Chapter Outline
Introduction
Anterior vaginal prolapse occurs commonly and may coexist with disorders of micturition. Mild anterior vaginal prolapse often occurs in parous women but usually presents few problems. As the prolapse progresses, symptoms may develop and worsen, and treatment becomes indicated. The anterior vaginal wall is the most common segment of the vagina to prolapse and the segment that is most likely to fail long-term after surgical correction. This chapter reviews the anatomy and pathology of anterior vaginal prolapse, with and without stress incontinence, and describes methods of surgical repair.
Anatomy and Pathology
Anterior vaginal prolapse (cystocele) is defined as pathologic descent of the anterior vaginal wall and overlying bladder base. According to the International Continence Society (ICS) standardized terminology for prolapse grading ( ), the term anterior vaginal prolapse is preferred over cystocele . This is because information obtained during the physical examination does not allow the exact identification of structures behind the anterior vaginal wall, although it usually is, in fact, the bladder. The ICS grading system for prolapse is discussed in detail in Chapter 8 .
The etiology of anterior vaginal prolapse is not completely understood, but it is probably multifactorial, with different factors implicated in prolapse in individual patients. Normal support for the vagina and adjacent pelvic organs is provided by the interaction of the pelvic muscles and connective tissue. The upper vagina rests on the levator plate and is stabilized by superior and lateral connective tissue attachments. The mid vagina is attached to the arcus tendineus fasciae pelvis (ATFP; white lines) on each side, and the apical portion of the anterior vagina is attached to the web of endopelvic fascia, including pubocervical fascia, and the cardinal and uterosacral ligaments. Pathologic loss of lateral and/or apical support may occur with damage to or impairment of the pelvic muscles, connective tissue attachments, or both.
described two types of anterior vaginal prolapse: distension and displacement. Distension was thought to result from overstretching and attenuation of the anterior vaginal wall, caused by overdistension of the vagina associated with vaginal delivery or atrophic changes associated with aging and menopause. The distinguishing physical feature of this type was described as diminished or absent rugal folds of the anterior vaginal epithelium caused by thinning or loss of midline vaginal fascia. The other type of anterior vaginal prolapse—displacement—was attributed to pathologic detachment or elongation of the anterolateral vaginal supports to the ATFP. It may occur unilaterally or bilaterally and often coexists with some degree of distension cystocele, with urethral hypermobility, or with apical prolapse. Rugal folds may or may not be preserved.
Another theory ascribes most cases of anterior vaginal prolapse to disruption or detachment of the lateral connective tissue attachments at the ATFP, resulting in a paravaginal defect and corresponding to the displacement type discussed earlier. This was first described by , but disregarded until reported by Richardson in 1976. described transverse defects, midline defects, and defects involving isolated loss of integrity of pubourethral ligaments. Transverse defects were said to occur when the “pubocervical” fascia separated from its insertion around the cervix, whereas midline defects represented an anteroposterior separation of the fascia between the bladder and vagina. A contemporary conceptual representation of vaginal and paravaginal defects is shown in Figure 23.1 .
There have been few systematic or comprehensive descriptions of anterior vaginal prolapse based on physical findings and correlated with findings at surgery to provide objective evidence for any of these theories of pathologic anatomy. In a study of 71 women with anterior vaginal wall prolapse and stress incontinence who underwent retropubic operations, described paravaginal defects in 87% on the left and 89% on the right. The ATFP were usually attached to the pubic bone but detached from the ischial spine for a variable distance. The pubococcygeal muscle was visibly abnormal, with localized or generalized atrophy in more than half the women.
Improvements in pelvic imaging are leading to a greater understanding of normal pelvic anatomy and the structural and functional abnormalities associated with prolapse. Magnetic resonance imaging (MRI) holds great promise, with its excellent ability to differentiate soft tissues and its capacity for multiplanar imaging. The pelvic organs, pelvic muscles, and connective tissues can be identified easily with MRI. Various measurements can be made that may be associated with anterior vaginal prolapse or urinary incontinence, such as the urethrovesical angle, descent of the bladder base, the quality of the levator muscles, and the relationship between the vagina and its lateral and apical connective tissue attachments. used an endoluminal surface coil placed in the vagina to image pelvic anatomy with MRI, and compared four continent nulliparous women with four incontinent women with anterior vaginal prolapse. Lateral vaginal attachments were identified in all continent women. In Figure 23.2 , the “posterior pubourethral ligaments” (bilateral attachment of the ATFP to the posterior aspect of the pubic symphyses) are clearly seen. In the two subjects with clinically apparent paravaginal defects, lateral detachments were evident ( Fig. 23.3 ). More recent studies based on MRI analysis and computer modeling suggest that apical support abnormalities are at least as important as, if not more important than, paravaginal defects; the degree of apical decent can explain about half of anterior wall descent ( ). Other factors, such as levator muscle impairment, levator avulsion, greater anterior wall length, and widened levator hiatus also contribute to anterior vaginal prolapse.
Anterior vaginal prolapse commonly coexists with urodynamic stress incontinence. Some features of pathophysiology may overlap, such as loss of anterior vaginal support with bladder-base descent and urethral hypermobility; other features, such as sphincteric dysfunction, may occur independent of vaginal and urethral support. The pathophysiology of stress incontinence is covered more fully in Chapter 15 .
Evaluation
History
When evaluating women with pelvic organ prolapse or urinary or fecal incontinence, attention should be paid to all aspects of pelvic organ support. The reconstructive surgeon must determine the specific sites of damage for each patient, with the ultimate goal of restoring both anatomy and function.
Patients with anterior vaginal prolapse complain of symptoms related directly to vaginal protrusion, or associated symptoms such as urinary incontinence or voiding difficulty. Symptoms related to prolapse may include the sensation of a vaginal mass or bulge, pelvic pressure, low back pain, and sexual difficulty. Stress urinary incontinence commonly occurs in association with anterior vaginal prolapse, particularly when it is mild. In contrast, women with anterior vaginal prolapse that extends beyond the hymen are less likely to complain of stress incontinence and are more likely to have obstructed voiding symptoms such as urinary hesitancy, intermittent flow, weak or prolonged stream, feeling of incomplete emptying, the need to reduce (splint) the prolapse manually to initiate or complete urination, and, in rare cases, urinary retention. The mechanism for this appears to be mechanical obstruction resulting from urethral kinking that occurs with progressively worsening anterior vaginal prolapse.
Physical Examination
The physical examination should be conducted with the patient in the lithotomy position, as for a routine pelvic examination. The examination is first performed with the patient supine. If physical findings do not correspond to symptoms or if the maximum extent of the prolapse cannot be confirmed, the woman is reexamined in the standing position.
The genitalia are inspected and, if no displacement is apparent, the labia are gently spread to expose the vestibule and hymen. The integrity of the perineal body is evaluated, and the approximate size of all prolapsed parts is assessed. A retractor or Sims speculum can be used to depress the posterior vagina to aid in visualizing the anterior vagina. After the resting examination, the patient is instructed to strain down forcefully or to cough vigorously. During this maneuver, the order of descent of the pelvic organs is noted, as is the relationship of the pelvic organs at the peak of straining.
It may be possible to differentiate lateral defects, identified as detachment or effacement of the lateral vaginal sulci, from central defects, seen as midline protrusion but with preservation of the lateral sulci, by using a curved forceps placed in the anterolateral vaginal sulci directed toward the ischial spines. Bulging of the anterior vaginal wall in the midline between the forceps blades implies a midline defect; blunting or descent of the vaginal fornices on either side with straining suggest lateral paravaginal defects. Studies have shown that the physical examination technique to detect paravaginal defects is not particularly reliable or accurate. In a study by of 117 women with prolapse, the sensitivity of clinical examination to detect paravaginal defects was good (92%), yet the specificity was poor (52%) and, despite an unexpectedly high prevalence of paravaginal defects, the positive predictive value was poor (61%). Less than two-thirds of women believed to have a paravaginal defect on physical examination were confirmed to have the same at surgery. Another study by demonstrated poor reproducibility of clinical examination in detecting specific anterior vaginal wall defects. Thus, the clinical value of determining the location of midline, apical, and lateral paravaginal defects remains unknown.
Anterior vaginal wall descent usually represents bladder descent with or without concomitant urethral hypermobility. In 1.6% of women with anterior vaginal prolapse, an anterior enterocele mimics a cystocele on physical examination ( ). Other uncommon conditions, such as anterior vaginal cysts or myomas, can also mimic anterior vaginal prolapse.
Diagnostic Tests
After a careful history and physical examination, few diagnostic tests are needed to evaluate patients with anterior vaginal prolapse. A urinalysis should be performed to evaluate for urinary tract infection if the patient complains of any lower urinary tract dysfunction. Hydronephrosis occurs in a small proportion of women with severe prolapse; however, even if identified, it usually does not change management in women for whom surgical repair is planned. Therefore, routine imaging of the kidneys and ureters is not necessary.
If urinary incontinence is present, further diagnostic testing is indicated to determine the cause of the incontinence. Urodynamic (simple or complex), endoscopic, or radiologic assessments of filling and voiding function are generally indicated only when symptoms of incontinence or voiding dysfunction are present. Even if no urologic symptoms are noted, voiding function should be assessed to evaluate for completeness of bladder emptying. This procedure usually involves a timed, measured void, followed by urethral catheterization or bladder ultrasound to measure postvoid residual urine volume.
In women with severe prolapse, it is important to check urethral function after the prolapse is repositioned. Women with severe prolapse may be paradoxically continent because of urethral kinking; when the prolapse is reduced, urethral dysfunction may be unmasked with occurrence of incontinence (occult stress incontinence). A pessary, vaginal retractor, or vaginal packing can be used to reduce the prolapse before office bladder filling or electronic urodynamic testing. If urinary leaking occurs with coughing or Valsalva maneuvers after reduction of the prolapse, the urethral sphincter may be incompetent, even if the patient is normally continent. This is reported to occur in 17% to 69% of women with stage III or IV prolapse. In this situation, the surgeon should choose an anti-incontinence procedure in conjunction with anterior vaginal prolapse repair. If stress incontinence is not present even after reduction of the prolapse, an anti-incontinence procedure probably is not indicated, although this is a subject of ongoing research.
Surgical Repair Techniques
Anterior Colporrhaphy
The objective of anterior colporrhaphy is to plicate the layers of vaginal muscularis and adventitia overlying the bladder (“pubocervical fascia”) or to plicate and reattach the paravaginal tissue in such a way as to reduce the protrusion of the bladder and vagina. Modifications of the technique depend on how lateral the dissection is carried, where the plicating sutures are placed, and whether additional layers (natural or synthetic grafts) are placed in the anterior vagina for extra support.
The operative procedure begins with the patient supine, with the legs elevated and abducted and the buttocks placed just past the edge of the operating table. Antibiotics should be given within 60 min of incision to achieve minimal inhibitory concentrations in the skin and tissues by the time the incision is made. This typically means a first-generation cephalosporin (cefazolin) or combination regimens (500 mg metronidazole and 400 mg ciprofloxacin) if the patient has an allergy to penicillin ( ). In general, all patients undergoing apical prolapse surgery are at moderate risk for thromboembolic events and require a prevention strategy ( ). Low-dose unfractionated heparin (5000 units every 12 h) or low-molecular weight heparins (e.g., 40 mg enoxaparin or 2500 units of dalteparin), an intermittent pneumatic compression device, or a combination of these are recommended. Either form of heparin should be started 2 h before surgery and the compression stockings should be placed on the patient in the operating room before incision. These treatment approaches should be continued until the patient is ambulatory.
The abdomen, vagina, and perineum are prepped sterilely and draped, and a 16-Fr Foley catheter with a 10-mL balloon is inserted for easy identification of the bladder neck. A weighted speculum is placed into the vagina. Hemostatic solution (such as 0.5% lidocaine with 1:200,000 epinephrine) or saline may be injected below the epithelium along the midline of the anterior vaginal wall to decrease bleeding and to aid in dissection. If a vaginal hysterectomy has been performed, the incised apex of the anterior vaginal wall is grasped transversely with two Allis clamps and elevated. Otherwise, a transverse or diamond-shaped incision is made in the vaginal epithelium near the apex. A third Allis clamp is placed about 2 cm below the posterior margin of the urethral meatus and pulled up. If a midurethral sling is to be done, then the incision is made to the bladder neck only. Additional Allis clamps may be placed in the midline between the urethra and apex. A scalpel is used to open the anterior wall in the midline ( Fig. 23.4 A ). Alternatively, the points of a pair of curved Mayo scissors are inserted between the vaginal epithelium and the vaginal muscularis, or between the layers of the vaginal muscularis, and gently forced upward while being kept half open/half closed ( Fig. 23.4 B ). Countertraction during this maneuver is important to minimize the likelihood of perforation of the bladder. The vagina is incised in the midline, and the incision is continued to the level of the mid urethra (or bladder neck, if a sling is being done). As the vagina is incised, the edges are grasped with Allis or T-clamps and drawn laterally for further mobilization. Dissection of the vaginal flaps is then accomplished by turning the clamps back across the forefinger and incising the vaginal muscularis with a scalpel or Metzenbaum scissors, as shown in Figure 23.4 C . An assistant maintains constant traction medially on the remaining vaginal muscularis and underlying vesicovaginal adventitia. This procedure is performed bilaterally until the entire extent of the anterior vaginal prolapse has been dissected; in general, the dissection should be carried farther laterally with more advanced prolapse. The spaces lateral to the urethrovesical junction are sharply dissected toward the ischiopubic rami. It is also important to use sharp dissection to mobilize the bladder base from the vaginal apex, if necessary.
Some surgeons routinely perform a bladder neck plication (Kelly-Kennedy plication) at the time of anterior colporrhaphy, particularly when a concurrent midurethral sling is not planned. Vesical neck plication was used to treat mild stress urinary incontinence in the past, but it is no longer done for that indication. It may, however, help to prevent the later development of stress incontinence in the patient. After the vaginal flaps have been completely developed, the urethrovesical junction can be identified visually or by pulling the Foley catheter downward until the bulb obstructs the vesical neck. Repair should begin at the urethrovesical junction, using No. 2-0 or 0 delayed absorbable sutures. The first plicating stitch is placed into the periurethral endopelvic fascia and tied ( Fig. 23.5 A ). One or two additional stitches are placed to support the length of the urethra and urethrovesical junction.
In a standard anterior colporrhaphy, stitches using No. 2-0 or 0 delayed absorbable sutures are placed in the vaginal tissue (muscularis and adventitia) medial to the vaginal flaps and plicated in the midline without excessive tension. Depending on the severity of the prolapse, one or two rows of plication sutures or a purse-string suture followed by plication sutures are placed ( Fig. 23.4 E – G ). Excess vaginal epithelium is then trimmed from the flaps bilaterally, and the remaining anterior vaginal wall is closed with a running No. 2-0 subcuticular or locking suture ( Fig. 23.4 H ).
Anti-incontinence operations are often performed at the same time as anterior vaginal prolapse repair to treat coexisting stress incontinence; suburethral bladder neck sling placement may also improve the cure rate of the prolapse. Bladder neck suspension procedures (sling procedures or retropubic colposuspension) treat effectively mild anterior vaginal prolapse associated with urethral hypermobility and stress incontinence. More advanced anterior vaginal prolapse will not be treated adequately and, in these cases, anterior colporrhaphy or anterior vaginal mesh repair should be performed, often in conjunction with a colpopexy procedure and a midurethral sling. Surgical judgment is required to perform the bladder plication tightly enough to reduce the anterior vaginal prolapse sufficiently, yet preserve some mobility of the anterior vagina. If anterior colporrhaphy is combined with a sling procedure (midurethral or bladder neck), the cystocele should be repaired before the final tension is set for the sling. A midurethral sling, such as a tension-free vaginal tape or transobturator sling, is best done through a separate midurethral incision after the cystocele repair is complete.
Anterior Prolapse Repair with Grafts
A prosthetic material can be used to provide support in the anterior vagina. This can be done in a number of ways, and the surgical techniques continue to evolve. Graft materials may include synthetic absorbable grafts (e.g., polyglactin 910 mesh), synthetic permanent meshes (e.g., polypropylene), and biologic materials. Biologic materials that have been used include autografts of harvested rectus fascia and fascia lata; human allografts including fascia lata and dura mater; and xenografts such as porcine dermis, porcine small intestinal submucosa, and bovine pericardium. In 2010, approximately 25% of surgeries for pelvic organ prolapse in the United States included transvaginal placement of biologic or synthetic mesh. Many surgeons use transvaginal graft placement in an attempt increase the efficacy and durability of their surgical repair. For anterior prolapse, studies have demonstrated improved anatomic outcomes after transvaginal placement of permanent synthetic mesh compared with anterior colporrhaphy without mesh (“native-tissue repair”). However, this comes at the expense of an increased rate of complications unique to synthetic mesh placement, including vaginal mesh exposure or extrusion, mesh erosion or perforation into an adjacent organ (bladder, urethra, or rectum), and vaginal mesh contraction with associated pain and dyspareunia. Concerns about increased adverse events from transvaginal mesh placement led to two separate U.S. Food and Drug Administration (FDA) notifications. In October 2008, the FDA issued a Public Health Notification (PHN) to inform clinicians and patients of adverse events related to urogynecologic use of surgical mesh and to provide recommendations on how to mitigate risks and counsel patients. In July 2011, the FDA provided an updated PHN on urogynecologic surgical mesh and reported that the complications of mesh used transvaginally are not rare.
When considering the use of transvaginal mesh for anterior prolapse, surgeons and patients must balance improved anatomic support of the anterior vaginal wall against the cost of the devices and increased complications such as mesh erosion, exposure, or extrusion; pelvic pain; groin pain; and dyspareunia. In a joint Committee Opinion published in December 2011, the American Urogynecologic Society and the American College of Obstetrics and Gynecology recommended that pelvic organ prolapse vaginal mesh repair should be reserved for high-risk individuals in whom the benefit of mesh placement may justify the risk, such as individuals with recurrent anterior prolapse or with medical comorbidities that preclude more invasive and lengthier open and endoscopic procedures. They also noted that surgeons placing vaginal mesh should undergo training specific to each device and have experience with reconstructive surgical procedures and a thorough understanding of pelvic anatomy.
Before considering treating anterior vaginal prolapse with graft or mesh, patients should undergo a thorough informed consent process, including discussion of risks, benefits, and both surgical and nonsurgical alternative treatments. There are several situations when mesh use is contraindicated. Many surgeons would not consider the use of mesh in a patient who has had a previous mesh complication. Mesh augmentations should not be used in pregnant women or women who are contemplating future pregnancy, because the mesh does not stretch significantly. In patients who have had pelvic radiation, mesh placement is not recommended because of the risk of poor wound healing. Similarly, preexisting local or systemic infection is a contraindication for vaginal mesh placement, particularly nonabsorbable synthetic mesh. Many surgeons would not recommend the use of nonabsorbable synthetic mesh if colorectal surgery is being performed concurrently. Chronic steroid use, smoking, uncontrolled diabetes mellitus, or other causes of a compromised immune system can impair wound healing, and many would consider these conditions to be relative contraindications to vaginal mesh placement. Pelvic pain syndromes such as endometriosis, vulvodynia, interstitial cystitis, fibromyalgia, and dyspareunia should be evaluated preoperatively to allow for comprehensive counseling regarding the best surgical and nonsurgical form of treatment.
Currently, there are three general categories of transvaginal mesh or graft placement options for the management of anterior vaginal prolapse: (1) self-tailored mesh, (2) commercially available trocar-guided mesh kits that use a transobturator approach, and (3) commercially available mesh kits that use a transvaginal fixation method rather than a trocar (nontrocar kits). Regardless of the placement option used, the general surgical approach to treat anterior vaginal wall prolapse is fixation of mesh to the ATFP or the coccygeus muscle. The initial incision for anterior vaginal mesh placement involves significant hydrodissection and a deeper colpotomy incision than is usually performed for a traditional native-tissue anterior colporrhaphy so that the perivesical space is entered. The mesh is spread laterally toward the ATFP proximally and distally and, in many of the newer nontrocar kits, attached apically to the sacrospinous ligament. Despite the lack of evidence that any one placement technique is best in managing a patient’s symptoms, most experts would agree on some basic perioperative tenets:
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The bladder should be drained with a transurethral catheter.
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A well-estrogenized vaginal wall is preferred before surgery. (We use intravaginal estrogen cream daily (0.5-1.0 g/day) for 2-3 weeks preoperatively.) A vaginal pessary should be removed 1 to 2 weeks before surgery to limit vaginal epithelium irritation.
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All patients require perioperative prophylactic antibiotics and efforts to prevent venous thromboembolic events, as noted earlier.
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Avoid making inverted “T-shaped” incisions from a concurrent hysterectomy and colporrhaphy, if possible.
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Exposure of the correct vesicovaginal space is performed with hydrodissection of 20 to 80 mL of 0.5% lidocaine with 1:200,000 epinephrine, dilute pitressin (20 U in 60-100 mL saline) or normal saline. The correct space for dissection is found using a “loss-of-resistance” technique similar to that used by an anesthesiologist placing an epidural. A wheal or blanching illustrates incorrect intraepithelial placement of the fluid. Hydrodissection in the correct plane will create a fluid bubble in the avascular vesicovaginal and rectovaginal spaces.
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As opposed to an anterior colporrhaphy, in which the vaginal epithelium and muscularis are split for plication, mesh should be placed underneath the vaginal muscularis. It is vital that the surgeon perform a full-thickness dissection deep into the vesicovaginal and rectovaginal spaces to avoid erosion of the mesh postoperatively. Proper hydrodissection, as described earlier, facilitates the identification of the proper dissection plane.
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It is unknown whether the bladder wall should be plicated in the midline below the graft.
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Place the graft loosely because mesh can contract by up to 20% after placement, compromising vaginal length and caliber. Allow enough room for Mayo scissors to be placed easily between the mesh and the vagina. Also, ensuring that the mesh is placed flat and has minimal tension will improve fibroblast growth and will minimize complications of pain or erosion.
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The vaginal epithelium should not be trimmed. Trimming the vaginal epithelium can lead to discomfort and may also contract. The colpotomy incision is closed using a nonlocking continuous absorbable suture.
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Cystourethroscopy with intravenous indigo carmine dye should be performed routinely after anterior mesh placement to identify potential urethral, bladder, or ureteral injury.
Self-tailored Mesh Placement
Self-tailored mesh can be customized by the surgeon to match the size and shape of each patient’s individual pelvic anatomy. Mesh is cut into a trapezoid multiarm shape for compartment augmentation and is fixed to the sacrospinous ligaments, obturator fascia, ATFP, and/or the distal bladder neck ( Fig. 23.6 ). This type of surgery requires a strong set of vaginal surgical skills because it involves dissections similar to sacrospinous ligament fixation, iliococcygeus suspension, uterosacral suspension, and vaginal paravaginal defect repair. No studies have compared standard repair techniques using self-tailored mesh with other mesh placement techniques.
