Cystocele and functional anatomy of the pelvic floor: review and update of the various theories

Introduction and hypothesis: We updated anatomic theories of pelvic organ support to determine pathophysiology in various forms of cystocele.

Methods: PubMed/MEDLINE, ScienceDirect, Cochrane Library, and Web of Science databases were searched using the terms pelvic floor, cystocele, anatomy, connective tissue, endopelvic fascia, and pelvic mobility. We retrieved 612 articles, of which 61 matched our topic and thus were selected. Anatomic structures of bladder support and their roles in cystocele onset were determined on the international anatomic classification; the various anatomic theories of pelvic organ support were reviewed and a synthesis was made of theories of cystocele pathophysiology.

Results: Anterior vaginal support structures comprise pubocervical fascia, tendinous arcs, endopelvic fascia, and levator ani muscle. DeLancey's theory was based on anatomic models and, later, magnetic resonance imaging (MRI), establishing a three-level anatomopathologic definition of prolapse. Petros's integral theory demonstrated interdependence between pelvic organ support systems, linking ligament-fascia lesions, and clinical expression. Apical cystocele is induced by failure of the pubocervical fascia and insertion of its cervical ring; lower cystocele is induced by pubocervical fascia (medial cystocele) or endopelvic fascia failure at its arcus tendineus fasciae pelvis attachment (lateral cystocele).

Conclusions: Improved anatomic knowledge of vaginal wall support mechanisms will improve understanding of cystocele pathophysiology, diagnosis of the various types, and surgical techniques. The two most relevant theories, DeLancey's and Petros's, are complementary, enriching knowledge of pelvic functional anatomy, but differ in mechanism. Three-dimensional digital models could integrate and assess the mechanical properties of each anatomic structure.