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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:

• Coughs

• Sneezes

• Laughs

• Or does any action that puts pressure on the bladder

Purpose

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.

Causes

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.

Symptoms

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.
Treatment:

• Pessary and Kegel exercises

• Surgical repair of supporting structures if necessary

• Treatment may initially consist of a pessary and Kegel exercises.

Pessaries are prostheses inserted in the vagina to maintain reduction of the prolapsed structures. Pessaries are of varying shapes and sizes, and some are inflatable. They may cause vaginal ulceration if they are not correctly sized and routinely cleansed (at least monthly if not more frequently).

Kegel exercises involve isometric contractions of the pubococcygeus muscle. Isolation of the correct muscle is difficult (about 50% of patients cannot do it) but important because a Valsalva maneuver is detrimental and buttock or thigh contraction is unhelpful. Contraction of the correct muscle is best initiated by asking patients to simulate attempting to hold in urine. Three sets of 8 to 10 contractions are done daily; contractions are initially held for 1 to 2 sec and increased up to 10 sec each when possible. 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 of supporting structures (anterior and posterior colporrhaphy) can help relieve symptoms that are severe or do not resolve with nonsurgical treatment. Perineorrhaphy (surgical shortening and tightening of the perineum) may also be needed. Colporrhaphy (surgical repair of the vagina) is usually deferred, if possible, until future childbearing is no longer desired because subsequent vaginal birth may disrupt the repair. Urinary incontinence can be surgically treated at the same time as colporrhaphy. After surgery, patients should avoid heavy lifting for 3 months. After surgery to repair a cystocele or cystourethrocele, a urethral catheter is used for < 24 h.

In cases of prolapse in young women following childbirth it is better to avoid immediate operative treatment. Since most cases of post natal prolapses respond well to abdominal exercise, massage and perineal exercises when done regularly. This conservative treatment must be followed regularly for 3 to 4 months following delivery.

Anterior Colporrhaphy is the operation performed to repair a Cystocele and Cystourethrocele.

After care

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.

Risk

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

Normal Results

A woman usually is able to resume normal activities, including sexual intercourse, in about four weeks after the procedure. After successful cystocele repair, symptoms recede, although a separate procedure may be needed to treat stress incontinence.

Alternatives

Surgery is generally reserved for more severe cystoceles. Milder cases may be treated by a number of medical interventions. The physician may recommend that the patient do Kegel exercises, a series of contractions and relaxations of the muscles in the perineal area. These exercises are thought to strengthen the pelvic floor and may help prevent urinary incontinence.

A pessary, a device that is inserted into the vagina to help support the pelvic organs, may be recommended. Pessaries come in different shapes and sizes and must be fitted to the patient by a physician. Hormone replacement therapy may also be prescribed if the woman has gone through menopause; hormones may improve the quality of the supporting tissues in the pelvis.