Uterine prolapse is generally the result of poor cardinal or uterosacral ligament apical support, which allows downward protrusion of the cervix and uterus toward the introitus.
Procidentia, which involves prolapse of the uterus and vagina, and total vaginal vault prolapse, which can occur after hysterectomy, represent eversion of the entire vagina (Fig. 27.5).
Figure 27.1 A sagittal view of the female pelvis with bladder and uterus removed (ureters, trigone, and cervix intact) illustrating anterior and posterior vaginal fibromuscular planes, their endopelvic fascial attachments, and a functional pelvic ﬂoor. (Redrawn by J. Taylor from Skandalakis JE, ed. Hernia: surgical anatomy and technique. New York: McGraw-Hill: 244–250.)
These descriptive terms are somewhat inaccurate and misleading, focusing on the bladder, rectum, small bowel, or uterus rather than the specific defects responsible for the alterations in vaginal support. Specific defect support issues will be discussed in the setting of the surgical management section.
Pelvic support structures include: 1.
The muscles and connective tissue of the pelvic ﬂoor 2.
The fibromuscular tissue of the vaginal wall 3.
The endopelvic connective tissue
Figure 27.2 A: Sagittal section of the pelvis showing normal anatomy. B: Cystocele and rectocele.
Figure 27.3 A: Posterior enterocele without eversion. B: Enterocele with eversion.
Figure 27.4 Uterine prolapse with apical detachment from the uterosacral ligament complex and lateral wall detachment from the endopelvic connective tissue.
Figure 27.5 Procidentia of the uterus and vagina.
Endopelvic connective tissue includes: 1.
The cardinal/uterosacral complex, which attaches the upper vagina and cervix posteriorly 2.
Lateral connective tissue attachments of the anterior vaginal wall to the arcus tendineus pelvis and of the posterior vaginal wall to the fascia of the levator ani and to the posterior arcus tendineus near the ischial spine 3.
Less dense areolar connective tissue surrounding retroperineal portion of the pelvic organs
The orientation of these structures is noted in Figure 27.1. In general, an intact pelvic ﬂoor, including a functional puborectalis muscle and an intact cardinal/uterosacral complex, should prevent pelvic organ prolapse by allowing posterior deﬂection of the rectum and vagina and compression of these structures against the pelvic ﬂoor in the upright position (Fig. 27.6). The fibromuscular layer of the vaginal wall and the other endopelvic connective tissue attachments augment the support structure and are particularly important when pelvic ﬂoor function is compromised.
Apical Compartment Normal apical support includes the integrity of the cardinal/uterosacral ligaments, the upper paravaginal fibromuscular connective tissue, and, when the uterus is present, the paracervical fascia. The fibromuscular tissue of the upper vagina blends in with the paracervical fascia. Both of these are attached laterally and posterior laterally to the cardinal ligaments and uterosacral ligaments (Fig. 27.1). The vaginal fibromuscular tissue is also