Treatment of Left Vaginal Wall Protrusion
For a patient with left vaginal wall protrusion (lateral cystocele), begin with conservative management including pelvic floor physical therapy and pessary fitting as first-line therapy, reserving surgery for symptomatic stage 2 or greater prolapse that fails conservative measures. 1
Initial Clinical Evaluation
The diagnosis is primarily clinical and requires systematic physical examination to determine:
- Which vaginal compartment is involved - left lateral vaginal wall protrusion typically represents anterior compartment prolapse (cystocele) with lateral defect 2, 3
- Extent of prolapse - assess whether the bulge extends beyond the hymen (stage 2 or greater) 1
- Associated symptoms - pelvic pressure, vaginal bulge sensation, urinary dysfunction, bowel symptoms, or sexual dysfunction 3, 4
- Involvement of other compartments - examine for apical and posterior compartment prolapse, as multi-compartment involvement is common 5
Physical examination should include:
- External genital assessment for lesions, trauma, or infection 2
- Speculum examination to visualize each vaginal wall compartment separately 2
- Assessment of levator muscle integrity, as defects predict surgical recurrence 6
Imaging Considerations
Imaging is NOT routinely needed for diagnosis but should be considered when: 2, 6
- Clinical examination is difficult or inadequate
- Symptoms persist after treatment
- Occult multi-compartment prolapse is suspected
If imaging is indicated, the preferred modality is transperineal ultrasound (TPUS) because it:
- Provides non-invasive anatomic and functional evaluation 6
- Detects levator muscle avulsion, which predicts recurrence after surgical repair 7, 6
- Shows significant correlation with physical examination for anterior compartment prolapse 6
- Is less expensive than MRI 6
MR defecography is reserved for: 7, 6
- Comprehensive multi-compartment evaluation when multiple compartments are suspected
- Detection of enteroceles, where it demonstrates superior diagnostic capability 7
- Cases requiring detailed assessment of pelvic floor muscles and fascia 7
Treatment Algorithm
First-Line Conservative Management (All Symptomatic Patients)
Pelvic floor muscle training and pessaries are recommended as initial therapy and can be offered in combination: 1
- Pelvic floor physical therapy - strengthens levator muscles and improves support 1
- Pessary fitting - can successfully manage symptoms in most patients who prefer non-surgical treatment 4, 1
- Modification of risk factors - address obesity, chronic constipation, heavy lifting 1
Observation (Asymptomatic Patients)
Patients with asymptomatic prolapse should be reassured that observation is appropriate, though gradual progression may occur over time 3, 4
Surgical Intervention
Surgery should be offered when: 1
- Conservative options fail to meet patient expectations
- Symptoms are disabling and related to prolapse
- Prolapse is stage 2 or greater on examination
- Patient desires definitive treatment
Surgical approach selection for anterior/lateral vaginal wall prolapse:
- Laparoscopic/robotic sacrocolpopexy with mesh - recommended for anterior and apical prolapse, offers superior durability 1
- Transvaginal repair with autologous tissue - recommended option for elderly and fragile patients 1
- Choice depends on: compartments involved, extent of prolapse, medical comorbidities, differences in durability and risk between operations, and shared decision-making 3, 4
Critical Clinical Pitfalls
Avoid these common errors:
- Failing to assess all compartments - lateral vaginal wall defects often coexist with apical or posterior prolapse 5
- Performing surgery without adequate conservative trial - pessaries and physical therapy should be attempted first unless patient strongly prefers surgery 1
- Not documenting preoperative prolapse assessment - record all compartments and degree of prolapse before surgical planning 5
- Overlooking levator muscle defects - these predict surgical recurrence and should influence surgical planning 7, 6
Post-Treatment Follow-Up
After surgical repair, patients require: 1
- Reassessment by surgeon even without symptoms or complications
- Long-term follow-up by primary care or specialist physician
- Monitoring for recurrence, particularly in presence of levator defects 7