Prolapse of the rectovaginal pouch or enterocele sometimes follows vaginal hysterectomy or the Manchester operation for prolapse and may occur either because the operator has failed to recognize and remove a pre-existing pouch or because he has failed to close the gap between the uterosacral ligaments,
Morbid anatomy Most of the anatomical changes in prolapse have already been described, but other secondary changes may now be mentioned.
The vaginal epithelium becomes stretched and increased in area, and if it is exposed it soon becomes thickened, and sometimes dry and ulcerated. Ulceration may also arise from a neglected ring pessary .
In cases with gross prolapse of the vaginal walls, the drag of these structures on the cervix leads to elongation of the supravaginal cervix and to oedema and enlargement of the vaginal portion. If the cervix is exposed, it may become ulcerated, and secondary infection gives rise to muco- purulent or blood-stained discharge.
If there is a large cystocele, the bladder often empties incompletely and cystitis from bacterial infection is a common sequel. In cases with uterine descent the ureters are carried downwards with the cardinal ligaments, but are not usually obstructed.
Symptoms
Local discomfort results from the prolapsed part bulging into the vagina and eventually protruding through the vaginal opening, with drag on the supporting structures. The sensation of prolapse is increased on coughing, standing or exertion. It is relieved when the patient lies down.
Backache sometimes accompanies the local discomfort, and similarly is worse on standing and relieved when the patient lies down. However, in the majority of patients with prolapse any backache will be found to have some other cause, and it is important to consider this possibility before promising patients that treatment of the prolapse will cure the backache.
Urinary symptoms. Frequency of micturition is almost invariable in patients who have a cystocele. Incomplete emptying of the bladder pre- disposes to urinary infection, causing dysuria. In procidentia the patient sometimes has to push up the prolapse before she can empty the bladder.
Stress incontinence is often associated with prolapse. In this condition the patient involuntarily passes a small quantity of urine whenever she coughs or strains. Strictly speaking, this is a separate lesion, for it can occur in the absence of any prolapse -and severe prolapse can occur without stress incontinence. Stress incontinence needs to be differentiated from urge incontinence caused by excessive detrusor tone (see p. 334).
Bowel symptoms. With a rectocele there may be difficulty in emptying the bowel. As the patient strains, the rectocele bulges into the vagina, preventing normal evacuation of the faeces through the anus unless she pushes the rectocele back with her frogers.
Ulceration and bleeding. In procidentia, exposed cervical and vaginal
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