Prolapsed Cystocele – Causes, Symptoms, Treatment

Prolapsed Cystocele is when the bladder begins to droop down from its normal position, so much so that it protrudes into the front wall of the vagina, the anterior wall. Prolapse can happen to any organ of the pelvis; the bladder, small bowel, rectum, uterus or even the vagina itself. Any pelvic organ prolapse happens because the muscular system that holds everything in place, the pelvic floor muscles, have weakened.

A cystocele can be inconvenient and embarrassing, but it’s comforting to know that they are very common in women, even if they’re not talked about directly much. You may have heard mum’s talk about not being able to go on trampolines or chase their children around the park without leaking. Pregnancy, childbirth, and menopause can all contribute to a weakened pelvic floor but thankfully, performing daily pelvic floor exercises can help prevent, and treat, a cystocele prolapse.

As with most medical problems, it’s important not to put off treatment. Allowing your prolapse to go untreated for a long period of time leads to weakened pelvic muscles and damage to associated nerves – increasing the risk of it reoccurring. To avoid unnecessary delays and speak to your doctor if you have any concerns.

What Is the Difference Between a Cystocele and Rectocele Prolapse?

Any organ within the pelvic area can be affected by a weak pelvic floor, which can no longer hold them in place. A cystocele prolapse is a name for when the bladder bulges into the front (anterior) vaginal wall, and a rectocele prolapse is a name for when the rectum bulges into the back (posterior) wall of the vagina. It is common for both cystocele and rectocele prolapses to occur together, and luckily, they have many of the same treatments so can often be treated together.

Stages of Cystocele Prolapse

There are three main stages of a cystocele prolapse, your doctor will be able to diagnose which stage you are at:

• Stage 1 – The bladder has protruded only a short distance into the vaginal wall and symptoms are mild.
• Stage 2 – The bladder has protruded sufficiently into the vagina that it has reached the opening of the vagina. This protrusion may be visible from the outside of the vagina temporarily through coughing or straining.
• Stage 3 – The bladder has significantly protruded into the vagina and is permanently visibly bulging from the outside of the vagina.

Causes of Prolapsed Cystocele

Being overweight or obese, having had multiple pregnancies, and going through menopause are all risk factors for developing a cystocele prolapse. As can anything that contributes to the weakening of the pelvic floor muscles:

• 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.
• 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.
• 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.
• Constipation – Continued straining to pass a stool will put extra pressure on the pelvic floor and could cause it to weaken.
• Bodyweight – Being overweight or obese can increase your chances of suffering a prolapse due to the weight of your pelvic area.
• Heavy lifting – Repeated and incorrect heavy lifting puts extra pressure on your pelvic floor.
• Strenuous activity – Heavy, high impact exercises such as running or plyometric training (jump training) can cause the pelvic floor muscles to weaken.
• Previous pelvic surgeries – A 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.
• Genetics – A family history of prolapse can suggest you are at a higher risk.
• Hysterectomy – The complete removal of the womb and cervix. The uterus provides support for the top of the vagina, if it is no longer there, then the top of the vagina can gradually fall towards the vaginal opening and the vaginal walls weaken.

Symptoms of  Prolapsed Cystocele

If you believe you are developing a cystocele prolapse, or you have been diagnosed with one, then you may experience some or all of the following symptoms. The most common symptom being frequent bladder and urinary tract infections (cystitis):

• frequent bladder and urinary tract infections (cystitis)
• urinary stress incontinence – passing small streams or drops of urine when you cough, sneeze, laugh, jump, run or lift a heavy object or child
• urinary incontinence – the inability to hold in urine at all during everyday life
• a frequent urge to pass urine
• an urgent need to pass urine
• difficulty passing urine
• discomfort, pain or blood when passing urine
• not feeling satisfied that your bladder has emptied fully after going to the toilet
• pain in the lower back or pelvic area
• pain when having sex
• a feeling that there is something uncomfortable inside the vagina
• a feeling that there is something about to fall out of your vagina
• a feeling of heaviness, dragging or pressure inside the vagina
• unusual bleeding not associated with your period
• red tissue poking from the vagina when you cough or strain
• red tissue poking from your vagina permanently

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 on which course of treatment is best for you.

Diagnosis of Prolapsed Cystocele

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

Rectoceles have 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

Physical Exam

A thorough examination will include a vaginal exam, rectal exam, abdominal exam, and focused neurological exam.

The focused neurological exam consists of levator ani muscle tone and contraction strength.

The vaginal exam can be evaluated using the Baden-Walker or POP-Q exam. The Baden-Walker system utilizes one measurement. The distance of the most distal portion of the prolapse from the hymen while the patient is completing the Valsalva maneuver.[rx]

Treatments of Prolapsed Cystocele

Sometimes, the only treatment you’ll need for a cystocele prolapse is regular pelvic floor exercises and some lifestyle changes. Usually, this will be the case if you have a mild cystocele or even a moderate one.

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. Non-surgical treatments are also preferred when future children are desired, which can reduce the success of previous surgical procedures:

• Kegel exercises – Performing daily pelvic floor exercises could be all you need to keep your urethrocele prolapse under control. Using an electronic pelvic toner such as the Kegel8 Ultra 20 Pelvic Toner will make them more beneficial. Also known as pelvic floor exercises; you can do them quickly and easily, at any time of day as no one will know you’re doing them. They help to strengthen the pelvic floor muscles. You can make them even more effective by using an electronic pelvic toner.
• Maintain your weight – Making sure you stick to a healthy weight will put less pressure on your pelvic floor muscles, giving you more chance of keeping them strong. The National Institute for Heath and Care Excellence (NICE) recommends keeping your BMI under 30.
• Avoiding constipation – Eating a high fiber diet of fruits, vegetables, and wholegrain cereals will help your bowels stay regular, as will drinking plenty of water.
• Avoid straining on the toilet – Straining on the toilet puts unnecessary pressure on the pelvic floor muscles. Using a toilet stool when you pass a bowel movement will help avoid straining as it puts your body in the optimum position for fully emptying your bowels.
• Lift heavyweights (and children) 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.
• Avoid too much high impact exercise – High impact exercises are great for overall health. But if you’re worried about a prolapse, then gentler, lower impact exercise like swimming will be better.
• Treat that cough – Persistent heavy coughing can cause a weakening in the pelvic floor muscles that may not become apparent straight away. Get medical help for a cough that lasts longer than a week.
• Good posture – Make sure you have good posture, especially when seated – walk tall and sit tall with no slouching and adopt the BBC, Bum to the Back of the Chair, method.
• Lifestyle changes – Maintain a healthy weight and avoid constipation, heavy lifting and prolonged coughing.
• Hormone treatment – Hormone supplements and topical estrogen creams can help boost the levels of the hormones you may be lacking through menopause or age that weaken the pelvic floor.
• Wearing a vaginal pessary – A vaginal pessary will support a pelvic organ prolapse. It’s a small, usually silicone, device that is placed inside the vagina to help support the vaginal wall and prevent other pelvic organs from collapsing further into it. Different shapes and sizes of vaginal pessaries suit different shapes and sizes of women. Your doctor can help you find the right one and help you change the pessary every four to six months. This is commonly the favored treatment for those unable to undergo surgery due to medical conditions or those wishing to have children in the future.

In the circumstance of non-surgical treatments not fully relieving your symptoms and they remain severe, you may be advised to have a surgical intervention for your cystocele prolapse. However, as cystocele prolapse is a long term condition that requires long term treatment, you will be advised to undergo lifestyle changes and daily Kegel exercises to complement any successes following surgery.

Several surgical procedures are currently available and may be completed in conjunction to repair all prolapses you are experiencing:

• Surgery – Cystocele repair surgery involves lifting and moving the bladder and tightening the ligaments that hold it in place. Your surgeon will also strengthen the walls of your vagina with a few deep surgical stitches as a preventative measure. The three most common techniques are called anterior colporrhaphy, anterior colporrhaphy with graft and paravaginal repair. 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. It is important to note that surgery is unable to repair the pelvic floor muscles. 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 recurrence.

How Long Does it Take to Recover from Cystocele Prolapse Surgery?

Following a cystocele repair surgery, a catheter and vaginal packing soaked with estrogen cream will be inserted and not removed until your appointment the following day. You would normally expect to be up and about as normal within four to six weeks. After six weeks, you should be able to have sex, but should refrain from heavy lifting or completing in any strenuous exercise for three months post-op. Further follow-up visits are usually 2 months after the operation, with a series of further follow-ups throughout the following year, and then eventually annually – at the discretion of the operating surgeon.

It is important to note that there are a number of reported complications associated with cystocele repair surgery. If a synthetic mesh has been used, there is a 25% risk of the material moving into the vagina causing pain. The use of synthetic mesh is also associated with three times more long-term complications than in patients without a synthetic mesh fitted. This includes feeling the mesh during sex, leading to painful sex for both parties, or in some cases the complete inability to have sex.

Following the recovery from a pelvic organ surgery, you may notice different or less sensation during sex. This can be improved by building pelvic floor / Kegel exercises, into your routine. A physiotherapist will be able to advise on the best pelvic floor exercises for you.

If you do opt for surgery, it is important to note that surgery cannot repair your pelvic floor muscles. You will need to perform pelvic floor exercises after your recovery, to prevent the prolapse from recurring. There is a 30% chance of developing a future prolapse following a pelvic organ surgery, due to the damage to the tissue. Other non-surgical treatments should also be followed to prevent future prolapses; such as eating well to avoid constipation and maintaining a healthy weight.

Complication

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

References