If the fistula is small, closure may be achieved spontaneously.

The patient should be treated by catheterization and continuous drainage. If closure has not occurred after 2–3 months, the fistula is unlikely to close spontaneously and surgical closure is recommended. The timing of further surgery is still a subject of controversy. Until recently, a delay of 6 months was recommended but there is increasing evidence that good results can be obtained with early surgical intervention. However, the fistulous site should be free of infection.

Surgical closure may be achieved vaginally by meticulous separation of the edges of the fistula and closure in layers of the bladder and vagina. Postoperative care includes continuous catheter drainage for 1 week and antibiotic cover. An abdominal approach to the fistula can also be used and has some advantages, allowing the interposition of omentum in cases where there is a large fistula.

Ureterovaginal fistulas are usually treated by reimplantation of the damaged ureter into the bladder.

Stress incontinence

Stress incontinence should be managed initially by pelvic floor physiotherapy. Surgical treatment is indicated where there is a failure to respond to conservative management. In the presence of anterior vaginal wall prolapse, anterior repair, with the placement of buttressing sutures at the bladder neck, has the virtue of simplicity. It will certainly relieve the prolapse but the results are variable as far as the stress incontinence is concerned, with relief in about 40–50% of cases. It is of no value in the absence of evidence of prolapse.

The following procedures are commonly used:

• Mid-urethral slings (Fig. 21.14)

 Tension-free vaginal tape (TVT™): Bladder neck elevation can be achieved by the placement of a tension-free vaginal tape. A polypropylene tape is inserted through a sub-urethral vaginal incision and guided via a needle paravesically to exit from the symphysis pubis. This can be carried out under local, regional or general anaesthetic and the tape is placed mid-urethrally in a tension-free manner. A cystourethroscopy is performed intra-operatively to rule out damage to the bladder and urethra. As this procedure is minimally invasive most women are able to return to normal activity within 1–2 weeks. The long-term success rates are around 80%.

    In recent times the procedure has become even less invasive than before and now it is possible to perform the procedure by passing needles through the obturator foramina and still site the tape as before, i.e. under the mid-urethra (MONARC™). The most recent version of the sling is called the MINIARC™. It is the most minimally invasive version of the mid-urethral sling that has the added advantage of not having to be passed through blind spaces like the retropubic space and transobturator foramina.

• Miscellaneous procedures still in vogue

 Laparoscopic Burch colposuspension involves bladder neck elevation by suturing the upper lateral vaginal walls to the iliopectineal ligaments under laparoscopic control. The success rates are around 60% and the procedure results in voiding dysfunction in a significant majority of patients. This procedure has more or less been invalidated by the more popular and safer mid-urethral slings.

 Transurethral injections: Injectable bulking agents can be injected via a cystoscope into the mid-urethra. These are simple procedures with very little perioperative morbidity and have success rates of about 40–60%. These are useful adjuncts to the mid-urethral slings especially in recurrences and in women with multiple failed operations. The commonest agents employed are collagen (glutaraldehyde cross-linked bovine collagen), silicon (macroparticulate silicon particles), Durasphere® (pyrolytic carbon-coated beads), etc.

The unstable bladder: overactive bladder syndrome (OAB)

The features of the unstable bladder are those of frequency of micturition and nocturia, urgency and urge incontinence. When confronted with this history, it is important to obtain some indication of the frequency as related to fluid intake and output. A chart should therefore be kept by the patient to clarify this aspect.

The assessment of predisposing factors includes urine culture, urinary flow rates and urodynamic studies.

Treatment will obviously be directed at the cause, so the presence of urinary tract infection necessitates the administration of the appropriate antibiotic therapy. Postmenopausal women with atrophic vaginal epithelium and symptoms of urgency and frequency often respond to replacement therapy with low-dose oestrogens.

Bladder outlet obstruction

Primary bladder neck obstruction in the female probably results from the failure of the vesical neck to open during voiding, and can be treated either with α-adrenergic blocking agents like tamsulosin (Flomax®) or by urethral dilatation. Secondary outlet obstruction is usually associated with previous surgery for incontinence and may respond to urethral dilatation but the results are not particularly good.

The neuropathic bladder

Loss of bladder function may be associated with a variety of conditions that affect the central nervous system. These conditions may also be associated with alteration in bowel function, sexual dysfunction and loss of function of the lower limbs.