The International Urogynecological Association and International Continence Society defined anterior vaginal wall (compartment) prolapse as the “observation of descent of the anterior vaginal wall (compartment).”¹ Most commonly, this might represent bladder prolapse (cystocele). Higher stage anterior vaginal wall prolapse will generally involve descent of the uterus or vaginal vault (if the uterus is absent). Occasionally, there might be an anterior enterocele (hernia of peritoneum and possibly abdominal contents), most commonly after prior reconstructive surgery.

This definition serves as a starting place for understanding anterior vaginal wall support and the defects in that support that can lead to prolapse. After reviewing the anatomy and histology of the anterior compartment, we review the epidemiology, workup, and treatment of anterior vaginal compartment support defects.

The vaginal canal has been described by DeLancey² as having three levels of support. Level 1 supports of the upper 2 to 3 cm of the vagina are composed of the cardinal-uterosacral ligament complex. At level 2, the vaginal canal is attached laterally to the arcus tendineus fascia pelvis (ATFP). The endopelvic connective tissue often called “pubocervical fascia” stretches from one ATFP laterally to the other. Finally, level 3 supports include the attachments of the vagina to the pelvic floor, levator ani, and urethra in the distal 2 to 3 cm of the vagina.

A defect in the midline of the endopelvic connective tissue may lead to a midline cystocele. This central defect had been previously described by Richardson et al.³ Alternatively, a disruption in the endopelvic connective tissue laterally at the point of attachment to the ATFP may lead to paravaginal support defects. Richardson popularized this terminology in 1981,⁴ but it was first described by White⁵ in 1912. This prolapse in the anterior compartment was reported to be related to descent of the lateral attachments of the anterior vaginal wall to the ATFP.⁶ Larson et al.⁷ described this paravaginal support defect using dynamic magnetic resonance imaging (MRI) and showed that women who had anterior compartment prolapse also had descent of the paravaginal tissues.

Anterior compartment prolapse is also highly associated with apical prolapse.⁸ Hsu et al.⁹ were able to explain up to 77% of anterior wall prolapse by relating it to the apical descent of the vagina. This relationship is important in considering treatment, as anterior compartment surgical procedures are often paired with apical procedures with improved outcomes. In 2020, Moalli et al.¹⁰ laid out a study to evaluate the mechanism of anterior vaginal compartment prolapse based on MRI after surgical repair. These results are eagerly anticipated and will serve to further the understanding of the pathophysiology of descent of the anterior vaginal wall.¹⁰

Histologically, the vaginal canal is a hollow fibromuscular organ (Fig. 43.1). The walls of the vagina have four layers: a nonkeratinized squamous epithelium, a dense connective tissue layer of the lamina propria, the smooth muscle layer of the muscularis, and the loose connective tissue of the adventitia.¹¹ There is no fascia in the vaginal wall. The epithelial layer overlies the lamina propria, neither of which contain glandular elements. This is why it is a misnomer to describe the vaginal epithelium as a mucosa. Within the muscularis layer is a network of blood vessels. The vaginal lubrication is not exudative in nature; rather, it is a transudate from these vessels together with secretions from the cervix and other glands at the introitus, such as the Bartholin and Skene glands. Finally, the adventitial layer is shared with the bladder adventitia, essentially forming the endopelvic connective tissue often called the “pubocervical fascia” or “endopelvic fascia.”

Because anterior vaginal wall prolapse symptoms overlap with the symptoms of other types of pelvic organ prolapse, patient survey is not a reliable way to assess prevalence. As such, prevalence must be estimated using studies that rely on physical examination. When evaluating the literature, anterior vaginal wall support defects are the most common location for pelvic organ prolapse to occur.¹²

Handa et al.¹² studied a cohort that had a baseline cystocele prevalence of 24.6%. They found that anterior vaginal wall prolapse was associated with increasing parity (odds ratio of 1.3 per pregnancy) and increasing waist circumference.¹² Hendrix et al.¹³ corroborated these findings with an incidence of anterior compartment prolapse of 34.3% in the Women’s Health Initiative trial. Although Hendrix et al.¹³ found similar risk factors to Handa et al.’s¹² study, this study also identified the body mass index as a significant risk factor.

Other risk factors for pelvic organ prolapse have not been studied independently for anterior vaginal prolapse. These include Latina or white race, chronically elevated intra-abdominal pressures, connective tissue disease, and family history.¹⁴,¹⁵,¹⁶,¹⁷ The role of genetics in pelvic organ prolapse remains unclear.¹⁸,¹⁹

A thorough history and physical examination is critical to evaluate a patient with anterior compartment prolapse. Symptoms of anterior vaginal wall prolapse are often nonspecific and include vaginal pressure, sensation of a bulge, vaginal fullness, low back pain, difficulty sitting, spotting, and dyspareunia.²⁰ Although nonspecific for anterior compartment prolapse, vaginal bulge symptoms are highly predictive of vaginal prolapse.

Anterior vaginal wall prolapse is often accompanied by urinary symptoms. Women may experience difficulty voiding due to a kinking of the urethra with advanced prolapse. The reduction of the prolapse may unmask “occult” stress urinary incontinence.²¹ Inquiry about urgency, frequency, nocturia, postmicturition dribbling, insensible loss, and nocturnal enuresis may prove helpful. Women with prolapse should be questioned about sexual function because pelvic organ prolapse is highly associated with sexual dysfunction.²²

The medical history should include a review of the patient’s prior surgical procedures. Knowledge of prior surgical procedures, including if there is mesh in the pelvis, is critical to accurately counsel the patient on the best treatment options.

As with all pelvic organ prolapse, treatment is contingent on patient satisfaction outcomes.²³ As such, a detailed discussion of the goals of care should be discussed at the initial patient encounter. This discussion may be paired with validated standardized questionnaires, which are calibrated to reflect small changes in symptoms. Although not specific to anterior compartment defects, the Pelvic Floor Distress Inventory (PFDI) and the shortened version, PFDI-20, are often used to assess prolapse symptoms.

The physical examination for evaluation of the anterior compartment is comparable to the examination of patients with all types of pelvic organ prolapse. The examination begins with inspection, followed by a speculum examination, and a bimanual examination. When evaluating the anterior compartment only, a rectovaginal examination is not helpful. The inspection phase of the exam is a careful observation of the vulva, labia, perineum, and perianal skin. The patient should be relaxed at first, followed by maximum Valsalva. The posterior blade of a bivalve speculum or a Sims speculum may be used to isolate the various compartments of the vagina. To evaluate the anterior wall and its supports, the posterior blade of the speculum should be placed posteriorly and the patient should be asked to Valsalva and/or cough strongly. The Baden-Walker or Pelvic Organ Prolapse Quantification system may be used to quantify the points of maximum descent (see Chapter 9). A scored popsicle stick, tongue depressor, ring forceps, or landmarks on the examiner’s finger may be used to measure points in relation to the hymen. This should be performed during maximum Valsalva. Finally, the bimanual exam is performed to assess the tone, tenderness and strength of the pelvic floor musculature, the adnexa, the uterus, the bladder, and the urethra. The exam may be repeated with the patient standing to evaluate the prolapse on a different axis with the assistance of gravity to help reveal the full
extent of the prolapse. This will often reveal greater degrees of prolapse compared to examination in the supine position.

The role of imaging in the evaluation of pelvic organ prolapse remains unclear in routine clinical care. Pelvic floor ultrasonography gives further texture to the diagnosis by evaluating the levator defects in pelvic floor support. Ultrasonography may also diagnose anterior compartment defects with a high correlation to the physical examination.²⁴ However, these added parameters, including the measurement of the levator hiatus, have yet to be proven clinically useful and at this time, routine ultrasound to image anterior compartment prolapse is not indicated.²⁵ MRI may also be used to evaluate pelvic organ prolapse, with a detailed view of support defects and the pelvic floor musculature.²⁶ However, routine dynamic MRI use is not indicated at this time and this modality should be reserved for research or complex patients. Ultrasonography and MRI may be useful in women who have recurrent anterior compartment prolapse after failed surgical reconstruction.

Adjunct testing may be necessary depending on the symptoms at the time of presentation. For example, if a patient presents with symptoms of incomplete emptying, a postvoid residual, uroflowmetry, or even multichannel urodynamics with support of the prolapse may be indicated. If pain or pressure is associated, cystoscopy may be useful as well. Sometimes, cystourethroscopy may help to clarify if the prolapsing viscus is the bladder and/or an anterior enterocele.