Definition and Overview
A cystocele, also known as an anterior, bladder or urethra prolapse, is a serious health condition that occurs when the supportive tissues in a woman’s vaginal wall weakens and becomes unable to hold the bladder in place, causing it to bulge out. It is one of the different types of pelvic organ prolapse that most commonly plagues elderly women, causing extreme discomfort and either urine leakage or the inability to fully empty the bladder. Either way, the condition presents a serious health issue as it commonly affects post-menopausal women whose estrogen levels have dropped and are thus unable to keep the vaginal tissues strong and elastic.
A cystocele may manifest in varying degrees of severity classified into different grades. Grade 1 cases are milder cases wherein the bladder only droops a bit into the vagina, while grade 2 cases are characterized by the bladder reaching as far as the vaginal opening. In advanced grade 3 cases, the bladder protrudes out of the vaginal opening. Both grade 2 and grade 3 cystoceles are easy to detect and diagnose because the bladder becomes fully visible even with a simple physical examination.
Cause of Condition
Cystoceles are triggered when the tough fibrous wall located between the vagina and the bladder loses its elasticity and, as a result, also loses its ability to support the bladder. This loss of elasticity may be caused by several possible factors, or a combination of them. These include:
- Old age
- Being overweight or obese
- Chronic constipation and repeated straining or pushing
- Vaginal childbirth
- Hormonal imbalance
- Gynecologic surgery
- Hysterectomy, or the surgical removal of the uterus
- Frequently engaging in high-impact activities
- Frequent heavy lifting
Additionally, some women may have a genetic susceptibility to developing cystoceles.
At the onset of the problem, cystoceles are asymptomatic, especially since the weakening of the vaginal wall may occur gradually as the woman ages.
Symptoms usually only begin to manifest when the condition progresses to a more severe grade. Possible symptoms include:
- Pressure in the vagina
- Fullness around the pelvic region
- A ball-like lump bulging out from the vagina
- Pressure in the lower back
- Back pain
- Difficulty urinating
- Frequent urination
- Urinary incontinence or urine leakage, especially when there is pressure on the bladder such as when the patient coughs, laughs, or sneezes
- Difficulty during bowel movements
- Pain or discomfort when coughing or lifting something up
- Vaginal bleeding
- Recurrent urinary tract or bladder infections
The discomfort associated with cystoceles are observed to be worse or more noticeable when the patient has been standing for an extended period, and tend to disappear when the patient lies down.
As this condition can increase a woman’s risk of infection or other serious diseases caused by an unhealthy bladder activity, it is important to seek medical help if any of the above symptoms is experienced. When left alone, the symptoms may continue to worsen until even normal activities are disrupted.
Who to See and Types of Treatments Available
Women who are experiencing the symptoms of cystoceles can seek medical attention from either their general physician or their gynecologist. Although it is possible to diagnose the condition through a physical examination, doctors may also request for some tests, such as:
Voiding cystourethrogram, which takes x-ray images of the bladder while the patient is urinating. This allows doctors to evaluate the severity of bladder obstruction, if any.
Bladder ultrasound, which sends sound waves off the bladder to determine the amount of urine that gets left behind after the patient urinates.
Catheterization, wherein a catheter is inserted into the bladder to remove any residual urine; this is done under local anesthesia.
Once the condition is diagnosed and severity is established, the doctor will suggest possible treatment options, including:
Surgical prolapse repair, which is reserved for patients with severe or large cystoceles and those who are in good health to withstand surgery; surgical prolapse repair currently has a high success and a low recurrence rate.
Vaginal pessary, a device that is inserted into the vagina to keep the bladder in its normal position; a pessary comes in different sizes and shapes so patients can use one that fits them comfortably. Those who are using a pessary, however, should follow proper care instructions and should remove the device regularly to prevent infection or ulcer.
Hormone replacement therapy, to help increase a woman’s estrogen levels to try and regain the elasticity of the pelvic muscles
Those undergoing surgery also have different options to choose from, classified into either vaginal or abdominal surgery. These procedures, which are done under general anesthesia, include:
- Anterior colporrhaphy
- Anterior colporrhaphy with graft
- Paravaginal prolapse repair
Surgery may also be used to help resolve stress urinary incontinence by lifting the urethra or placing the bladder back to its original position. This surgery, however, does not guarantee that the problem will not recur. All types of surgery used to treat cystoceles will also require the patient to stay in the hospital for up to 2 days, and will be asked to wear a catheter temporarily after the surgery. Recovery takes anywhere between 6 weeks to 3 months, during which patients are advised to return to their normal activities at a gradual pace. It may also take 2 to 6 weeks for their bladder function to return to normal. Taking it easy after the procedure is also important, as standing for long periods, engaging in strenuous activities, and straining or lifting may increase the risk of recurrence.
Mild cases of cystoceles, however, may not require treatment especially if symptoms are few, very mild, or non-existent. When the problem is diagnosed in its early stages, doctors usually prescribe a period of watchful waiting, during which the patient will be asked to visit the doctor regularly to check if the condition is worsening.
During this period, some steps may be taken to prevent the continued progress of the condition. These include doing Kegel exercises to strengthen the muscles of the pelvic floor, eating a proper diet, and making healthy lifestyle changes.
Lentz GM. Anatomic defects of the abdominal wall and pelvic floor: abdominal and inguinal hernias, cystocele, urethrocele, enterocele, rectocele, uterine and vaginal prolapse, and rectal incontinence: diagnosis and management. In: Lentz GM, Lobo RA, Gershenson DM, Katz VL, eds. Comprehensive Gynecology. 6th ed. Philadelphia, Pa: Mosby Elsevier; 2012:chap 20.
Winters JC, Togamai JM, Chermansky CJ. Vaginal and Abdominal Reconstructive Surgery for Pelvic Organ Prolapse. In: Wein AJ, ed. Campbell-Walsh Urology. 10th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 72.