Medial Cystocele – Causes, Symptoms, Treatment

Medial Cystocele forms in the mid-vagina and is related to a defect in the suspension provided by to a sagittal suspension system defect in the uterosacral ligaments and pubocervical fascia. The pubocervical fascia may thin or tear and create the cystocele. Aid in diagnosis is the creation of a ‘shiny’ spot on the epithelium of the vagina. This defect can be assessed by MRI.^[ex][rx]

A cystocele otherwise known as a protrusion of the bladder occurs when the bladder descends into the vagina. The bladder bulges through the anterior wall of the vagina, with which it is anatomically associated. There are multiple underlying causes for the development of cystocele resulting in weakness of the muscles and the connective tissue surrounding the bladder and vagina.[rx]

A cystocele is the most common type of pelvic organ prolapse. Pelvic organ prolapse occurs when the vaginal walls, uterus, or both lose their normal support and prolapse, or bulge, into the vaginal canal or through the vaginal opening. Other nearby pelvic organs, such as the bladder or bowel, may be involved and also drop from their normal position in the body.

Types of Cystocele

Cystocele can be further described as being apical, medial, lateral, or mediolateral.

• Apical cystocele is located in the 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.^[rx][rx]
• Medial cystocele – forms in the mid-vagina and is related to a defect in the suspension provided by to a sagittal suspension system defect in the uterosacral ligaments and pubocervical fascia. The pubocervical fascia may thin or tear and create the cystocele. Aid in diagnosis is the creation of a ‘shiny’ spot on the epithelium of the vagina. This defect can be assessed by MRI.^[ex][rx]
• Lateral cystocele – forms when both the pelvic perineal 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 the anterior vaginal wall and the arcus tendinous fasciae pelvis – the essential ligament structure.^[rx][rx]

Causes of Medial Cystocele

Cystoceles result from a weakness of the pelvic-floor support system. The main associated risk factors are obesity, increasing age, and parity. They can also occur due to chronically increased intra-abdominal pressure, collagen abnormality, family history of cystocele, and following pelvic surgery.

• Obesity – Giri et al., in their systematic review, reported that women with BMI >25 had a risk ratio of 1.36 (95% confidence interval) for developing prolapse, while women with BMI >30 had a risk ratio of 1.47 (95% confidence interval).[rx] Another study suggested that in overweight and obese women, the risk of progression of a cystocele increased by 32% and 48%, respectively, compared with participants with normal BMI.[rx] However, few studies have shown that weight loss did not lead to symptoms resolution or regression of the prolapse. In particular, in some of them, weight loss was associated with a borderline worsening of uterine prolapse, indicating that the damage to the pelvic floor is irreversible.[rx][rx]
• Advancing Age – A number of studies have shown a strong link between aging and vaginal prolapse.[rx][rx] It is suggested that age-related changes in pelvic anatomy, innervation, and vasculature cause weakness in pelvic floor strength.[rx] A study of vaginal tissue biopsies discovered that collagen in the vaginal wall changes its structure over time, which might explain the link between aging and cystocele development.[rx]
• Parity and Other Childbirth-related Factors – Vaginal delivery carries a high risk for pelvic floor weakness.[rx] The attenuation of the pelvic floor muscles has been shown to increase with parity. Nygaard et al. showed that the prevalence of pelvic floor disorders increases by 12.8%, 18.4%, 24,6%, and 32.4% for 0, 1, 2, and 3 deliveries, respectively.[rx] Moreover, it was found that forceps delivery plays a critical role in levator ani muscle avulsion.[rx] Mant et al. specifically suggest that the first stage of labor is responsible for developing a vaginal prolapse.[rx]
• Increased Intra-abdominal Pressure – Increased intra-abdominal pressure seems to have a weak correlation with anterior vaginal prolapse. Several studies indicated a correlation between cystocele development and constipation, chronic cough, and obstructive pulmonary disease, which are all associated with chronically increased abdominal pressure.[rx][rx][rx]
• Collagen Abnormality – The predominant type of collagen found in the vaginal wall is type III, designed to be resistant to sudden pressure changes, which is essential in tissues that require elasticity. In women with vaginal prolapse, the amount of collagen III in the vaginal tissue was higher than in healthy women, possibly due to the underlying remodeling.[rx] Women with congenital conditions affecting collagen production, such as Marfan and Ehlers-Danlos syndrome, are predisposed to developing cystocele.[rx][rx] Up to a third of women with Marfans and three-quarters of women with Ehlers-Danols have a history of vaginal wall prolapse.[rx]
• Family History – Even though there are no known specific genes responsible for the development of vaginal prolapse, a review of sixteen studies has revealed that women with pelvic prolapse are highly likely to have a relative suffering from the same condition.[rx]
• Pelvic Surgery – Surgery of the pelvis, especially hysterectomy, causes damage to the endopelvic fascia and nerves. This, in turn, results in a greater risk of vaginal prolapse and herniation of the bladder.[rx]

Risk factors

Risk factors for developing a cystocele are:

Connective tissue disorders predispose women to developing cystocele and another pelvic organ prolapse. The tissues tensile strength of the vaginal wall decreases when the structure of the collagen fibers change and become weaker.^[rx]

Symptoms of Medial Cystocele

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^[rx]
• frequent urinary tract infections
• back and pelvic pain
• fatigue
• painful sexual intercourse^[rx]
• bleeding^[rx]
• A feeling of fullness or pressure in your pelvis and vagina
• In some cases, a bulge of tissue in your vagina that you can see or feel
• Increased pelvic pressure when you strain, cough, bear down or lift
• Problems urinating, including difficulty starting a urine stream, the feeling that you haven’t completely emptied your bladder after urinating, feeling a frequent need to urinate or leaking urine (urinary incontinence)
• A cystocele also called a prolapsed or dropped bladder, is the bulging or dropping of the bladder into the vagina.
• A cystocele occurs when the muscles and supportive tissues between a woman’s bladder and vagina weaken and stretch, letting the bladder sag from its normal position and bulge into the vagina or through the vaginal opening.
• Diagnosing a cystocele requires medical tests and a physical exam of the vagina.
• Cystocele treatment depends on the severity of the cystocele and whether a woman has symptoms.

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.^[rx]

Diagnosis of Medial Cystocele

The most objective and standard tool for evaluating the severity of the anterior wall prolapse is the POPQ system, which was introduced in 1996. This system is recognized by The American College of Obstetricians and Gynecologists and consists of 4 stages.

• Stage 0 – no prolapse
• Stage 1 – most distal part of prolapse is -1cm (above the level of the hymen)
• Stage 2 – most distal part of prolapse is >= -1cm but <= +1cm (<=1cm above or below the hymenal plane)
• Stage 3 – most outside portion of the prolapse >+1cm but <+(total vaginal length -2)cm (beyond the hymen; protrudes no farther than 2cm less than the total vaginal length)
• Stage 4 – complete eversion of the vagina; most distal portion of the prolapse >= +(total vaginal length -2) cm.[rx]

Three stages are used for patients after removal of the uterus and four if the uterus is present.

Medical history

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

Diagnosis of anterior prolapse may involve

• 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

Treatment of Medial Cystocele

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. There are sometimes complications with the use of a pessary.^[rx]
• 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.^[rx][rx]
• Dietary changes – Ingesting high fiber foods will aid in promoting bowel movements.^[rx]
• Estrogen – intravaginal administration helps to prevent pelvic muscle atrophy^[rx]
• Kegel exercises – (pelvic muscle exercises) can be advised for women with stage 1 or 2 prolapse. It is found that these exercises improve prolapses by 1-2 cm on average. A systematic review and meta-analysis of the effectiveness of Pelvic Floor Muscle Therapy (PFMT) showed that women involved in pelvic muscle training showed better outcomes regarding symptoms and reduction of the size of the prolapse compared to control groups.[rx] Supervised muscle training for at least 12-16 weeks can be considered for such women to measure the improvement.[rx] The exercises should be continued if they are proved to be beneficial for the patient.

• Hormone Replacement Therapy – is not a treatment for cystocele. There is no evidence that estrogen’s topical or systemic use reduces the size of cystocele; the creams or estrogen-containing vaginal pessaries can still be used for women with cystocele for treating signs of vaginal atrophy, which may occur concurrently.[rx] Another study has shown the pre-operative use of topical estrogen creams improve the synthesis of collagen, preventing thinning of the vaginal wall, and reducing the activity of degrading enzymes.[rx]

It is essential to encourage the patient to work on modifiable risk factors, such as a high BMI (>30), smoking, heavy lifting, chronic cough, or constipation.

Surgical Management

Surgical management is the next step for symptomatic women, those who require immediate relief, those who have declined conservative treatment, or for whom the conservative approach has failed to provide benefit. It should be noted that surgical management should follow the completion of the patient’s family as the pelvic support system can be further damaged during labor.

Surgical planning depends on whether the anterior vaginal prolapse is isolated or is combined with apical or posterior vaginal prolapse. A careful examination is required as a part of preoperative planning.

Anterior colporrhaphy

Anterior repair is performed trans-vaginally to repair central vaginal wall defects and to lessen the size of the anterior vaginal wall.

For this procedure, a patient is placed in the lithotomy position and catheterized; a Sims speculum is inserted to achieve a better view of the defect. An Allis forceps are placed at the midline of the anterior wall 1cm proximal to the urethra and two more forceps on each side next to the cervix or the vaginal cuff. Local infiltration with an adrenaline/lidocaine solution is commonly used to achieve hydro-dissection, analgesia, and to minimize intraoperative bleeding. With the use of Metzenbaum scissors, dissection of vaginal mucosa from the underlying vesicovaginal fascia is performed. When the mucosal layer is entirely free, a folding of the muscular layer and adventitia using figure-of-eight sutures is performed. Careful placement of the sutures is crucial in order not to damage the bladder.

2-0 Vicryl or PDS sutures are most often used. After successful plication, the excessive vaginal mucosa is removed, and the wound is closed with absorbable sutures.  The surgeon should be careful not to reduce the diameter of the vagina too much, as later it may cause pain during sexual intercourse. One study has reported the success rate of surgical approach ranging from 63% to 76.5%, depending on the procedure followed.[rx]

Sacral colpopexy

The other way to repair a bladder prolapse is to perform a sacral colpopexy, which is usually done laparoscopically. This procedure aims to place a permanent mesh to the anterior and posterior walls of the vagina and then attach it to the anterior longitudinal ligament below the sacral promontory. The operation can be performed together with anterior colporrhaphy or on its own. The benefit of sacral colpopexy is that it avoids vaginal incisions and scarring, which results in a lower risk of vaginal shortening or dyspareunia. The success rate of this procedure is 60% to 89%.[rx] A randomized trial indicated that laparoscopic sacral colpopexy has a higher success rate and a lower chance of repeat procedure for both anterior and posterior vaginal prolapses.[rx]

In many countries, including the US and the UK, the use of mesh for cystocele repairs has been suspended since 2019, pending an investigation into their use.[rx]

Complication

Post-surgical complications can develop. The complications following surgical treatment of cystocele are:

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