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Bladder Prolapse (Cystocele)

Cystocele is a medical condition which results in the prolapse (protrusion) of the bladder into the vagina.

This can occur when the upper portion of the anterior vaginal wall droops down and protrudes out of the vaginal canal in some cases. Apart from this, the urethra may also collapse along with the lower 1/3rd of the anterior vaginal wall, which is then known as urethrocele. This condition results in stress incontinence.


What are the grades of Cystoceles?

Cystocele is classified into progressing grades according to the severity of the drooping vaginal wall, such as:

  • Grade 1 - mild - when the bladder droops only a short way into the vagina

  • Grade 2 - more severe - when the bladder has sunk into the vagina far enough to reach the opening of the vagina

  • Grade 3 - most advanced - when the bladder bulges out through the opening of the vagina


What does Cystocele do?

In addition to discomfort, the resulting dropped bladder can cause two kinds of problems to occur:

  • unwanted urine leakage

  • incomplete emptying of the bladder


The dropped bladder stretches the opening into the urethra, and urine may leak when a woman:

  • Coughs

  • Sneezes

  • Laughs

  • Or does any action that puts pressure on the bladder


Factors that are believed to develop cystocele include age, repeated childbirth, hormone deficiency, menopause, constipation, ongoing physical activity, heavy lifting, and prior hysterectomy.


What are the symptoms of Cystoceles?

Symptoms of bladder prolapse/Cystoceles include:

  • Stress incontinence (inadvertent leakage of urine with physical activity)

  • Urinary frequency

  • Difficult urination

  • Vaginal bulge

  • Vaginal pressure/pain

  • Painful sexual intercourse and

  • Lower back pain.

Urinary incontinence is the most common symptom of a Cystocele.


What are the causes of Cystoceles?

The most important cause of prolapse is atonicity and asthenia that follow menopause. The ligaments and pelvic floor muscles become weak and this is the cause of prolapse in women of menopausal age. Some women however, develop prolapse soon after child birth. Birth injury is another important cause. Delivery of a big baby also stretches the ligaments and muscles leading to prolapse. Rapid succession of pregnancies increases the tendency of prolapse. Prolonged bearing down in the second stage of labor and ventouse extraction of the fetus before the cervix is fully dilated increases the risk of prolapse.

A raised intra abdominal pressure due to chronic bronchitis, large abdominal tumors or obesity tends to worsen Cystocele and other forms of prolapse as well.


How are Cystoceles diagnosed?

There are several methods that are used to diagnose bladder prolapse or Cystocele, these are:

Physical examination – This is a commonly used diagnostic test for Cystocele. A speculum is inserted into the vagina and the patient is asked to strain or sit in an upright position; this increase in intra-abdominal pressure maximizes the degree of prolapse and aids in diagnosis. The physician then inspects the walls of the vagina for prolapse or bulging.

In some cases, a physical examination cannot sufficiently diagnose pelvic prolapse. For example, cystography may be used to determine the extent of a cystocele; the bladder is filled by urinary catheter with contrast medium and then x rayed.

Imaging tests - Ultrasound or magnetic resonance imaging (MRI) may also be used to visualize the pelvic structures.


How are Cystoceles treated?

Initially, the doctor may advise non-surgical treatment for treating Cystocele, such as:

Pessaries – These are prostheses inserted in the vagina to maintain reduction of the prolapsed structures. Pessaries are of varying shapes and sizes, and some are inflatable. These need monthly cleaning for better maintenance and safety from complications.

Kegel exercises – These involve isometric contractions of the pubococcygeus muscle. Contraction of the correct muscle is best initiated by asking patients to simulate attempting to hold in urine. Exercises can be facilitated by use of weighted vaginal cones, which help patients focus on contracting the correct muscle, by biofeedback devices, or by electrical stimulation, which causes the muscle to contract.

Surgical repair – Surgical procedure is useful for supporting structures (anterior and posterior colporrhaphy) and can help relieve symptoms that are severe or do not resolve with nonsurgical treatment. There are several surgical methods used for treatment of Cystoceles and the doctor will help to decide the best-suited in individual cases.


What is recovery like after Cystocele surgical treatment?

A Foley catheter may remain for one to two days after surgery. The patient is given a liquid diet until normal bowel function returns. The patient also is instructed to avoid activities for several weeks that cause strain on the surgical site; these include lifting, coughing, long periods of standing, sneezing, straining with bowel movements, and sexual intercourse.


Are there any risks associated with Cystocele surgical treatment?

Risks of surgical cystocele repair include potential complications associated with anesthesia, infection, bleeding or injury to other pelvic structures, dyspareunia (painful intercourse), recurrent prolapse, and failure to correct the defect.

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