Types of pelvic organ prolapse: rectocele, cystocele and others
In pelvic organ prolapse, a pelvic organ descends into the vagina because its supports have weakened, and each type takes its name from the organ that descends.
Remember
The organ that descends gives the prolapse its name: bladder and urethra at the front, uterus in the middle, and rectum or bowel at the back.
Pelvic organ prolapse happens when the supports of the pelvic organs (the pelvic floor muscles, ligaments and connective tissue) have weakened, so that an organ sags into the vagina. The name of each type tells you which organ descends, and the ending -cele means a bulge.
The types are grouped by where they appear in the vagina. In an anterior (front) prolapse, the bladder descends into the vagina in a cystocele, and the urethra collapses in a urethrocele. The bladder and urethra can both be involved, which is called a cystourethrocele.
A central prolapse involves the uterus itself. After a hysterectomy (removal of the uterus), the top of the vagina can fall instead, which is called a vault prolapse.
A posterior (back) prolapse can involve a rectocele, in which the rectum, which lies behind the vagina, bulges forwards into the posterior vaginal wall, or an enterocele, a sac of peritoneum (the lining of the abdominal cavity) holding bowel, typically small bowel, that bulges against the upper vagina.
Women often notice a dragging or bulging feeling in the vagina. A front-wall prolapse may bring urinary symptoms, whereas a rectocele may make bowel emptying difficult, and some women use their fingers to press on the back wall, which is called splinting, so that stool can pass.
Key facts
- Cystocele
- the bladder bulges into the vagina because the anterior (front) vaginal wall has weakened.
- Urethrocele
- collapse of the urethra into the front wall of the vagina, which often occurs with a cystocele.
- Rectocele
- the rectum bulges forwards into the posterior (back) vaginal wall, and it may make bowel emptying difficult.
- Enterocele
- a peritoneal sac holding bowel, typically small bowel, descends between the rectum and the vagina and bulges against the upper vagina, and it is also a posterior prolapse.
- Central types
- a uterine prolapse is descent of the uterus, and a vault prolapse is the top of the vagina falling after a hysterectomy.
- Risk factors
- older age, parity (having given birth: more children means a higher risk), the number of vaginal births, oestrogen deficiency (usually seen during the menopause) and chronically increased abdominal pressure, for example from obesity.
Exam traps
- An enterocele is also a posterior prolapse, but it holds bowel in a peritoneal sac rather than the rectum, so the rectum bulging into the back wall of the vagina is a rectocele.
- A urethrocele also belongs to the anterior group, but it is descent of the urethra, so the bladder bulging into the vagina is a cystocele.
- A vault prolapse is descent of the top of the vagina after a hysterectomy, so descent of the uterus while it is still in place is a uterine prolapse instead.
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