eMedicine Specialties > Obstetrics and Gynecology > Prolapse and Incontinence
Relaxed Vaginal Outlet
Updated: Dec 22, 2008
Introduction
The current generation of women is maintaining a more active lifestyle into an older age, resulting in an increase in the number of women who seek treatment for prolapse conditions. An active lifestyle and improved quality of life can usually be preserved; however, this requires a thorough understanding of pelvic anatomy and pathophysiology and experience in selecting appropriate surgical procedures.
Problem
A relaxed vaginal outlet can be defined as a weakening of the tissues of the distal rectovaginal septum and perineal body. A relaxed outlet is almost always associated with some degree of weakening of the more proximal rectovaginal fascias, which may result in a rectocele. Common symptoms include difficulty with defecation and, possibly, difficulty with sexual function.
Frequency
In the United States, the exact incidence of relaxed vaginal outlet is unknown because not all patients are symptomatic; however, it is thought to be quite common.
Etiology
The main support for the pelvic viscera is provided by a group of muscles collectively called the levator ani. An intact pelvic floor allows the pelvic and abdominal viscera to "rest" on the levator ani, significantly reducing the tension on the supporting fascia and ligaments. These pelvic ligaments are not true ligaments and are simply condensations of endopelvic fascia covering the pelvic structures.
The pelvic floor musculature and the pelvic ligaments work together to provide support to the pelvic floor structures. Most of the weight of the pelvic viscera is supported by the levator ani, whereas the pelvic ligaments stabilize these structures in position, much as a ship's weight is supported by the water and the moorings simply keep the ship from straying from the dock. When the levator ani is damaged, excessive force is placed on the ligaments, creating a predisposition for pelvic prolapse.1
Pathophysiology
Conditions of vaginal prolapse, including urethral hypermobility, cystocele, rectocele, enterocele, perineal relaxation, and uterine prolapse, all result from weakness or damage to the normal pelvic support systems. Collectively, these conditions are called pelvic floor relaxation.2,3
The pathophysiology of this relaxation can often be linked to multiparity, advanced age, hormonal insufficiency, obesity, neurogenic dysfunction of the pelvic floor, connective tissue abnormalities, or strenuous physical activity. However, pelvic relaxation can occur in young, inactive, nulliparous patients; therefore, a single etiology can rarely be implicated.4,5,6
An association between collagen and connective tissue disorders and pelvic floor relaxation has been established.7 Some vaginal prolapse conditions may be caused by prior pelvic surgery.8 For example, a hysterectomy may cause an enterocele or vault prolapse to form if the vault is not adequately resuspended and the cul-de-sac is not prophylactically obliterated. A bladder neck suspension can alter the vaginal axis, predisposing the patient to enterocele formation.9
A rectocele is a prolapse of the rectum into the vagina through a damaged rectovaginal septum. The most likely etiology for rectocele formation and perineal relaxation presumably is childbirth because these conditions are essentially confined to parous women. In some cases, a relaxed outlet may be caused by an inadequately or incompletely healed episiotomy performed at the time of childbirth.10,11
The most important fascia within the rectovaginal septum is Denonvilliers fascia, which is fused to the inner layer of the posterior vaginal wall and is believed to be disrupted at the caudal and lateral attachments at the perineal body during childbirth.12,13 In some cases, enterocele and rectocele formation occur simultaneously, especially if the patient had a hysterectomy.14 Although a high rectocele may be distinguished from an enterocele only at the time of surgery, a rectocele often forms a pocket just proximal to the anal sphincter. This pocket can trap stool and cause the typical symptoms of straining or the need for digital manipulation to facilitate bowel movements.15
Perineal body relaxation, a separate and distinct entity from a rectocele, usually manifests as a wide vaginal opening and is usually repaired at the same time as a rectocele. Because the levator ani is attached at the perineal body, strengthening of the perineal body by perineorrhaphy tightens the levator plate, improving the overall degree of pelvic relaxation.4,5
Presentation
Relaxed outlet/pelvic prolapse is associated with many symptoms, some of which are nonspecific to the underlying pelvic pathology. It is imperative for the physician to try to determine which symptoms are specifically related to the prolapse condition through meticulous patient interviewing and physical examination. The goal of treatment is improvement, if not complete resolution of these symptoms.
The most common symptoms of a rectocele and relaxed outlet are constipation, which is nonspecific, and splinting, which is the need to place fingers on the posterior wall of the vagina to effectively empty the rectum and complete defecation. Although uncommon, other presenting symptoms may include perineal pain or sexual dysfunction. In general, the larger the rectocele, the more severe the symptoms; however, approximately 10% of symptomatic patients have small rectoceles. Conversely, dyspareunia has been reported after surgical repair in as many as 30% of cases; however, the incidence today is less than 10% because the older method of repair is seldom used.16,17
For excellent patient education resources, visit eMedicine's Kidneys and Urinary System Center. Also, see eMedicine's patient education article Prolapsed Bladder.
Indications
A weak perineal body and/or rectocele does not always require surgical repair unless the defect is significant or symptomatic. The potential for postoperative dyspareunia is rarely justified to repair a small asymptomatic rectocele or perineal body. Conversely, some investigators believe that not performing these repairs at the time of an incontinence procedure or hysterectomy may cause undue pressure on other areas of the pelvic floor, possibly necessitating additional surgery at a later date. This has not been the authors' experience, however.
Relevant Anatomy
The vagina can be anatomically divided into the proximal, middle, and distal regions. The proximal segment, called the vault or cuff, is stabilized by the parametrium, which includes the cardinal and uterosacral ligaments. Uterine and vault prolapse are both associated with damage to these supportive structures.1,3
The mid portion of the vagina is attached laterally to the pelvic sidewalls by the lower portion of the paracolpium to the arcus tendineus fascia pelvis (ATFP), which creates the superior lateral vaginal sulcus observed during a physical examination. The pubocervical fascia stretches between the ATFP to support the anterior vaginal wall and bladder. A cystocele can occur when damage to the pubocervical fascia in the central or lateral areas (or both) allows the bladder to prolapse into the vagina.3
In a similar fashion, the posterior vaginal wall in the mid vagina is supported centrally and laterally by the rectovaginal fascia, which is attached to the fascia of the levator ani musculature. These attachments prevent the rectum from prolapsing into the vagina and causing a rectocele. The distal vagina is firmly attached to the surrounding structures, including the urethra and symphysis pubis anteriorly, levator ani laterally, and perineal musculature posteriorly. Damage to the perineal musculature by childbirth or surgery are common causes of a relaxed outlet.
Contraindications
Although no absolute contraindications to performing these procedures exist, they are usually not performed unless the patient is symptomatic. In most cases, these procedures are performed in conjunction with other pelvic prolapse repairs.
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Further Reading
Keywords
relaxed vaginal outlet, relaxed perineum, perineoplasty, vaginal prolapse, pelvic prolapse, uterine prolapse, urethral hypermobility, cystocele, rectocele, enterocele, perineal relaxation, pelvic floor relaxation, perineorrhaphy
