What is Cystocele (Prolapsed Bladder)?
A cystocele, or a bladder protrusion, happens when the bladder lowers down into the vagina. Essentially, the bladder pushes through the front wall of the vagina, a place where they’re structurally connected. There are many reasons why a cystocele could occur, mainly due to weakened muscles and connective tissue around the bladder and vagina.
In women, muscles in the pelvic floor and a complex tissue structure called endopelvic fascia provide vital support for the organs within the pelvis. There are three main muscles involved: the pubococcygeus, puborectalis, and iliococcygeus. Together, they form a muscle group called the levator ani. Additionally, two sets of ligaments, the cardinal and uterosacral, give extra support and stability.
A bladder that has shifted out of its normal position can significantly impact a woman’s quality of life, affecting everyday activities and sexual activity. For some women, the symptoms could be mild and might not even need treatment. In some instances, the condition might even improve on its own after menopause. But, on the opposite end, there can be slow-progressing cases where the bladder could eventually shift entirely outside the vaginal entrance.
What Causes Cystocele (Prolapsed Bladder)?
Cystoceles, or bladder prolapses, happen when the muscles that support the pelvic floor weaken. Several risk factors contribute to this weakness, including obesity, aging, childbirth, ongoing high pressure in the abdomen, collagen irregularities, family history of cystocele, and previous pelvic surgery.
Obesity is a noted risk factor, as research has discovered that women with a Body Mass Index (BMI) over 25 have a higher chance of developing a prolapse. The risk increases even more for those with a BMI over 30. It is important to note that while losing weight could potentially decrease the risk of a cystocele, some studies suggest that once damage to the pelvic floor has occurred, it can be irreversible.
Getting older also plays a role in cystoceles, due to changes in the body that can weaken the pelvic floor. The structure of collagen, the major component of vaginal walls, changes over time due to aging, which might explain why older age increases the likelihood of cystoceles.
Childbirth, and especially vaginal delivery, is another major risk factor for cystoceles, as it can weaken the muscles in the pelvic floor. Specifically, the risk of developing pelvic floor disorders has been found to increase with each delivery. Additionally, the use of forceps during delivery can also contribute to muscle damage.
Having persistent high pressure in the abdomen, due to chronic conditions like constipation, chronic cough, or lung disease, could slightly increase the risk of a cystocele as well.
Collagen irregularities can also heighten the risk, as in the case of conditions like Marfan and Ehlers-Danlos syndrome that affect collagen production. Women with these conditions are more likely to develop cystoceles.
A family history of pelvic prolapse, while not linked to any specific genes, seems to also increase the likelihood of developing a cystocele.
Lastly, pelvic surgery such as a hysterectomy, which causes damage to the tissues and nerves in the pelvic area, can result in a higher chance of developing a cystocele.
Risk Factors and Frequency for Cystocele (Prolapsed Bladder)
Anterior vaginal wall prolapse affects a significant but uncertain number of women, because many either display very few symptoms, or feel too embarrassed to seek medical help. The Women’s Health Initiative study suggested that over a third of all women, regardless of whether they’ve had a uterus removal surgery, experience bladder prolapse.
- A study of nearly 2000 women over 20 found 2.9% had some degree of pelvic organ prolapse.
- Women with low socio-economic status were found to experience more severe symptoms.
- By the age of 80, around 11.1% of women have needed surgery for prolapse management. Of these, about one in three needed a repeat procedure.
Signs and Symptoms of Cystocele (Prolapsed Bladder)
Bladder prolapse, or falling of the bladder into the vagina, can lead to a variety of uncomfortable symptoms. These generally include a sensation of pressure in the vagina along with unusual urinary behaviors, difficulties during sexual activity, and, less commonly, issues with bowel movements. Clinicians often use a series of questions known as the Pelvic Floor Impact Questionnaire to assess these symptoms.
- Sensation of pressure: Women might feel like something is bulging from, or is about to fall out of, the vagina. This typically begins when the prolapse reaches the opening of the vagina. In later stages, there might also be discharge, bleeding, or pain in the vagina.
- Urinary symptoms: These could include urinary incontinence, especially during physical activity, as well as frequent or urgent need to urinate associated with an overactive bladder. Women could also struggle to start urinating, feel unsure if the bladder is empty, and experience a blockage of the bladder outlet in later stages. Some women might need to press against the front wall of the vagina to urinate successfully.
- Sexual dysfunction: This problem could have physical, psychological, or partner-related roots. Prolapse can lead to pain during intercourse, urinary incontinence during sexual activity, obstruction, and dryness. The fear or embarrassment of potentially urinating during sexual activity can also contribute to this dysfunction.
- Bowel movement issues: These are less common but can include constipation and incomplete emptying. This tends to occur more with prolapses of the back and upper vaginal walls.
A vaginal examination is required to diagnose and stage a cystocele, or bladder prolapse. The Pelvic Organ Prolapse Quantification System is a tool used to objectively describe and measure the severity of the issue. If the vaginal walls are visible beyond the opening of the vagina, the tissues should be checked for ulcers or other abnormalities. The exam should be repeated with the patient straining or coughing to watch for any episodes of urinary incontinence or release of gas.
Next, an examination with a Sims speculum is done to get a better look at the vaginal walls. Providing simulated apical support, or pressing on the top of the vagina, can also help determine if a pessary could be beneficial. Lastly, a bimanual exam checks for any other masses or pelvic issues.
Testing for Cystocele (Prolapsed Bladder)
The POPQ system is a tool used by doctors to understand how severe a condition known as anterior wall prolapse is. This system was introduced in 1996 and is recognized by The American College of Obstetricians and Gynecologists. It has four different stages:
Stage 0 is where there is no prolapse at all. Stage 1 is when the lowest part of the prolapse is -1 cm, meaning it’s above the area of the hymen. Next, Stage 2 is where this part of the prolapse is between -1 cm and +1 cm, either a little bit above or below the hymen. When it comes to Stage 3, the prolapse extends beyond the hymen, but the farthest part of the prolapse does not protrude more than 2 cm less than the total length of the vagina. Lastly, Stage 4 is the most severe, where the vagina is completely everted, and the farthest part of the prolapse extends as much as or more than (total vaginal length -2) cm.
The POPQ system measures six different points within the vagina, with two in the front, two at the bottom, and two at the top, to provide a clear picture of the prolapse. The measurements are all noted in centimeters, and the hymenal plane level helps as a reference point. Negative numbers indicate points above the hymen, while positive numbers denote points below the hymen.
There’s another system also used named the Baden-Walker Halfway Scoring System. This one has three grades instead of stages: 0 (normal position), 1 (midway descent to the hymen), 2 (descent reaches the hymen), and 3 (descent halfway past the hymen). Despite being used, it is considered less precise than POPQ because there are no clear boundaries between grades, and thus, many of medical societies do not recommend it.
Besides these evaluations, doctors also use imaging and other tests to check for any complications related to bladder function or for further investigation of the prolapse. For instance, they may take medical photographs to track the changes in the prolapse over time, notably before a surgery. The ultrasound scan of the pelvic floor can detect muscle tears from the pubic bone that can lead to a higher risk of cystocele (bladder herniation into the vagina). Other tests might include urodynamics or a specific X-ray called cystourethrogram to evaluate for potential urinary issues. If a urinary tract infection is suspected, a urine test may be conducted to guide treatment.
Treatment Options for Cystocele (Prolapsed Bladder)
Treatment for a cystocele, or a “fallen bladder,” is usually only suggested for women who are experiencing noticeable symptoms. No treatments may be needed for women with Stage 1 prolapse as this condition can sometimes improve on its own.
The treatment options can be separated into three categories: expectant, conservative, and surgical. In other words, options could include waiting to see how the condition progresses, using non-surgical methods to manage the condition, or taking a surgical response. All these possibilities should be thoroughly discussed with the patient before deciding on a treatment plan.
Treatment decisions depend on several factors, including the woman’s age, sexual activity, whether she plans to have more children, the severity and nature of her symptoms, the degree of the prolapse, any associated conditions, and surgical expertise and previous treatment results.
In the “watch and wait” approach, treatment may not be needed for patients with low grade cystoceles or who can manage minor symptoms without discomfort. For women who choose not to have treatment for any reason, regular check-ups are required for severe cystoceles to prevent complications.
Conservative treatments include vaginal pessaries and pelvic muscle exercises. Vaginal pessaries are silicone devices placed inside the vagina to support the vaginal walls, reducing the symptoms of the prolapse. They are a preferred option because they don’t involve the risks of surgery, like infection or bleeding. However, they can’t be used for women who are allergic to the pessary materials or who are unable to follow the treatment regimen.
Pelvic muscle exercises can help women with Stage 1 or 2 prolapse. Research shows these exercises can improve prolapses by 1-2 cm on average and result in better symptoms and reduction of the prolapse size compared to not having any treatment. These exercises should be done under supervision for 12-16 weeks to measure improvements and continued if they show benefits.
Hormone replacement therapy (HRT) is not a treatment for cystocele. HRT doesn’t reduce cystoceles, although estrogen creams or pessaries can be used to treat vaginal atrophy, which can occur at the same time. For women getting ready for surgery, using estrogen creams beforehand can help to build collagen and prevent the vaginal wall from thinning.
Surgery is the next option for women who are experiencing symptoms, need immediate relief, have declined conservative treatment, or have not improved with conservative treatment. It’s important to note that surgery should be considered after a woman is done having children.
The surgical procedure used depends on the individual patient’s condition. Two commonly used procedures are anterior colporrhaphy and sacral colpopexy. Anterior colporrhaphy involves reducing the size of the anterior vaginal wall for central vaginal wall repair. On the other hand, sacral colpopexy places a permanent mesh to secure both the anterior and posterior vaginal walls, and then attaching it to a ligament below the sacrum. Both procedures show good success rates.
Just remember, treatment for a cystocele should be selected according to each individual woman’s needs and conditions. It should also involve a complete discussion with the healthcare provider to understand the benefits and possible downsides of each option.
What else can Cystocele (Prolapsed Bladder) be?
There are numerous conditions that can show symptoms similar to bladder prolapse. These conditions need to be considered when trying to correctly diagnose the issue. These might include:
- Rectal or uterine prolapse, which is when the uterus or rectum drops into or out of the normal place in the body
- Ovarian or uterine tumors that can be benign (non-cancerous) or malignant (cancerous)
- Cancer of the vulva, which is the part of a woman’s genitals on the outside of her body
- Benign lesions on the vulva, such as a Bartholin’s or Skene’s cyst which can cause a lump or swelling
- Urethral diverticulum, which is a pocket or pouch that forms along the urethra
- Various causes of incontinity, where you’re not able to control your bladder
- Causes of urinary retention, which is where you’re not able to fully empty your bladder
- Causes of hyperreactive bladder, where you continually feel the need to urinate
It’s essential for the doctor to consider all these possibilities and carry out the necessary tests to determine the exact cause of the symptoms.
What to expect with Cystocele (Prolapsed Bladder)
A cystocele isn’t a life-threatening problem by itself. However, it can get worse if not properly treated, leading to a whole host of symptoms and health issues. This is due to the bladder wall pushing into the vagina, which can lead to issues with urinating. This might also result in urinary tract infections and kidney damage.
If the bladder drops beyond the vaginal opening, ulcers can form on the vaginal tissue, making it bleed and become more susceptible to infection. The emotional distress brought on by issues with intimate relations and the inability to control urination can also be quite significant.
Possible Complications When Diagnosed with Cystocele (Prolapsed Bladder)
Complications from cystocele, or a fallen bladder, depend on the type of treatment the patient gets. If a woman does not follow her prescribed treatment, or decides not to get treated, the condition could worsen and cause the vagina to protrude completely (a condition called procidentia).
Non-surgical treatments can also lead to issues. For instance, vaginal pessaries—devices inserted into the vagina to support its structure—can cause pain, vaginal erosion, bleeding, or infection.
The majority of complications come from surgery. Recurring prolapse, or falling again, is the most common, leading to the need for additional surgery. Nearly 40% of women need another surgery after an anterior colporrhaphy—a procedure to repair the front wall of the vagina—because of recurring symptoms. Other potential complications of surgery include:
- Bleeding after surgery
- Formation of a hematoma (a collection of blood outside of blood vessels)
- Damage to nearby pelvic organs
- Infections of the surgical site
- Failure of the wound to heal properly (dehiscence)
- Urinary tract infections
- Pain during sexual intercourse
- Difficulty or inability to urinate (urinary retention)
- Formation of a vesicovaginal fistula, an abnormal connection between the bladder and vagina
Additionally, using mesh for surgery in the vagina can lead to a higher rate of complications, most notably constant pelvic pain.
Preventing Cystocele (Prolapsed Bladder)
The Association of Pelvic Organ Prolapse Support is a resource that provides the latest information about vaginal prolapses, including anterior vaginal wall prolapse. You can also find a questionnaire on their website that helps assess your risk for Pelvic Organ Prolapse, commonly known as POP.
The International Urogynecological Association provides useful leaflets in various languages about cystocele and the different ways it can be managed. These leaflets are usually handed out to women during their appointments for conditions like pelvic organ prolapse.
The American Urogynecologic Society (AUGS) has an online tool that displays the various stages of vaginal wall prolapse in an interactive way. This kind of visual tool can be really helpful during doctor-patient discussions about what to expect and how to manage pelvic organ prolapse.
Research shows that a combination of educational leaflets and personal conversations can significantly improve a woman’s understanding of her condition and the care options available to her. This seems to be true regardless of the woman’s level of education.