As with all patients with symptomatic pelvic floor dysfunction, a detailed history of bladder, bowel, and sexual function should be elicited. Patients with anterior vaginal prolapse often complain of symptoms directly related to the prolapse as well as symptoms of bladder dysfunction. Patients with prolapse at or beyond the level of the hymen often complain of pelvic pressure and bulging. Stress urinary incontinence often occurs in association with anterior vaginal prolapse and approximately one-third of women with stage II or greater prolapse will complain of symptoms of urinary urgency, frequency, and/or urge incontinence. Symptoms of voiding dysfunction such as a feeling of incomplete emptying, intermittent or reduced urine flow, or the need to splint to complete urination are common in women with prolapse beyond the hymen. Sexual difficulty is also a common complaint of women with advanced prolapse. In addition to this functional assessment, a detailed history of previous prolapse or antiincontinence surgery should also be elicited.

1. The attenuation or defects of the vaginal muscularis in the midline (central defect)

2. Loss of lateral attachments from the anterior vagina to the pelvic sidewall (lateral or paravaginal defect)

3. Loss of bladder neck support

4. Separation of the cardinal-uterosacral ligament complex from the vaginal apex (superior defect)

These four defects accompany most large cystoceles and must be corrected to achieve good support, elevation of the bladder base, and a solid, durable repair. A detailed

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