Bladder Prolapse – Causes, Symptoms, Treatment

A bladder prolapse causes the pressure inside the bladder to increase, causing discomfort and urinary incontinence. We’ve all experienced what it feels like to have a full bladder, with nowhere to empty it, and how it no longer sits comfortably within the pelvis. Urinary incontinence can range from occasional stress urinary incontinence, where women may leak a small amount of urine if they cough or sneeze, to a more severe inability to hold in urine.

The bladder is a balloon-shaped, muscular bag that sits comfortably within the pelvis as it constantly fills with urine. The muscular front walls of the vagina (anterior walls) and the pelvic area help to support the bladder and hold it in place. If the muscles in the front wall of the vagina loosen and deteriorate too much, then a bladder prolapse can occur, where the bladder falls into the vagina.

Bladder prolapse is a common condition in women. It can be disruptive, embarrassing, and inconvenient, but it is treatable.

bladder are held in their normal positions just above the inside end of the vagina by a “hammock” made up of supportive muscles and ligaments. Wear and tear on these supportive structures in the pelvis can allow the bottom of the uterus, the floor of the bladder or both to sag through the muscle and ligament layers.

When this occurs, the uterus or bladder can create a bulge into the vagina. In severe cases, it is possible for the sagging uterus or bladder to work its way down far enough that the bulge can appear at the vagina’s opening or even protrude from the opening.

When the uterus sags downward, it is called uterine prolapse. When the bladder sags, it is called bladder prolapse, also known as a cystocele.

Types of Bladder Prolapse

Types of Bladder Prolapse Various stresses can cause the pelvic muscles and ligaments to weaken and lead to uterine or bladder prolapse. The most significant stress on these muscles and ligaments is childbirth. Women who have had multiple pregnancies and vaginal delivery are more likely to develop prolapse.

There are three different types of bladder prolapse, cystocele, urethrocele, and cystourethrocele. These can occur in isolation or together:

• Cystocele – The most common type of pelvic organ prolapse, when the whole bladder bulges or drops into the vagina. Cystocele is commonly associated with the prolapse of other organs within the pelvis.
• Urethrocele – When the tissues surrounding the urethra (the tube that carries urine from the bladder and out of the body) prolapse, or drop down into the vagina.
• Cystourethrocele – Both the bladder and the urethral tissues prolapse into the vagina together.

Stages of a Bladder Prolapse

Bladder prolapse is diagnosed by a doctor or surgeon, and can occur in three stages, or grades:

• Stage 1 – The bladder has dropped only a short distance into the vagina, and bladder prolapse symptoms are mild.
• Stage 2 – The bladder has dropped a further distance into the vagina and has reached the outer opening of the vagina. Bladder prolapse symptoms are moderate.
• Stage 3 – The bladder has dropped so sufficiently into the vagina, that it begins to protrude out through the outer opening of the vagina. Bladder prolapse symptoms become the most advanced they can get.

Causes of Bladder Prolapse

The bladder and/or the urethral tissue can prolapse into the vagina if the pelvic floor muscles are weakened. These can be weakened by several factors:

• Pregnancy – Extra weight on the pelvic floor can cause the muscles to weaken.
• Childbirth – Again, around 50% of women who give birth vaginally will experience some level of prolapse. A large baby or a difficult birth where you’ve had to push a lot or forceps were used may increase your risk. More than one birth also increases your risk of experiencing a vaginal prolapse. Mothers who deliver four babies vaginally are at 12 times greater risk than women who have not given birth vaginally.
• Menopause – The change in hormones you experience during this time of your life, particularly the drop in estrogen, can cause your pelvic floor muscles to weaken. Effects can be worsened by the general loss of muscle tone associated with aging.
• Bodyweight – Being overweight or obese can increase your chances of suffering a pelvic organ prolapse due to the weight on your pelvic area.
• Persistent coughing – Constant heavy coughing can add pressure to the pelvic floor. If you smoke and have a persistent smoker’s cough or if you have a lung condition that results in a cough, such as asthma or bronchitis, then you could be at a higher risk.
• Heavy lifting – Repeated and incorrect heavy lifting puts extra pressure on your pelvic floor.
• Constipation – Continued straining to pass a stool will put extra pressure on the pelvic floor and could cause it to weaken.
• Hysterectomy – Many women who have had a hysterectomy (the complete removal of the womb and cervix) suffer a secondary prolapse. The uterus provides support for the other pelvic organs, if it is no longer there, then the bladder can gradually fall towards the vaginal opening.
• Previous pelvic surgeries – A hysterectomy or previous vaginal prolapse surgery can weaken the pelvic floor muscles, and is likely to be part of the cause of any future pelvic organ prolapses.
• Medical conditions – Medical conditions that weaken the pelvic floor muscles, such as joint hypermobility syndrome (the ability to maneuver joints into unusual positions).

Symptoms of Bladder Prolapse

There are many symptoms that accompany bladder prolapse. In the early stages of a prolapsed bladder, they may even be unnoticeable. The following warning signs are common and can be experienced as very mild to severe, you may also only experience a few of these symptoms:

• heaviness or a feeling of pressure in the vagina
• a feeling that there is something inside and/or falling out of the vagina
• visible tissue poking out from the vagina that is tender and/or bleeds
• a frequent urge and/or an urgent need to pass urine
• difficulty urinating, not feeling like your bladder has fully emptied after passing urine
• urinary incontinence – the inability to hold urine in when not on the toilet
• stress incontinence – passing small amounts of urine when coughing, sneezing, laughing, exercising or lifting heavyweight
• Nocturia – the medical term for getting up more than once during the night to pass urine
• discomfort and pain when urinating
• frequent bladder or urinary infections such as cystitis
• pain during sex
• pain in the lower back, pelvis or groin

With the number of different prolapse conditions and their close proximity to each other in the body, it can be difficult to know which symptoms point to which condition. Visiting your doctor to get a diagnosis is important and can help you decide which course of treatment is best for you.

or

Mild cases of bladder or uterine prolapse usually don’t cause any symptoms. A prolapse that is more advanced can cause any of the following symptoms:

• Discomfort in the vagina, pelvis, lower abdomen, groin or lower back. The discomfort associated with prolapse often is described as a pulling or aching sensation. It can be worse during sexual intercourse or menstruation.
• Heaviness or pressure in the vaginal area. Some women feel like something is about to fall out of the vagina.
• A bulge of moist pink tissue from the vagina. This exposed tissue may be irritated and cause itching or small sores that can bleed.
• Leakage of urine, which can be worse with heavy lifting, coughing, laughing or sneezing
• Frequent urination or a frequent urge to urinate
• Frequent urinary tract infections, because the bladder can’t empty completely when you urinate
• A need to push your fingers into your vagina, into your rectum, or against the skin near your vagina to empty your bladder or have a bowel movement
• Difficulty having a bowel movement
• Pain with sexual intercourse, urine leakage during sex, or an inability to have an orgasm
• Moist discharge that soils your undergarments

Diagnosis of Bladder Prolapse

A health care professional may ask about your

• symptoms, such as bulges or lumps in the vagina, pelvic pressure or heaviness, and urinary incontinence
• pregnancy and childbirth history
• current and past medical problems, including surgeries
• family history
• over-the-counter and prescription medicines
• bowel habits

History

It has a broad range of symptoms. Some patients may present as asymptomatic while others may demonstrate a significant impact on the quality of life, including the following symptoms[rx]:

• Pelvic pain/pressure
• Posterior vaginal bulge
• Obstructive defecation
• Incomplete defecation
• Constipation
• Dyspareunia
• Erosions and bleeding of mucosa if there is tissue exposure to the outside environment

Evaluation

• A pelvic exam – You may be examined while lying down and possibly while standing up. During the exam, your doctor looks for a tissue bulge in your vagina that indicates pelvic organ prolapse. You’ll likely be asked to bear down as if during a bowel movement to see how much that affects the degree of prolapse. To check the strength of your pelvic floor muscles, you’ll be asked to contact them, as if you’re trying to stop the stream of urine.
• Filling out a questionnaire – You may fill out a form that helps your doctor assess your medical history, the degree of your prolapse, and how much it affects your quality of life. This information also helps guide treatment decisions.
• Bladder and urine tests – If you have significant prolapse, you might be tested to see how well and completely your bladder empties. Your doctor might also run a test on a urine sample to look for signs of a bladder infection if it seems that you’re retaining more urine in your bladder than is normal after urinating.
• Urodynamics – Measures the bladder’s ability to hold and release urine.
• Cystoscopy (cystourethroscopy) – A long tube-like instrument is passed through the urethra to examine the bladder and urinary tract for malformations, blockages, tumors, or stone
• A special test – that can be done to confirm a rectocele is defecography. The patient will have a contrast medium instilled in the vagina, bladder, and rectum. Using a special commode, the patient will be instructed to defecate while the X-ray is taken. This test can be useful to determine the size of the rectocele, larger than 2 cm is considered abnormal.[rx]
• Urodynamic studies – can be helpful in patients with rectocele and complex voiding issues. If a patient is receiving surgery, it may be useful to determine if the patient has urinary incontinence with the prolapse reduced. If there is incontinence with reduction with prolapse, it may be helpful to include a procedure to prevent urinary incontinence in the plan.[rx]
• Pelvic floor strength test – During the pelvic examination, the doctor tests the strength of the pelvic floor, the sphincter muscles, and muscles and ligaments that support the vaginal walls, uterus, rectum, urethra, and bladder. Irregularities in this test can help diagnose vaginal prolapse and determine if kegel exercises would be helpful to the patient.
• Bladder function test – Otherwise known as urodynamics, bladder function tests determine the ability of the bladder to store and eliminate urine. This is measured in two ways. Uroflowmetry measures the volume and force of the urine stream. Cystometrogram is a procedure that fills the bladder with water via a catheter. Measurements of the volume are noted when the patient indicates the urgency of urination.

Another useful diagnostic tool for surgical planning is dynamic MRI (DMRI) which provides visualization of the rectocele and movements of the pelvic floor.[rx] DMRI is a valuable adjunct test when a patient’s symptoms are more significant than the physical examination findings suggest. Its use for preoperative planning has made it more widespread.[rx]

Treatments of Bladder Prolapse

Non-pharmacological

• Kegel exercises – Also known as pelvic floor exercises, Kegel exercises are simple and quick to do and can easily be slotted into your day. No one will even know you’re doing them! Kegel exercises are essential in preventing existing prolapses from deteriorating further.
• Maintain your weight – Excess weight is not only unhealthy for your heart, being overweight can put extra pressure on your pelvic floor muscles and cause, or worsen, a bladder prolapse. The National Institute for Heath and Care Excellence (NICE) recommends keeping your BMI under 30.
• Avoid constipation – Constant straining can weaken your pelvic floor muscles, cause hemorrhoids and anal bleeding. Eat well and stay hydrated so that your bowel movements are regular. A high fiber breakfast will help. You can also use a toilet stool to bring your knees up and force you into the ideal posture for fully eliminating your bowels when you’re on the toilet.
• Lift heavy weights safely – Lifting correctly will make all the difference to not only your back but your pelvic area too. The National Health Service (NHS) suggest holding the load close to your waist and avoid bending your back.
• Have good posture, even when sitting down – Walk tall and sit tall; no slouching at your desk or in the car. Remember BBC – Bum to the Back of the Chair.
• Wearing a vaginal pessary – A vaginal pessary will help to better support even severely prolapsed bladders. It’s a small device, usually made from silicone, that is placed inside the vagina to help support the vaginal wall and keep the bladder in place. Different shapes and sizes of vaginal pessaries suit different shapes and sizes of women; your doctor can help you find the right one.
• Avoiding high impact exercise – High impact exercise puts increased pressure on the pelvic floor, especially troublesome if you suffer with stress incontinence. Stick to low impact, prolapse friendly workouts, such as swimming and road cycling.
• Using a pelvic toner – The Kegel8 Ultra 20 Pelvic Toner features a program specifically developed with prolapse in mind. Depending on the severity of your bladder prolapse, it can help reduce your symptoms and improve your bladder prolapse within 12 weeks by strengthening your pelvic floor muscles.

Your prolapsed bladder treatment very much depends on the severity of your condition. Many minor cases will not require treatment, and following the tips above can help prevent it from becoming a bladder prolapse that does.

• Non-surgical prolapsed bladder treatment – Kegel exercises using weighted vaginal cones to strengthen your pelvic muscles, and electronic pelvic toners with specific prolapsed bladder exercise programs, maybe all the treatment you need. Losing weight can also help significantly, as can wearing a vaginal pessary. In some menopausal women, estrogen replacement therapy can also help. These non-surgical treatments are often preferred, particularly when future children are desired, which may reduce the success of previous surgical procedures.
• Surgical prolapsed bladder treatment – There are circumstances when you might need surgical intervention for your prolapsed bladder; such as when non-surgical treatments do not fully relieve the symptoms and they remain severe. Procedures involve surgically repairing the vaginal wall and placing the bladder back into its natural position within the pelvic cavity. The most common surgical prolapsed bladder treatment is called an ‘anterior vaginal repair’. Your surgeon repairs the walls of the vagina by stitching the folded tissues onto themselves, to make them stronger. Some surgeries use synthetic or biological mesh as added support to weakened muscle. The use of synthetic mesh in these surgeries is currently only recommended within the context of research, as current evidence into the safety of the procedure is insufficient. Surgery is considered as an option only when symptoms are severe and cannot be treated through other means, as there is a risk of further damage in the case of complications. It is important to note that surgery is unable to repair the pelvic floor muscles, so you will need to perform pelvic floor exercises after your recovery to prevent the prolapse from returning and to support any synthetic or biological mesh from stretching which could lead to a prolapse reoccurring.

References

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