Here’s a term you don’t hear very often: Posterior Fornix Syndrome. Sounds odd, right? These pelvic pain patients struggle with many of the symptoms associated with interstitial cystitis, particularly nocturia, urgency, frequency and abnormal emptying. But rather than having a bladder disease, their condition is caused by weakness or tears of ligaments (uuterosacral) that support the vagina. This often occurs after a difficult labor, leaving the uterus “hyper mobile” and, in some cases, turned out of position. Therapy is usually surgery that repairs the ligament and/or the use of a pessary.

In this fascinating case, a 73 year old woman diagnosed with with Hunner’s lesions, urgency, nocturia and prolapse underwent mini sling surgery to repair the prolapse and weakness in her ligaments. Remarkably, her Hunner’s lesions and other symptoms were completely cured after the surgery. The authors note that this was initially discussed eighty years ago: “The concept of USL laxity causing chronic pelvic pain and bladder symptoms is not new. It was published in the German literature by Heinrich Martisu in 1938 and by Petros… in 1993.” This, however, is the first report that Hunner’s lesions could be linked to this ligament dysfunction.

The authors point to a very simple speculum test to determine if the ligament is the problem. At the top of the vagina, there are two small pockets extend past the cervix, the anterior fornix (facing the front of your body) and the posterior fornix (facing the rear). If symptoms improve with the insertion of a speculum into the posterior fornix, which provides support where the ligament is lacking, the diagnosis is confirmed.

The authors raise an important question. Are patients being screened for this condition which, when identified correctly, is curable. Fascinating and, yet again, reminds us all that bladder symptoms aren’t always the result of a bladder disease. A simple diagnostic swab could reduce the suffering of many. Further research is needed, particularly in trying to understand how and why a lesion forms in this circumstance. Fascinating.

Reference: Scheffler K, Hakenberg O, Petros P. Cure of Interstitial Cystitis and Non-Ulcerating Hunner’s Ulcer by Cardinal/Uterosacral Ligament Repair. Url Int. 2021 May 21;1-4