6.2 Structural Disorders

Cystocele, Rectocele, and Uterine Prolapse

A cystocele occurs when the bladder bulges into the anterior wall of the vagina. Signs may include vaginal pressure or a feeling of fullness. The patient may experience lower back pain and decreased sexual satisfaction. Urinary dysfunction in the form of the need to urinate often and urgently may be present in varying degrees. The patient may also have trouble emptying the bladder completely. All of these conditions may lead to frequent urinary tract infections.

A rectocele occurs when the rectum bulges into the posterior wall of the vagina. Signs are similar to those of a cystocele. Signs may include vaginal pressure, a feeling of fullness, the feeling that something is falling down or out of the pelvis. Lower back pain, decreased sexual satisfaction or pain, constipation, trouble with stool becoming trapped in the rectocele, and urinary and bowel dysfunction may also be present in varying degrees.

When the pelvic floor weakens, it can no longer support the uterus, and the uterus descends into the vagina, a condition called uterine prolapse. Symptoms of uterine prolapse include urinary incontinence, feeling of fullness in the vagina, bulging of the vagina, constipation, and back pain. The symptoms of cystocele, rectocele, and uterine prolapse are all caused by pelvic floor relaxation.

Diagnosis and Treatment of Cystocele, Rectocele, and Uterine Prolapse

Diagnosis of these conditions is based on a physical examination and review of symptoms from the patient. The first step is to rule out any infectious process. Once it has been determined that the problem is functional, the provider will assess the impact the condition has on the patient’s emotional, physical, and social life. One method of assessment is administering a pelvic floor questionnaire. Pelvic floor questionnaires evaluate feelings of pressure, bulging, difficulty in passing stool, incontinence of urine or stool, and pain. These self-scoring tools assist the provider in understanding the goals of the patient and can help to guide the treatment. Diagnostic testing, such as cystoscopy, urodynamics, and colonoscopy, can also assist in diagnosing severity of the issue.

Medical management of cystocele, rectocele, and uterine prolapse has many similarities. Surgical intervention can be performed to reconstruct or reinforce the bladder or rectum or to remove the uterus. Management of modifiable risk factors is an important adjunct to any other therapy for pelvic floor disorders. Other potential treatments include pelvic floor strengthening exercises, bladder training, hormone replacement therapy, wearing a pessary, or surgical repair.

Pelvic floor therapy can be accomplished at home with proper instruction by the health-care provider and has been shown to improve the quality of a patient’s life (Torres-Lacomba et al., 2022). In some cases, patients may find it useful to work with a pelvic floor therapist. Pelvic floor strengthening has been shown to improve symptoms for many people (Basnet, 2021).

Hormone replacement therapy (HRT) is another potential treatment that may contribute to increased muscle tone, vaginal elasticity, and integrity. Replacing these hormones can increase blood flow to the vagina and other pelvic structures, adding to tissue integrity and strength.

A pessary is a device worn inside the vagina to provide support to the pelvic floor muscles and organs. Pessaries (Figure 6.5) are made of medical-grade silicone and come in many different sizes and shapes. It is not uncommon for a patient to be fitted for multiple sizes and shapes of pessaries before finding the most comfortable and effective fit.

Figure 6.5 Vaginal Pessaries Pessaries come in a range of shapes and sizes. (credit: “Pessaries” by “Huckfinne”/Wikimedia Commons, Public Domain)

Fistulas

A fistula is an abnormal connection between two surfaces in the body that are not meant to be connected. A vaginal fistula is one type of fistula that is an opening from the vagina to another anatomical structure. A rectovaginal fistula is an opening from the rectum to the vagina, a vesicovaginal fistula is an opening between the bladder and the vagina, and a urethrovaginal fistula is an opening between the urethra and the vagina. Signs of these conditions can include leaking of urine or stool from the vagina, frequent urinary and vaginal infections, and a foul odor. Very small fistulas may heal on their own, but most will require surgical intervention. Figure 6.6 shows the common areas where fistulas form.

Figure 6.6 Common Sites of Fistulas Fistulas (abnormal openings) commonly occur between the vagina and bladder and between the vagina and rectum. Pressure from the fetus can cause soft tissues to become ischemic and cause tissue breakdown and malfunction, leading to fistula formation. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

The most common reason for fistula formation is obstetric trauma. This can happen because of the pressure applied to the bladder and pelvic floor muscles during childbirth, causing an opening to form. Fistulas can also result from episiotomy or laceration repairs that transcend two structures, such as the vagina and rectum. These complications are more prevalent in low-resource countries where nutrition is poor, labor or pushing is allowed to continue for extended periods, or cesarean birth is not readily available. Operative vaginal deliveries (the use of vacuum or forceps) can increase the risk of this complication. Other potential causes are congenital malformations, a gynecologic surgical complication, or the practice of female genital mutilation (FGM) (United Nations Population Fund, 2022a).

Female genital mutilation is the nonmedical partial or total removal of external female genitalia (United Nations Population Fund, 2022a). This cultural practice is routinely performed in communities around the world. This practice is not promoted or endorsed by any religious group and is recognized as a human rights violation internationally. (United Nations Population Fund, 2022b). It is important that nurses caring for persons assigned female at birth be aware of these practices and the lasting physical and emotional complications that accompany them.

Uterine Malformations

A congenital malformation that includes changes to the shape of the uterus is a uterine malformation (American Society of Reproductive Medicine, 2012). Examples of these malformations are shown in Figure 4.14. Some of the different shapes include a didelphys shape, which includes two separate cavities and two cervixes, and a bicornuate uterus, which is two separate cavities with one cervix. A unicornuate shape is defined as a single horn to the uterus. Other uterine shapes include arcuate or concave (instead of straight) and a septate uterus with a septum that separates the two cavities.

These variations of the uterine shape may lead to symptoms such as painful periods, miscarriages, and preterm birth. Some of these conditions can be corrected with surgical intervention. In other situations, such as with an arcuate shape, conception and pregnancy may not be affected, and the shape is considered a variation of normal (Garcia, 2023).

Vaginal Malformations

Vaginal malformations include a septum forming in the vagina. Variations on this malformation are shown in Figure 6.7. This condition is usually not discovered until the patient becomes sexually active and experiences pain with an attempt at vaginal penetration. Patients with vaginal malformations may also have uterine and bladder malformations because these organs develop during the same time frame in utero. A comprehensive evaluation should be completed by a urogynecologist. Painful menstruation may be present if the septum prevents blood from leaving the body. A simple surgical procedure to remove the septum can be done to relieve the symptoms.

Figure 6.7 Vaginal Septum Variations Patients with vaginal malformations may also have uterine and bladder malformations. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)