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Native Tissue Vaginal Repair of Cystocele, Rectocele, and Enterocele


Anterior Vaginal Wall Prolapse

Anterior vaginal wall prolapse, or cystocele, is defined as pathologic descent of the anterior vaginal wall and overlying bladder base. The cause of anterior vaginal wall prolapse is not completely understood but is probably multifactorial, with different factors implicated in individual patients. Until recently, two types of anterior vaginal wall prolapse were described: distention and displacement cystocele. Distention cystocele was thought to result from overstretching and attenuation of the anterior vaginal wall, and displacement cystocele was attributed to pathologic detachment or elongation of the anterior lateral vaginal supports to the arcus tendineus fascia pelvis. More recently, three distinct defects have been described that can result in anterior vaginal wall prolapse: the midline defect, which has been previously described as a distention-type cystocele; the paravaginal defect, which is a separation of the normal attachment of the connective tissue of the vagina at the arcus tendineus fascia pelvis (white line); and the transverse defect, which occurs when the pubocervical fascia separates from its insertion around the cervix or at the apex ( Figs. 52.1 to 52.5 ). Anterior vaginal wall prolapse, especially in the posthysterectomy patient, may be commonly associated with an apical enterocele or, more rarely, a true anterior enterocele ( Fig. 52.6 ).

FIG. 52.1, Two views of normal and abnormal support of the anterior vaginal wall. A. Lateral view of normal anterior vaginal wall support with bladder support extending back to the level of the ischial spines. Note normal midline and lateral support. B. Trapezoid concept of the support of the anterior vaginal wall. Note that the trapezoid extends back to the ischial spine on each side, and the fascia or the muscular lining of the vagina extends from one side of the pelvic sidewall to the opposite side with good midline support and lateral and transverse attachments. C. Lateral view of a midline defect. Note the bulging of the bladder into the midportion of the vagina with maintenance of lateral support. Thus the anterior vaginal fornix is maintained on each side. D. Midline defect demonstrates weakening in the midportion of the trapezoidal support of the anterior segment. E. Lateral view of bilateral paravaginal defects. Note the complete detachment of the white line from its normal attachment, resulting in complete loss of the anterolateral supports of the anterior segment. F. Bilateral paravaginal defects. Complete lateral detachment of the normal support is noted as the trapezoid rotates outwardly. G. Lateral view of a transverse defect. Note that the bladder prolapse is between the normal upward attachment and the cervix or vaginal apex, usually resulting in what is termed a high cystocele. H. Note that the bladder descends around the normal upper attachment of the fascia or the muscular lining of the vagina.

FIG. 52.2, Normal intact pubocervical fascia is demonstrated ( A ). The relationship to the bladder is visualized ( B ) and represents paravaginal, midline, and transverse defects ( C ) .

FIG. 52.3, The anterior vaginal wall showing the urethrovaginal crease. Note that the vagina over the bladder base shows minimal rugae, a situation that is more consistent with a midline defect.

FIG. 52.4, The anterior vaginal wall with rugae, a situation that is more consistent with a paravaginal defect.

FIG. 52.5, Cross-sectional drawing of the pelvic floor to demonstrate ( A ) normal anatomy, ( B ) a midline defect of the anterior vaginal wall, and ( C ) a lateral or paravaginal defect of the anterior vaginal wall.

FIG. 52.6, Loss of anterior vaginal wall support. A cystocele is coexistent with an apical or possibly an anterior enterocele in the posthysterectomy patient. Note that grossly, the vaginal epithelium over an enterocele will appear to be much thinner than the vaginal epithelium over the prolapsed bladder.

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