Pelvic floor tissue relaxation often leads to prolapse of the uterus as well as bulging of the vaginal wall. Injury to the pubovesical cervical ligament and surrounding muscle fibers can cause bulging of the anterior vaginal wall, and the adjacent organs, losing their support, often bulge along with it, known as cystocele. Damage to the rectovaginal fascia and pubococcygeus muscle can result in the rectum losing support and prolapsing along with the posterior vaginal wall, referred to as rectocele. Severe injury to the posterior part of the pubococcygeus muscle can lead to the formation of a posterior fornix hernia, where the intestine bulges through the herniated area, known as enterocele. Bulging of the anterior vaginal wall (cystocele).

bubble_chart Diagnosis

1. Mild cases may be asymptomatic or present with a sensation of something protruding from the genital area, while severe cases may involve a feeling of heaviness, with the prolapse enlarging during exertion or straining. Gradually, difficulty in urination may develop, accompanied by a sensation of incomplete voiding; in extreme cases, urine may not be passed at all, and increased straining worsens the inability to void, necessitating manual reduction of the prolapse into the vagina to allow urination. The latter occurs because when the bladder prolapses, the angle between the bladder and urethra affects urine excretion. Increased abdominal pressure exacerbates the prolapse, creating an acute angle between the bladder and urethra, further obstructing urine flow. If urinary retention occurs, it often leads to secondary bladder inflammation. Injury to the pubourethral ligament can cause urethral prolapse, potentially resulting in stress urinary incontinence. Grade III anterior vaginal wall prolapse is often accompanied by first-degree uterine prolapse.
2. During physical examination, the patient should refrain from voiding initially. The anterior vaginal wall may appear as a spherical bulge toward the vaginal opening, soft on palpation with indistinct borders. Inserting a metal catheter through the urethral orifice may reach the prolapsed mass, and after urine drainage, the mass shrinks. Based on the degree of anterior vaginal wall prolapse during straining, it is classified as mild, moderate, or severe. Grade I prolapse—the vaginal wall reaches the hymenal ring but has not yet protruded outside the vagina. Grade II prolapse—part of the vaginal wall has protruded outside the vagina. Grade III prolapse—the entire vaginal wall has prolapsed outside the vagina. Vaginal wall prolapse and uterine prolapse often coexist, but their severity may not fully correlate; sometimes the former is very pronounced while the latter is minimal. To check for stress urinary incontinence: ask the patient to cough or strain downward and observe for urine leakage. If leakage occurs, the examiner can press upward on both sides of the urethra and bladder neck with the index and middle fingers; if no urine leaks when the patient increases abdominal pressure, this indicates stress urinary incontinence.

bubble_chart Treatment Measures

Refer to the treatment section of uterine prolapse.

bubble_chart Prevention

Perineal lacerations should be promptly sutured according to anatomical structures to prevent excessive weakening of pelvic floor support. During vaginal childbirth, perineal protection should be moderate. Sometimes the epithelial membrane remains intact, but the pelvic floor tissues may become overstretched and lax. For cases with a long perineal body, a large fetal head, or prolonged second stage of labor, timely episiotomy and assisted delivery should be performed. Ensure urination during labor to reduce bladder distension entering the second stage. Strengthen constitution and actively treat conditions like constipation and cough. Posterior vaginal wall prolapse (rectocele) occurs when childbirth overstretches and thins the closely interwoven fibers of the pubococcygeus muscle and pelvic floor tissues between the vaginal and rectal fascia, reducing their ability to support the rectum. This causes the posterior vaginal wall and mid-rectum to protrude forward. During childbirth, the levator ani muscles may split at the midline, leading to forward prolapse of the mid-rectum and vaginal wall, forming a rectocele. Posterior vaginal wall prolapse does not always accompany rectocele, but rectocele always presents as a bulging of the mid-posterior vaginal wall. The grading of posterior vaginal wall prolapse is similar to that of anterior vaginal wall prolapse. Grade III rectocele is often associated with grade III uterine prolapse.

bubble_chart Differentiation

Mainly differentiated from vaginal wall cysts.