Cystocele

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1- Introduction

2- Anatomical Overview

3- Causes

4- Treatment

Introduction

A cystocele, also known as a prolapsed bladder, occurs when the wall between a woman’s bladder and her vagina weakens and allows the bladder to droop or bulge into the vagina. This condition is a type of pelvic organ prolapse (POP), which can occur when the muscles and tissues supporting the pelvic organs become stretched or weakened, often due to childbirth, aging, or other factors.

Anatomical Overview

Damage to the pelvic floor during childbirth (e.g., laceration of perineal muscles, a lesion of the nerves supplying them, or rupture of the fascial support of the vagina (the paracolpium can result in a loss of bladder support, leading to collapse of the bladder onto the anterior vaginal wall. When intra-abdominal pressure increases (as when relaxing the pelvic floor and “bearing down” to compress the bladder during urination), the base of the bladder and upper urethra is pushed against the anterior wall of the vagina, which lacking support will in turn bulge into the vaginal lumen and may protrude through the vaginal orifice into the vestibule—cystocele (herniation of the urinary bladder). Even in the absence of a cystocele, weakened support to the vagina or pelvic floor may result in a lack of support of the urethra, which runs in close proximity to (essentially “embedded against”) the anterior vaginal wall. The lack of support may alter the normal placement, direction, or angle of the urethra (urethrocele), diminishing the usual passive compression of the urethra that helps to maintain urinary continence during temporary increases in intra-abdominal pressure at times outside of urination (e.g., during physical exertion, coughing, sneezing, or laughing) producing spurting or dribbling of urine—urodynamic stress incontinence. Nonsurgical treatments include pelvic floor muscle exercises, pessaries (devices placed in the vagina to provide support and resistance), and pharmacotherapy. Surgical treatment involves retethering of the vagina, and/or the placement of support directly to the urethra (e.g., urethral bulking agents, fascial or synthetic slings) to restore its direction and enable passive compression.

Causes

Childbirth: Childbirth, particularly vaginal delivery, is one of the most common causes of cystocele. The stretching and tearing of the pelvic floor muscles and connective tissues during childbirth can weaken the support structures that hold the bladder in place. Multiple vaginal deliveries or difficult deliveries, such as prolonged pushing or the use of forceps or vacuum extraction, may increase the risk of cystocele.
Aging: As women age, the muscles and tissues in the pelvic floor naturally weaken and lose elasticity. This age-related weakening of the pelvic floor can contribute to the development of cystocele, particularly in postmenopausal women.
Chronic Straining: Chronic straining or bearing down, often associated with constipation, chronic coughing, or heavy lifting, can increase intra-abdominal pressure and strain the pelvic floor muscles. Over time, this increased pressure can weaken the supportive tissues and contribute to pelvic organ prolapse, including cystocele.
Obesity: Excess body weight can place additional stress on the pelvic floor muscles and tissues, increasing the risk of pelvic organ prolapse, including cystocele. Obesity is associated with higher intra-abdominal pressure, which can further exacerbate pelvic floor weakness.
Hormonal Changes: Changes in hormone levels, such as those occurring during pregnancy, menopause, or hormone replacement therapy, can affect the strength and elasticity of the pelvic floor tissues. Estrogen, in particular, plays a role in maintaining the health and integrity of the pelvic floor muscles and connective tissues.
Genetic Factors: Some women may have an inherited predisposition to pelvic floor weakness or connective tissue disorders, which can increase their risk of developing cystocele.
Previous Pelvic Surgery: Previous pelvic surgeries, such as hysterectomy or pelvic organ prolapse repair, can disrupt the normal anatomy and weaken the supportive structures of the pelvic floor, potentially leading to cystocele or other types of pelvic organ prolapse.
Chronic Conditions: Certain chronic conditions, such as chronic obstructive pulmonary disease (COPD), which can cause chronic coughing, or neurological disorders that affect bladder function or pelvic floor muscles, may increase the risk of cystocele.
Heavy Lifting: Repetitive or heavy lifting, particularly without proper lifting techniques or pelvic floor support, can strain the pelvic floor muscles and contribute to pelvic organ prolapse, including cystocele.

Treatment

Pelvic Floor Muscle Exercises (Kegel exercises):
- Pelvic floor muscle exercises, also known as Kegel exercises, can help strengthen the muscles that support the pelvic organs, including the bladder. Regularly performing Kegel exercises may improve pelvic floor tone and reduce symptoms of cystocele, such as urinary leakage and pelvic pressure.
Lifestyle Modifications:
- Lifestyle changes can help alleviate symptoms and prevent further worsening of a cystocele. These may include:
  - Avoiding heavy lifting and activities that increase intra-abdominal pressure.
  - Maintaining a healthy weight to reduce strain on the pelvic floor muscles.
  - Treating and managing chronic conditions that contribute to cystocele, such as constipation or chronic cough.
Pessary Use:
- A pessary is a removable device that is inserted into the vagina to provide support to the prolapsed organs and alleviate symptoms of pelvic organ prolapse, including cystocele. Pessaries come in various shapes and sizes and can be fitted by a healthcare provider. Regular cleaning and follow-up care are necessary with pessary use.
Estrogen Therapy:
- In postmenopausal women, estrogen therapy may be prescribed to improve the health and elasticity of the vaginal tissues and support structures. Estrogen creams, tablets, or vaginal rings may be used to alleviate symptoms of cystocele and other forms of pelvic organ prolapse.
Surgical Repair:
- In cases where conservative measures are ineffective or symptoms are severe, surgical intervention may be necessary to repair the cystocele and restore pelvic floor support. Surgical options for cystocele repair include:
  - Anterior colporrhaphy: This procedure involves tightening and repairing the front wall of the vagina to support the bladder.
  - Vaginal mesh or graft placement: Synthetic mesh or biological grafts may be used to provide additional support to the weakened pelvic floor tissues. However, the use of vaginal mesh has been associated with potential risks and complications, and careful consideration is necessary.
  - Minimally invasive procedures: Laparoscopic or robotic-assisted techniques may be used to perform cystocele repair with smaller incisions and faster recovery times compared to traditional open surgery.
Combined Procedures:
- In some cases, a cystocele may coexist with other pelvic floor disorders, such as rectocele or uterine prolapse. Surgical repair of multiple pelvic floor defects may be performed concurrently during a single procedure, known as combined or staged prolapse repair.