Chapter 13: Posterior Vaginal Wall Prolapse

POSTERIOR WALL PROLAPSE

Posterior wall prolapse, bulging or herniation of the bowel along the dorsal aspect of the vagina, is a component of the constellation of pelvic floor disorders. Pelvic floor dysfunction, primarily involving pelvic organ prolapse, urinary and fecal incontinence, affects nearly one in four (23.7%) community-dwelling women.¹ As women age, prolapse and incontinence become more common. One-half of women aged 80 years and older have at least one pelvic floor disorder.¹

The elderly population is expected to grow significantly over the next 40 years. By 2050, those 65 years of age or older are projected to more than double, from 38.6 million to 88.5 million.² The population of people 85 years or older is expected to grow exponentially from 5.4 to 19 million and the majority of people in this category will be women.² Therefore, the demand for prevention and treatment of pelvic floor dysfunction will also grow dramatically.

Treatment for pelvic floor disorders varies from conservative measures to surgical management. The lifetime risk of undergoing surgery for pelvic organ prolapse or urinary incontinence is approximately 11%.^3,4 Currently, approximately 200,000 women undergo prolapse surgery in the United States each year.⁵ One-third to one-half of all the prolapse surgeries include posterior wall prolapse repair.^3,5 Understanding the anatomy, etiology, and treatment options for posterior wall prolapse is vital and will become increasingly important as our aging population multiplies.

DEFINITION

Prolapse of the posterior vaginal wall may be secondary to the presence of a rectocele, sigmoidocele, enterocele, or a combination of these entities (Figure 13-1A, B and C). This loss of support may be defined symptomatically, radiographically, or by physical examination.

To recognize and correct abnormal anatomy such as prolapse, you must understand normal anatomy. Support of the posterior vaginal wall is provided by a complex interaction of the integrity of the vaginal tube, the connective tissue support, and muscular support of the pelvic floor. John DeLancey divided the connective tissue support of the vagina into three levels.⁶ All three levels of support should be evaluated and addressed during the physical examination and in consideration of surgical management of the posterior vaginal wall.

At level I, the apical portion of the posterior vaginal wall is suspended and supported primarily by the cardinal-uterosacral ligaments.^7,8 This mesentery ...