Cystocele

What is a Cystocele?

A cystocele ― also known as a prolapsed, herniated, dropped or fallen bladder (where your urine or “water” is stored) ― occurs when ligaments that hold your bladder up and the muscle between a woman’s vagina and bladder stretches or weakens, allowing the bladder to sag into the vagina.

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There are three grades of cystocele:

. Grade 1 (mild): The bladder drops only a short way into the vagina.

. Grade 2 (moderate): The bladder drops to the opening of the vagina.

. Grade 3 (severe): The bladder bulges through the opening of the vagina.

Before Cystocele Repair Surgery

Symptoms

What are the symptoms of a cystocele?

. Feeling or seeing something bulging through the vaginal opening

. Difficulty emptying the bladder (urinating)

. Having to run to the bathroom frequently to pass water, or just a feeling as if you have to go a lot.

. Frequent urinary tract infections.

. Feeling of fullness, heaviness, or pain in the pelvic area or lower back. This feeling may get worse when the person is standing, lifting, coughing, or as the day goes on.

. The bladder bulging into or out of the vagina.

. Painful sex.

. Problems inserting tampons or applicators.

Causes

What causes a cystocele?

Risk factors for a cystocele include:

. Vaginal births, which may involve straining the muscles of the floor of the pelvis.

. Family history.

. Obesity.

. Intense physical activity, including lifting heavy objects.

. Hysterectomy.

. Constipation and/or repeated muscle straining during bowel movements.

. Frequent coughing.

. Aging and a drop in the hormone estrogen. Estrogen helps keep muscles around the vagina strong, but women produce less estrogen as they enter menopause (the end of menstrual periods).

Diagnosis

How is a cystocele diagnosed?

Diagnosing a cystocele requires medical tests and a physical exam of the vagina. Medical tests take place in a health care provider’s office, an outpatient center, or a hospital. The health care provider will ask about symptoms and medical history. A health care provider uses a grading system to determine the severity of a woman’s cystocele. A cystocele receives one of three grades depending on how far a woman’s bladder has dropped into her vagina:

. Grade 1—mild, when the bladder drops only a short way into the vagina

. Grade 2—moderate, when the bladder drops far enough to reach the opening of the vagina

. Grade 3—most advanced, when the bladder bulges out through the opening of the vagina

If a woman has difficulty emptying her bladder, a health care provider may measure the amount of urine left in the woman’s bladder after she urinates. The remaining urine is called the postvoid residual. A health care provider can measure postvoid residual with a bladder ultrasound. A bladder ultrasound uses a device, called a transducer that bounces safe, painless sound waves off the bladder to create an image and show the amount of remaining urine. A specially trained technician performs the procedure, and a radiologist—a doctor who specializes in medical imaging—interprets the images. A woman does not need anesthesia.

A health care provider can also use a catheter—a thin, flexible tube—to measure a woman’s postvoid residual. The health care provider inserts the catheter through the woman’s urethra into her bladder to remove and measure the amount of remaining urine after the woman has urinated. A postvoid residual of 100 mL or more is a sign that the woman is not completely emptying her bladder. A woman receives local anesthesia.

A health care provider may use a voiding cystourethrogram—an x-ray exam of the bladder—to diagnose a cystocele as well. A woman gets a voiding cystourethrogram while urinating. The x-ray images show the shape of the woman’s bladder and let the health care provider see any problems that might block normal urine flow. An x-ray technician performs a voiding cystourethrogram, and a radiologist interprets the images. A woman does not need anesthesia; however, some women may receive sedation. A health care provider may order additional tests to rule out problems in other parts of a woman’s urinary tract.

Risks and Complications

Most people who have cystocele repair surgery don’t have problems after their surgery. Rarely, the following complications can happen:

. Urine leakage

. Narrowing of the vagina

. Painful sex

. Wearing away of the material on the sling, if you had one placed

. Injury to your bladder or ureters (tubes that take urine from your kidneys to your bladder).

. Long-term or permanent problems urinating. To help with this, you may:

   . Have to insert a catheter (a thin, flexible tube) into your bladder to drain your urine.

   . Need another surgery to correct the problem.

. Not being able to hold your urine until you reach a toilet

. Wearing away of the sling into the vagina, urethra, or bladder. If this happens, the sling may need to be removed.

. Cystoceles may come back with time

How can a cystocele be prevented?

Certain risk factors, including heavy physical work, being overweight, and constipation, can be controlled, while risk factors such as family history cannot. As the population ages, the occurrence of cystocele is likely to increase.

During Cystocele Repair Surgery

Treatment

How is a cystocele treated?

Cystocele treatment depends on the severity of the cystocele and whether a woman has symptoms. If a woman’s cystocele does not bother her, a health care provider may recommend only that she avoid heavy lifting or straining, which could worsen her cystocele. If a woman has symptoms that bother her and wants treatment, the health care provider may recommend pelvic muscle exercises, a vaginal pessary, or surgery.

Pelvic floor, or Kegel, exercises involve strengthening pelvic floor muscles. Strong pelvic floor muscles more effectively hold pelvic organs in place. A woman does not need special equipment for Kegel exercises.

The exercises involve tightening and relaxing the muscles that support pelvic organs. A health care provider can help a woman learn proper technique.

A vaginal pessary is a small, silicone medical device placed in the vagina that supports the vaginal wall and holds the bladder in place. Pessaries come in a number of shapes and sizes. A health care provider has many options to choose from to find the most comfortable pessary for a woman.

A heath care provider may recommend surgery to repair the vaginal wall support and reposition the woman’s bladder to its normal position. The most common cystocele repair is an anterior vaginal repair—or anterior colporrhaphy. The surgeon makes an incision in the wall of the woman’s vagina and repairs the defect by folding over and sewing together extra supportive tissue between the vagina and bladder. The repair tightens the layers of tissue that separate the organs, creating more support for the bladder.

A surgeon who specializes in the urinary tract or female reproductive system performs an anterior vaginal repair in a hospital. The woman receives either regional or general anesthesia. The woman may stay overnight in the hospital, and full recovery may take up to 4 to 6 weeks.

After Cystocele Repair Surgery

After Your Surgery

. A catheter will drain urine from your bladder while the area heals. It will be taken out the day after your surgery before you leave the hospital.

. You will have a gauze dressing in your vagina to help stop bleeding. It will be removed before you go home.

. Your body will absorb your sutures (stitches) in 7 to 14 days. You won’t need to have them taken out.

. You will have mild vaginal bleeding. Make sure you have sanitary napkins at home.

. You will go home 1 day after your surgery, whether or not a sling was placed.

. You can shower when you go home. Don’t bathe or soak in a pool or hot tub until your doctor or nurse says it’s okay.

Follow-up

. Make an appointment to see your doctor 2 weeks after your surgery.

. Don’t lift anything heavier than 10 pounds for 6 weeks after your surgery.

. Avoid strenuous exercise, such as running or jogging, for 6 weeks after your surgery.

. Don’t have sexual intercourse or put anything in your vagina (such as tampons) for 6 weeks after your surgery.

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Bladder spasms

While you’re recovering, you may experience bladder spasms that can cause urine leakage. While they may feel uncomfortable or even painful, try not to take any medication for them. It will take longer for you to be able to urinate normally if you take medication to prevent the spasms.

Take your medications

You get 3 medications:

1. An antibiotic. You must follow the instructions on the bottle until all the pills are gone.
2. Medication to relieve pain after surgery.
3. A stool softener to keep your bowel movements soft. Stop taking it if you have diarrhea (loose or watery bowel movements).

Call Your Doctor or Nurse if You:

. Have a fever of 101 °F (38.3 °C) or higher

. Have severe bladder spasms

. Aren’t able to urinate

. Have pain that doesn’t go away with your pain medication

. Have more vaginal bleeding than when you were in the hospital

Kegel exercises

Kegel exercises are exercises you can do at home to strengthen your pelvic floor muscles. A strengthened pelvic floor provides better support for your pelvic organs and relief from symptoms associated with cystocele.

To perform Kegel exercises, follow these steps:

. Tighten (contract) your pelvic floor muscles — the muscles you use to stop urinating.

. Hold the contraction for five seconds, and then relax for five seconds. (If this is too difficult, start by holding for two seconds and relaxing for three seconds.)

. Work up to holding the contraction for 10 seconds at a time.

. Do three sets of 10 repetitions of the exercises each day.

Ask your doctor for instructions on how to properly perform a Kegel, and for feedback on whether you're using the right muscles. Once you've learned the proper method, you can do Kegel exercises discreetly just about any time, whether you're sitting at your desk or relaxing on the couch.

What can be expected after treatment for a cystocele?

In mild cases, non-surgical treatments may be all that is needed to successfully deal with a cystocele.

When surgery is performed for more serious cases, some women will eventually need another surgery because the first surgery failed, the cystocele returned or another pelvic floor problem developed. Women who are older, who smoke, are diabetic, or who have had a hysterectomy, may be at higher risk for complications.

What is the prognosis (outlook) for someone with a cystocele?

Although not life-threatening, a cystocele can have a negative impact on a woman’s quality of life. If it is not treated at all, the condition can continue to get worse. In the worst cases, the woman may be unable to urinate, which can cause kidney damage or infection.