Bladder Prolapse (Cystocele)
A cystocele is the protrusion or prolapse of the bladder into the vagina. A number of surgical interventions are available to treat cystoceles.
In prolapse of the anterior vaginal wall, the upper part of the anterior vaginal wall descends and in severe cases may protrude outside the vaginal orifice. In such cases, the vesical and vaginal fasciae are thinned out and fail to support the bladder, so that the bladder prolapses with the anterior vaginal wall. This condition is termed Cystocele. In cases when the urethra prolapses along with the lower one third of the anterior vaginal wall it is termed as Urethrocele. In such cases the patient invariably complains of stress incontinence.
What are the grades of cystoceles?
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 are the results of a cystocele?
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:
Or does any action that puts pressure on the bladder
A prolapse occurs when an organ falls out of its normal anatomical position. The pelvic organs normally have tissue (muscle, ligaments, etc.) holding them in place. Certain factors, however, may cause those tissues to weaken, leading to prolapse of the organs. A cystocele may be the result of a central or lateral (side) defect. A central defect occurs when the bladder protrudes into the center of the anterior (front) wall of the vagina due to a defect in the pubocervical fascia (fibrous tissue that separates the bladder and vagina). The pubocervical fascia is also attached on each side to tough connective tissue called the arcus tendineus; if a defect occurs close to this attachment, it is called a lateral or paravaginal defect. A central and lateral defect may be present simultaneously. The location of the defect determines what surgical procedure is performed.
Factors that are linked to cystocele development include age, repeated childbirth, hormone deficiency, menopause, constipation, ongoing physical activity, heavy lifting, and prior hysterectomy. Symptoms of bladder prolapse include stress incontinence (inadvertent leakage of urine with physical activity), urinary frequency, difficult urination, a vaginal bulge, vaginal pressure or pain, painful sexual intercourse, and lower back pain. Urinary incontinence is the most common symptom of a cystocele.
Surgery is generally not performed unless the symptoms of the prolapse have begun to interfere with daily life. A staging system is used to grade the severity of a cystocele. A stage I, II, or III prolapse descends to progressively lower areas of the vagina. A stage IV prolapse descends to or protrudes through the vaginal opening. Surgery is generally reserved for stage III and IV cystoceles.
The most important cause of prolapse is atonicity and asthenia that follow menopause. The ligaments and pelvic floor muscles become slack and this is the cause of prolapsed in women of menopausal age. Most of the women complaining of prolapse are of menopausal age.
Some women however, develop prolapse soon after child birth. Postnatal pelvic floor exercises help greatly to restore the tone of the muscles and thus reverse mild cases and considerably reduce severe cases of prolapse
Birth injury is another important cause.
Peripheral nerve injury such as pudendal nerve injury during child causes prolapse in 60 % of the cases.
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 labour 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 prolapses as well.
Diagnosis / Preparation
Physical examination is most often used to diagnose a 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. Ultrasound or magnetic resonance imaging may also be used to visualize the pelvic structures.
Women who have gone through menopause may be given six weeks of estrogen therapy prior to surgery; this is thought to improve circulation to the vaginal walls and thus improve recovery time. Antibiotics may be administered to decrease the risk of postsurgical infection. An intravenous (IV) line is placed and a Foley catheter is inserted into the bladder directly preceding surgery.
The patient complains of something protruding from the vulva. The prolapse is aggravated on coughing, straining or excessive physical work. If the prolapse is large there will be an external swelling. Owing to friction the epithelium of this external mass may become thickened, hypertrophied and keratinized. In some cases there may be an ulcer on the most dependent part of the swelling called a decubitus ulcer.
Vaginal discharge is another common symptom, if there is a decubitus ulcer however the discharge may be blood stained.
Difficulties in coition are common with third degree uterine prolapse.
Micturition disorders are one of the most important symptoms of Cystocele. The defective control of micturition is due to lack of support to the sphincter of the urethra. Some complain of increased frequency of passing urine. Others complain of incomplete emptying of the bladder. Due to retention of urine, patients suffer from recurrent urinary tract infections. In severe degrees of bladder prolapse, patients complain that the more they strain the less easily they can pass urine.
Pessary and Kegel exercises
Surgical repair of supporting structures if necessary
Treatment may initially consist of a pessary and Kegel exercises.