Bladder prolapse/bulge (Cystocele)
Overview
A bladder prolapse cystocele, also known as a dropped bladder, occurs when a woman’s bladder drops from its normal positioning within the pelvis. This causes the bladder to push on the wall of the vagina, creating pressure and discomfort.
Normally, the bladder, uterus, and intestines are held in place by connective tissues and muscles on the pelvic floor. Sometimes, the pelvic floor endures too much pressure or becomes weak. This causes a bladder prolapse cystocele.
There are many potential causes for a bladder prolapse. The most common causes are childbirth and pregnancy. Additional causes include chronic coughing, lifting heavy objects, frequent constipation, and genetic pelvic floor weakness.
Mild and moderate cases can often be treated with non-surgical interventions. However, severe cases of bladder prolapse may require surgery to keep vital pelvic organs in their correct positions.
Symptoms
There are several common symptoms that are present in most cases of bladder prolapse. These symptoms include:
- A feeling of pressure or fullness in the pelvis and vagina
- A bulge of tissue in the vagina that is visible
- Increase in pelvic pressure when coughing, straining, or lifting
- Difficulty urinating or starting a stream of urine
These symptoms tend to be most prevalent after standing up for extended periods of time. Signs of bladder prolapse may fade away when patients lie down.
Diagnosis
There are several ways to diagnose a bladder prolapse cystocele. These include:
Pelvic Exam
The most effective way of diagnosing a prolapse is through a pelvic exam. You may be examined while standing or while lying down. During the examination, your physician will look for a visible tissue bulge in your vagina. A bulge is a strong indicator of bladder prolapse.
Your doctor will likely ask you to exert yourself as if you are having a bowel movement. This allows them to determine how much that action impacts the degree of your prolapse. They will also ask you to contract your pelvic muscles so that they can check for normal strength.
Questionnaire
Your physician may provide you with a questionnaire so that they can assess how much the prolapse is affecting your overall quality of life. This will guide their treatment.
Urine and Bladder Tests
Patients with a significant prolapse may not be able to adequately empty their bladders. If your physician is concerned that your bladder prolapse is severe, then they may run tests on your urine to check for bladder infections.
Treatment
The right treatment for you will depend on the severity of your bladder prolapse cystocele symptoms. Patients that are experiencing severe discomfort and urinary incontinence will likely require surgical intervention. Milder cases can be treated with non-invasive options.
The three primary treatment options include:
Home Exercises
Pelvic floor muscles exercises are a great way of providing added support to your pelvic organs. These exercises are successful at relieving many milder symptoms of bladder prolapse cystocele when performed correctly. Your doctor or a licensed physical therapist can provide you with detailed instructions on how to perform these exercises.
Pessary
A pessary is a supportive device that is inserted into your vagina. It is a rubber or plastic ring that offers added support to relieve prolapse symptoms. Your doctor will show you how to clean the device and reinsert it without assistance. These devices can buy time and allow you to delay surgery.
Surgery
Surgical treatment for bladder prolapse cystocele is performed vaginally. During the procedure, the physician will hold the bladder into place with stitches. They will also remove excess vaginal tissue, if necessary.
In some cases, a hysterectomy is performed at the same time. This is done to alleviate other issues, such as cancer or excessive bleeding.
Cystocele Repair and Sacrospinous Ligament Fixation
Pelvic organ prolapse refers to pelvic organs “falling” into the vaginal vault. When the bladder does this it is referred to as a cystocele. One of the main associated areas of prolapse is the anterior vaginal vault where the uterus or small bowel (if the uterus is not present) may also bulge into the vagina. If the posterior vault or rectum are involved, a gynecologist may be needed to assist in the repair of these defects. Urologists repair the bladder and the anterior apex of the vagina at the same time to prevent recurrence. We also typically use mesh to perform the repairs despite some of the well-known mesh-associated risks because there is good evidence that these repairs last longer. For the FDA opinion on the risks of using mesh in vaginal prolapse, see the following link:
https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/Implants…
The procedure is performed under general or spinal anesthesia in a hospital setting. You are placed in lithotomy position (position used to do pelvic exams in office), and prepped using antiseptic solution on the inside of the vagina, the labia, and surrounding areas. A catheter is placed and the vaginal wall underlying the bladder is injected with local anesthetic. This tissue is then incised and the bladder is carefully mobilized off of the vagina until the ligaments of the pelvis are palpated. A mesh kit is then used to anchor the mesh to the sacrospinous ligaments (along the back of the pelvis) and to the lateral muscle or tendon of the pelvis. This gives support to the sides and back of the vagina. Antibiotic solution is then used to cleanse the area. A scope of the bladder is performed so the bladder can be evaluated for any injury. The vaginal incision is then closed and a packing is inserted vaginally to prevent bleeding. You are then kept overnight in the hospital. The next morning, the packing and catheter are removed and the bladder is checked with an ultrasound to make sure that you are emptying normally. This is particularly important if a procedure was done for urinary leakage during the same operation.
What to expect afterwards:
- Vaginal bleeding similar to a light period or spotting is normal for several weeks after surgery.
- Some pelvic pressure or discomfort is common. If severe, let your doctor know.
- You will be instructed to do no heavy lifting, intercourse, bathing or swimming in a pool for 6 weeks.
- You may shower the next day, drive when you are no longer on pain medicine and moving your legs normally, and resume normal daily activities as tolerated.
- No baths until seen by your urologist for follow-up in the office.
If you would like more specific information on the type of repair “kit” that will be used for your repair, please ask your doctor who can direct you to the website for that company or provide you with materials to review.
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FAQ’s
A prolapse is a hernia of a woman’s vagina. It often presents as pressure or a distinct bulge. It is referred to by many different terms, including a bladder prolapse cystocele, dropped uterus, or dropped rectum.
Prolapse is attributed to a weakening of vaginal tissues. It is often associated with childbirth and pregnancy but prolapse can occur in women that have no children. A chronic cough, heavy lifting, and poor tissue health can also contribute to prolapse.
Prolapse is often characterized by discomfort, but it is generally non-life-threatening. There are several treatment options available.
Most women elect to use conservative treatments that include pelvic floor muscle exercises, dietary changes, and physical therapy. However, some women experience significant discomfort and opt for surgical intervention.
Mild cases of bladder prolapse can effectively be treated with conservative methods. However, prolapse that is not addressed will usually get worse over time. Surgical treatment is the best way to address prolapse.
Hysterectomies are not a mandatory part of prolapse treatment. However, many physicians recommend undergoing both procedures at the same time. Removing the uterus makes it easier to repair the prolapse. A hysterectomy may also be necessary to address other issues, such as excessive vaginal bleeding.
Unfortunately, no surgical intervention has a 100% success rate. Roughly 5% to 15% of women experience a failure after prolapse surgery. Most of the time, these are partial failures that require a minor corrective procedure, no treatment, or the use of a pessary (intervaginal device).