Anterior and posterior vaginal wall prolapse involve protrusion of an organ into the vagina. Anterior vaginal wall prolapse is commonly referred to as cystocele (protrusion of the bladder) or urethrocele (urethra). Posterior vaginal wall prolapse is commonly referred to as enterocele (small intestine and parietal peritoneum) and rectocele (rectum). Symptoms include pelvic or vaginal fullness or pressure, urinary incontinence, urinary retention, and/or difficulty passing stool. Diagnosis is clinical. Treatment includes conservative management with pelvic muscle exercises or pessaries, and sometimes surgery.
Many patients have multiple sites of pelvic organ prolapse; a combination of cystocele, enterocele, and rectocele are particularly likely to occur together. Cystocele is often accompanied by urethrocele (cystourethrocele).
Cystocele commonly develops when the pubocervical vesical fascia is weakened. In enterocele, weakness in the pubocervical fascia and rectovaginal fascia allows the apex of the vagina, which contains the parietal peritoneum and small bowel, to descend. Rectocele results from disruption of the levator ani muscles (see also Overview of Pelvic Organ Prolapse).
Symptoms and Signs of Vaginal Wall Prolapse
Pelvic or vaginal fullness, pressure, and a sensation of organs falling out are common. Organs may bulge into the vaginal canal or through the vaginal opening (introitus), particularly during straining or coughing.
Mild prolapse may be asymptomatic.
Anterior vaginal wall prolapse can be accompanied by stress urinary incontinence if there is insufficient support of the urethra. Urinary retention may occur if prolapse causes a bladder angle that results in urethral obstruction.
Enteroceles may cause pelvic discomfort, vaginal pressure, and incomplete emptying of the bowels.
Rectoceles may cause constipation and incomplete defecation; patients may have to insert fingers into the vagina and apply pressure to the posterior vaginal wall (called splinting) and thus change the angle of the rectum so that they can defecate.
Patients may also experience sexual dysfunction, sometimes due to embarrassment about changes in anatomy or possible urinary or anal incontinence during sexual activity.
Diagnosis of Vaginal Wall Prolapse
Pelvic examination at rest and while a patient strains
Diagnosis of vaginal wall prolapse is made clinically with pelvic examination by retracting the posterior vaginal wall and observing the anterior vaginal wall with the patient at rest and then with the patient straining. The Pelvic Organ Prolapse-Quantification (POP-Q) system is usually used to document severity.
Cystocele is diagnosed by inserting a single-blade speculum in the vagina and retracting the posterior vaginal wall. Asking patients to strain makes cystoceles visible or palpable as soft reducible masses bulging into the anterior vaginal wall.
Enterocele and rectocele are detected by using a single-blade speculum to retract the anterior vaginal wall. Asking patients to strain can make enteroceles and rectoceles visible and palpable during rectovaginal examination. Patients are also examined while standing with one knee elevated (eg, on a stool) and straining; sometimes abnormalities are detected only by rectovaginal examination during this maneuver.
Urinary incontinence, if present, is also evaluated.
Treatment of Vaginal Wall Prolapse
Pelvic floor muscle exercises (eg, Kegel exercises)
Pessary
Sometimes surgical repair of supporting structures
Treatment of anterior or posterior vaginal wall prolapse is individualized, based on a patient's symptoms, with the goal of improving quality of life (1). Asymptomatic prolapse does not require treatment. Treatment may consist of pelvic floor muscle exercises, a pessary, and, if these measures are unsuccessful or if the patient prefers, surgical repair.
Pelvic floor muscle exercises
Pelvic floor muscle exercises (eg, Kegel exercises) are usually first-line therapy for stage I or II pelvic organ prolapse. Pelvic floor muscle exercises have no or a very low risk of harm to the patient. With consistent use, they can lessen bothersome symptoms of prolapse (and stress incontinence), but do not appear to reduce the anatomic severity of prolapse (2).
Kegel exercises are isometric contractions of the pubococcygeus muscle. These muscles are contracted tightly for about 1 or 2 seconds, then relaxed for about 10 seconds. Gradually, contractions are held for about 10 seconds each. The exercise is repeated about 10 times in a row. Doing the exercises several times a day is recommended.
Exercises can be facilitated by
Use of weighted vaginal cones (which help patients focus on contracting the correct muscle)
Use of biofeedback devices provide muscle-effort feedback. There are many different types of devices, varying from simple hand-held mirrors to devices that turn patient muscle activity into audio or visual information.
Electrical stimulation, which causes the muscle to contract
Pessaries
Pessaries are devices that are inserted in the vagina to maintain normal anatomy and reduction of the prolapsed structures, resulting in improved objective and subjective benefit (3). Pessaries are typically made of silicone and vary in shape and size; some are inflatable.
To fit a pessary, a clinician should do a pelvic examination and insert the pessary and allow the patient to stand up and walk around to assess comfort. The clinician should provide instructions for removing, cleaning, and reinserting the pessary. In some countries, pessaries may be available over the counter. Proper size, fit, and position are important, because a pessary can cause vaginal ulceration with bleeding if it is does not fit correctly and vaginal discharge if it is not cleaned regularly (at least monthly if not more frequently).
Surgical repair
Surgical repair can help relieve symptoms that are severe or do not resolve with nonsurgical treatment. The surgical approach used depends on the type of prolapse, symptoms, patient age and comorbidities, patient preference, and the surgeon's expertise. Surgery may include one (or a combination) of the following procedures
Anterior or posterior colporrhaphy (vaginal repair)
Vaginal apex suspension or repair
Colpocleisis (closure of the vagina after removal of the uterus or with the uterus in place [Le Fort procedure])
Surgical repair of the vagina is usually deferred, if possible, until future pregnancy is no longer desired because subsequent vaginal delivery may disrupt the repair. After surgery, patients should avoid heavy lifting for at least 6 weeks.
References
1. Pelvic Organ Prolapse: ACOG Practice Bulletin, Number 214. Obstet Gynecol. 2019 (reaffirmed 2024);134(5):e126-e142. doi:10.1097/AOG.0000000000003519
2. Wiegersma M, Panman CM, Kollen BJ, Berger MY, Lisman-Van Leeuwen Y, Dekker JH: Effect of pelvic floor muscle training compared with watchful waiting in older women with symptomatic mild pelvic organ prolapse: randomised controlled trial in primary care. BMJ. 2014;349:g7378. Published 2014 Dec 22. doi:10.1136/bmj.g7378
3. Sansone S, Sze C, Eidelberg A, et al: Role of Pessaries in the Treatment of Pelvic Organ Prolapse: A Systematic Review and Meta-analysis. Obstet Gynecol. 2022;140(4):613-622. doi:10.1097/AOG.0000000000004931
Key Points
Anterior and posterior vaginal wall prolapse involve protrusion of an organ into the vagina; many patients have both anterior and posterior prolapse.
Anterior vaginal wall prolapse is commonly referred to as cystocele (protrusion of the bladder) or urethrocele (urethra).
Posterior vaginal wall prolapse is commonly referred to as enterocele (small intestine and parietal peritoneum) and rectocele (rectum).
Symptoms include pelvic or vaginal fullness, pressure, and a sensation of organs falling out. Organs may bulge into the vaginal canal or through the vaginal opening (introitus), particularly during straining or coughing.
Diagnose cystocele on pelvic examination by retracting the posterior vaginal wall and observing the anterior vaginal wall with the patient at rest and then with the patient straining.
Diagnose enterocele or rectocele on pelvic examination by retracting the anterior vaginal wall and observing the posterior vaginal wall with the patient at rest and then with the patient straining, and with a rectovaginal examination.
First-line conservative treatment options include pelvic floor physical therapy (for less severe pelvic organ prolapse) and pessaries, with surgical options available based on patient preference and clinical pelvic organ prolapse severity.
