A cystocele is a structural problem of the genitourinary (GU) tract that occurs in women. The urinary bladder presses against a weakened anterior vaginal wall, thus causing the bladder to protrude into the vagina. The weakened vaginal wall is unable to support the weight of urine in the bladder, and this results in incomplete emptying of the bladder and cystitis.
A rectocele is a defect in the rectovaginal septum causing a protrusion of the rectum through the posterior vaginal wall. The rectum presses against a weakened posterior vaginal wall, thus causing the rectal wall to bulge into the vagina. The pressure against the weakened wall is intensified each time the woman strains to have a bowel movement; feces push up against the vaginal wall and intensify the protrusion. Frequently a rectocele is associated with an enterocele, a herniation of the intestine through the cul-de-sac.
The primary cause of cystoceles and rectoceles is a weakened vaginal wall. Factors that contribute to this loss of pelvic muscle tone are repeated pregnancies, especially those spaced close together, congenital weaknesses, and unrepaired childbirth lacerations. Obesity, advanced age, chronic cough, constipation, forceps deliveries, and occupations that involve much standing and lifting are also contributing factors. Lack of estrogen after menopause frequently aggravates the condition.
Nursing care plan assessment and physical examination
Patients with a cystocele often have a history of frequent and urgent urination, frequent urinary tract infections, difficulty emptying the bladder, and stress. Ask about the pattern and extent of incontinence: Does incontinence occur during times of stress, such as laughing and sneezing? Is it a constant, slow seepage? Is the amount such that the patient needs to use a peripad or adult diaper? Patients with a rectocele have a history of constipation, hemorrhoids, pressure sensations, low back pain, difficulty with intravaginal intercourse, and difficulty controlling and evacuating the bowel. Symptoms may be worse when standing and lifting and are relieved somewhat when lying down. Obstetric history often reveals a forceps delivery. Some report that they are able to facilitate a bowel movement by applying digital pressure along the posterior vaginal wall when defecating to prevent the rectocele from protruding.
Upon inspection, the bulging of the bladder and/or rectum may be visualized when the patient is asked to bear down. This bulge may also be palpated. In addition, inspect the patient for hemorrhoids and assess sphincter tone. Levator ani muscles are tested by inserting two fingers in the vagina and asking the patient to tighten or close the introitus.
Assess feelings regarding stress incontinence and the patient’s knowledge of the problem. Explore the effects on the patient’s social life, ability to travel, ability to meet occupational demands, and sexual function.
Nursing care plan primary nursing diagnosis: Altered urinary elimination.
Nursing care plan intervention and treatment plan
Mild symptoms of a cystocele may be relieved by Kegel exercises to strengthen the pelvic musculature. If the patient is postmenopausal, estrogen therapy may be initiated to prevent further atrophy of the vaginal wall. Sometimes, the bladder can be supported by use of a pessary, a device worn in the vagina that exerts pressure on the bladder neck area to support the bladder. Pessaries can cause vaginal irritation and ulceration and are better tolerated when the vaginal epithelium is well estrogenized. When the symptoms of cystoceles and rectoceles are severe, surgical intervention is indicated. For a cystocele, an anterior colporrhaphy (or anterior repair), which sutures the pubocervical fascia to support the bladder and urethra, is done. A posterior colporrhaphy (or posterior repair), which sutures the fascia and perineal muscles to support the perineum and rectum, is performed to correct a rectocele. A newer surgical technique for rectoceles involves the use of a dermal allograft to augment the defect repair.
Preoperative care specifically for posterior repairs includes giving laxatives and enemas to reduce bowel contents. If the new allograft technique is used, postmenopausal patients need to be told to apply estrogen cream for 3 to 4 weeks preoperatively to improve intraoperative handling and postoperative healing. Postoperatively monitor the patient’s vaginal discharge, which should be minimal, as well as the patient’s pain level and response to analgesics. Sitz baths may be used for comfort. In an anterior repair, an indwelling urethral catheter is inserted and left in place for approximately 4 days. Encourage fluid intake to assure adequate urine formation. After a posterior repair, stool softeners and low-residue diets are often given to prevent strain on the incision when defecating.
Preventive measures include teaching the patient to do Kegel exercises 100 times a day for life to maintain the tone of the pubococcygeal muscle. Menopausal women should be encouraged to evaluate the appropriateness of estrogen replacement therapy, which can help strengthen the muscles around the vagina and bladder. If the patient has symptoms that are managed conservatively, teach the patient the use of a pessary—how to clean and store it; how to prevent infections— and to report any complications that may be associated with pessary use, including discomfort, leukorrhea, or vaginal irritation. Answer questions about treatment options, and explain the procedures and possible complications. Listen to the patient’s and her partner’s concerns and assist them in decision making about care. For additional support, have the patient speak to others who have undergone similar treatments.
Nursing care plan discharge and home health care guidelines
Instruct the patient on all medications, including the dosage, route, action, and adverse effects. Instruct the patient to notify the physician if signs of infection or increased vaginal bleeding are noted. If patient is discharged with a catheter, assure that they understand that the catheter must remain patent and to notify physician if the catheter fails to drain urine. Instruct the patient to avoid enemas, heavy lifting, prolonged standing, and sexual intercourse for approximately 6 weeks. Note that it is normal to have some loss of vaginal sensation for several months. Emphasize the importance of keeping follow-up visits.
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