Cystocele


A cystocele, also known as a prolapsed bladder, is a medical condition in which a woman's bladder bulges into her vagina. Some may have no symptoms. Others may have trouble starting urination, urinary incontinence, or frequent urination. Complications may include recurrent urinary tract infections and urinary retention. Cystocele and a prolapsed urethra often occur together and is called a cystourethrocele. Cystocele can negatively affect quality of life.
Causes include childbirth, constipation, chronic cough, heavy lifting, hysterectomy, genetics, and being overweight. The underlying mechanism involves weakening of muscles and connective tissue between the bladder and vagina. Diagnosis is often based on symptoms and examination.
If the cystocele causes few symptoms, avoiding heavy lifting or straining may be all that is recommended. In those with more significant symptoms a vaginal pessary, pelvic muscle exercises, or surgery may be recommended. The type of surgery typically done is known as a colporrhaphy. The condition becomes more common with age. About a third of women over the age of 50 are affected to some degree.

Signs and symptoms

The symptoms of a cystocele may include:
  • a vaginal bulge
  • the feeling that something is falling out of the vagina
  • the sensation of pelvic heaviness or fullness
  • difficulty starting a urine stream
  • a feeling of incomplete urination
  • frequent or urgent urination
  • fecal incontinence
  • frequent urinary tract infections
  • back and pelvic pain
  • fatigue
  • painful sexual intercourse
  • bleeding
A bladder that has dropped from its normal position and into the vagina can cause some forms of incontinence and incomplete emptying of the bladder.

Complications

Complications may include urinary retention, recurring urinary tract infections and incontinence. The anterior vaginal wall may protrude though the vaginal introitus. This can interfere with sexual activity. Recurrent urinary tract infections are common for those who have urinary retention. In addition, though cystocele can be treated, some treatments may not alleviate troubling symptoms, and further treatment may need to be performed. Cystoceles may affect the quality of life; women who have cystoceles tend to avoid leaving their homes and avoid social situations. The resulting incontinence puts women at risk of being placed in a nursing home or long-term care facility.

Cause

A cystocele occurs when the muscles, fascia, tendons and connective tissues between a woman's bladder and vagina weaken, or detach. The type of cystocele that can develop can be due to one, two or three vaginal wall attachment failures: the midline defect, the paravaginal defect, and the transverse defect. The midline defect is a cystocele caused by the overstretching of the vaginal wall; the paravaginal defect is the separation of the vaginal connective tissue at the arcus tendineus fascia pelvis; the transverse defect is when the pubocervical fascia becomes detached from the top of the vagina. There is some pelvic prolapse in 40–60% of women who have given birth. Muscle injuries have been identified in women with cystocele. These injuries are more likely to occur in women who have given birth than those who have not. These muscular injuries result in less support to the anterior vaginal wall.
Some women with connective tissue disorders are predisposed to developing anterior vaginal wall collapse. Up to one third of women with Marfan syndrome have a history of vaginal wall collapse. Ehlers-Danlos syndrome in women is associated with a rate of 3 out of 4.

Risk factors

Risk factors for developing a cystocele are:
Connective tissue disorders predispose women to developing cystocele and other pelvic organ prolapses. The tissues tensile strength of the vaginal wall decreases when the structure of the collagen fibers change and become weaker.

Diagnosis

There are two types of cystocele. The first is distension. This is thought to be due to the overstretching of the vaginal wall and is most often associated with aging, menopause and vaginal delivery. It can be observed when the rugae are less visible or absent. The second type is displacement. Displacement is the detachment or abnormal elongation of supportive tissue.
The initial assessment of cystocele can include a pelvic exam to evaluate leakage of urine when the women is asked to bear down or give a strong cough, and the anterior vaginal wall measured and evaluated for the appearance of a cystocele. If a woman has difficulty emptying her bladder, the clinician may measure the amount of urine left in the woman's bladder after she urinates called the postvoid residual. This is measured by ultrasound. A voiding cystourethrogram involves taking X-rays of the bladder during urination. This X-ray shows the shape of the bladder and lets the doctor see any problems that might block the normal flow of urine. A urine culture and sensitivity test will assess the presence of a urinary tract infection that may be related to urinary retention. Other tests may be needed to find or rule out problems in other parts of the urinary system. Differential diagnosis will be improved by identifying possible inflammation of the Skene's glands and Bartholin glands.

Grading

Several scales exist to grade the severity of a cystocele.
The pelvic organ prolapse quantification assessment, developed in 1996, quantifies the descent of the cystocele into the vagina. The POP-Q provides reliable description of the support of the anterior, posterior and apical vaginal wall. It uses objective and precise measurements to the reference point, the hymen. Cystocele and prolapse of the vagina from other causes is staged using POP-Q criteria and can range from good support reported as a POP-Q stage 0 or I to a POP-Q score of IV which includes prolapse beyond the hymen. It is also used to quantify the movement of other structures into the vaginal lumen and their descent.
The Baden–Walker Halfway Scoring System is used as the second most used system and assigns the classifications as mild when the bladder droops only a short way into the vagina; cystocele, the bladder sinks far enough to reach the opening of the vagina; and when the bladder bulges out through the opening of the vagina.

Classifications

Cystoceles can be further described as being apical, medial, or lateral.
Apical cystocele is located upper third of the vagina. The structures involved are the endopelvic fascia and ligaments. The cardinal ligaments and the uterosacral ligaments suspend the upper vaginal-dome. The cystocele in this region of the vagina is thought to be due to a cardinal ligament defect.
Medial cystocele forms in the mid-vagina and is related to a defect in the suspension provided by a sagittal suspension system defect in the uterosacral ligaments and pubocervical fascia. The pubocervical fascia may thin or tear and create the cystocele. An aid in diagnosis is the creation of a 'shiny' spot on the epithelium of the vagina. This defect can be assessed by MRI.
Lateral cystocele forms when the pelviperineal muscle and its ligamentous–fascial develop a defect. The ligamentous– fascial creates a 'hammock-like' suspension and support for the lateral sides of the vagina. Defects in this lateral support system result in a lack of bladder support. Cystocele that develops laterally is associated with an anatomic imbalance between anterior vaginal wall and the arcus tendineus fasciae pelvis – the essential ligament structure.

Prevention

Cystocele may be mild enough not to result in symptoms that are troubling to a woman. In this case, steps to prevent it from worsening include:
  • smoking cessation
  • losing weight
  • pelvic floor strengthening
  • treatment of a chronic cough
  • maintaining healthy bowel habits
  • * eating high fiber foods
  • * avoiding constipation and straining

    Treatment

Treatment options range from no treatment for a mild cystocele to surgery for a more extensive cystocele. If a cystocele is not bothersome, the clinician may only recommend avoiding heavy lifting or straining that could cause the cystocele to worsen. If symptoms are moderately bothersome, the doctor may recommend a pessary, a device placed in the vagina to hold the bladder in place and to block protrusion. Treatment can consist of a combination of non-surgical and surgical management. Treatment choice is also related to age, desire to have children, severity of impairment, desire to continue sexual intercourse, and other diseases that a woman may have.

Non-surgical

Cystocele is often treated by non-surgical means:
  • Pessary – This is a removable device inserted into the vagina to support the anterior vaginal wall. Pessaries come in many different shapes and sizes. Vaginal pessaries can immediately relieve prolapse and prolapse-related symptoms. There are sometimes complications with the use of a pessary.
  • Pelvic floor muscle therapy – Pelvic floor exercises to strengthen vaginal support can be of benefit. Specialized physical therapy can be prescribed to help strengthen the pelvic floor muscles.
  • Dietary changes – Ingesting high fiber foods will aid in promoting bowel movements.
  • Estrogen – intravaginal administration helps to prevent pelvic muscle atrophy