Vaginal lumps- rapid differentials
Cystocele-Anterior vaginal prolapse- there is an underlying failure of the investing fascia and the bladder also descends -this is called cystocele or bladder prolapse
Severity of vaginal wall prolapse can be graded by the Baden-Walker system- based on level of protrusion Grade 0 No prolapse Grade 1 halfway to hymen Grade 2 to the hymen Grade 3 halfway past the hymen Grade 4 maximal possible
frequency and dysuria pelvic or vaginal fullness bulging upper front wall of vagina some times patient may find it impossible to urinate except by pushing up the cystocele with her finger.
diagnosis can be via examination – apply a single bladed speculum against the posterior vaginal wall while patients are in lithotomy position cystogram treatment ○ observe- mild prolapse ○ lifestyle changes e.g weight reduction , avoiding constipation ○ pelvic floor exercises ○ pessary ○ surgery
Urethrocele –Urethral prolapse is circumferential protrusion of the distal urethra through the external urethral meatus ( an uncommon condition ).Two variants Prepubertal Post menopausal Presentation would be different based on age.
Prepubertal urethral prolapse is generally asymptomatic Post menopausal prolapse often symptomatic with vaginal bleeding associated with voiding symptoms. Intravenous pyelograms and voiding cystourethrogramps Summarisation of treatment is difficult but is divided into ○ medical management ○ surgery
Rectocele –Prolapse of the rectum or large bowel into the posterior vaginal wall.Various classification schemes have been used for e.g Baden-Walker system Pelvic organ prolapse quantification ( POP-Q ) system ( see links and resources ).Constipation or difficulty emptying fully Patient may report that she has to reduce the herniation by putting a finger in her vagina before opening bowel Obstructive defecation due to accumulation of stool within the rectocele reservoir lead to ↑ ing degrees of perineal pressure.
lower posterior vaginal bulge examination of rectum should also be undertaken examination can be in lithotomy position or prone-jackknife or left lateral position Barium enema or MRI scan Anorectal physiologic tests Treatment ○ medical – optimise constipation ○ surgical- several approaches are employed e.g vaginal approach- posterior colporrhaphy.
Enterocele –When upper part of the posterior vaginal wall prolapses , the Pouch of Douglas becomes elongated and small bowel or omentum may descend- this is enterocele which is often accompanied with cystocele and rectocele.
Unlike other pelvic organ prolapses enterocele is a true herniation with a peritoneal sac containing small bowel or sigmoid colon Usually seen in elderly multiparous women.Pelvic discomfort – pelvic pain or pressure Obstructed defecation Bulging of upper posterior vaginal wall.Barium enema Dynamic MRI Dynamic transperineal ultrasound Surgical repair – follows general principles of hernia repair
Uterine prolapse –The uterus descends into the vagina , as vagina is typically involved – term uterovaginal prolapse is also used.Patients may present with varying degree of descent Procidentia – uterus protrudes through the genital hiatus Vault prolapse -post hysterectomy vaginal vault prolapse ( PHVP ) descent of the apex of vagina ( vaginal vault or cuff scar after hysterectomy ).
Normally a disorder of parous women – due to damage to the musculature , ligaments and nerves a dragging sensation as if something is coming down urinary symptoms , incontinence bowel problems. Pelvic floor exercises Pessary Surgery
Other causes–CYSTS – for e.g ○ Bartholins cysts ○ Endometriosis cysts ○ Gartners duct cysts ○ vaginal inclusion cysts Vaginal POLYPS Vaginal WARTS for eg HPV- usually on the outside Vaginal CANCER.
- BMJ Best Practice Uterine prolapse
- MSD Manual Professional version – Anterior and Posterior Vaginal Wall Prolapse
- Rectocele David E Beck MD & Nechol L Allen MD Clin Colon Rectal Surg 2010 Jun ; 23 (2) : 90-98
- Urethral Prolapse Treatment and Management Medscape Feb 2018
- Enterocele diagnosis and treatment D M J Oom et al Colrectal Research Group , Erasmus Medical Center, Rotterdam , Netherlands
- What to do about vaginal cysts sores and bumps via Medicalnewstoday.com
- Uterine prolapse Medscape Assessing and managing pelvic organ prolapse NICE 2019
LINKS AND RESOURCES
A useful page from National Institute of Diabetes and Digestive and Kidney Diseases on Cystocele https://www.niddk.nih.gov/health-information/urologic-diseases/cystocele-prolapsed-bladder#what
Another resource on Cystocele from Mayoclinic https://www.mayoclinic.org/diseases-conditions/cystocele/symptoms-causes/syc-20369452
A complete resource on Pelvic Organ Prolapse from RCOG – print and hand over after assessment ( 4 pages 2 sided printing ) https://www.rcog.org.uk/globalassets/documents/patients/patient-information-leaflets/gynaecology/pi-pelvic-organ-prolapse.pdf
Another wonderful resource on prolapse from Jeanhailes.org with further printable information https://jeanhailes.org.au/health-a-z/bladder-bowel/prolapse-bladder-weakness
Urology Care Foundation – American Urological Association on Cystocele https://www.urologyhealth.org/urologic-conditions/bladder-prolapse-(cystocele)
Rectocele from American Society of Colon and Rectal Surgeons https://www.fascrs.org/patients/disease-condition/rectocele-expanded-information
Uterine and Bladder prolapse info from Harvard Health Publishing https://www.health.harvard.edu/a_to_z/uterine-and-bladder-prolapse-a-to-z
Vaginal cancer information from The womens the royal womens hospital Vitoria Australia https://www.thewomens.org.au/health-information/womens-cancers-pre-cancers/vaginal-cancer
American Cancer Society on Vaginal cancer https://www.cancer.org/cancer/vaginal-cancer/detection-diagnosis-staging/signs-symptoms.html
British Society of Urogynaecology has produced a large collection of leaflets on topics related to prolapse , incontinence etc- an absolute treasure https://bsug.org.uk/pages/information-for-patients/111
INFORMATION FOR CLINICIANS
Mesh and tape complications – information for GPs from RCGP and RCOG https://elearning.rcgp.org.uk/pluginfile.php/108712/mod_page/content/30/Mesh%20Leaflet.pdf
Surgery for Uterine Prolapse– patient decision aid by NICE https://www.nice.org.uk/guidance/ng123/resources/surgery-for-uterine-prolapse-patient-decision-aid-pdf-6725286112
NICE : Urinary incontinence and pelvic organ prolapse in women management NG 123 April 2019 https://www.nice.org.uk/guidance/ng123
Gynaecological cancers by NICE USC guidance https://a4medicine.co.uk/gynaecological-cancers/#