Vaginal prolapse affecting bladder function.

When pelvic reconstructive surgery is being considered, it is important that the presence of cystocele be carefully and accurately assessed preoperatively and intraoperatively so that appropriate correction can be achieved. Continence is under the influence of urethral tone and the response of the proximal urethra to changes in intra-abdominal pressure. Cranial elevation of a rotated vesicourethral junction to a normal retropubic position should be provided. Any surgical technique that alters the normal axis of the vagina should be accompanied by simultaneous obliteration of the cul-de-sac of Douglas to lessen the chance of postoperative enterocele and subsequent eversion of the vault of the vagina. When massive vaginal eversion causes displacement of the vesicourethral junction, a restoration of vaginal depth and axis by posthysterectomy transvaginal sacrospinous colpopexy with appropriate colporrhaphy will relocate a defective urethrovesical site to a higher and retropubic level within the pelvis, where the proximal urethra may once again be responsive to changes in intra-abdominal pressure.