Cystocele (Dropped Bladder) Repair

 

Cystocele is one of the pelvic relaxation problems that can occur as a result of weak pelvic tissues.  Normally, the bladder is well supported and sits in front of the uterus. A cystocele results when the bladder drops down into an abnormal position and bulges through the roof of the vagina. Picture a hammock that has been used for too long. If someone lies in an old hammock, his or her bottom sinks through the middle. Even if the fabric on the sides of the hammock is strong and supportive, the middle is still loose. Now picture a cystocele, which is the bladder bulging through the roof (the hammock) of the vagina. In severe cases, the bladder actually protrudes outside the vagina. 

Who gets a Cystocele?

Vaginal deliveries, particularly if the labor is long and the baby is large, are the greatest risk factor for pelvic relaxation. It isn't the only risk factor, since most women who deliver vaginally don't end up with problems. Family history seems to be a major factor. Tissue that is prone to damage is an inherited tendency, and it is not unusual for a woman with a cystocele to mention that her mother and grandmother had the same problem. Take a genetic predisposition, add a nine-pound baby and three hours of pushing, and something is going to give. Once the tissue is damaged, it never completely regains its strength and elasticity; the effects of gravity and age then compound the problem.

Smoking is also a major risk factor. Smokers have poor tissue in general and chronic coughing weakens tissue even further. Long distance runners may also have a greater propensity for cystocele and other pelvic relaxation problems. The running probably doesn’t cause the weakened tissue; it just makes an already tenuous situation worse from the constant pounding.

 It's not unusual for women with only a slight cystocele to be unaware of the problem until they go through menopause. Vaginal and pelvic tissues depend on estrogen to maintain their strength and elasticity. The decline of estrogen, which occurs at menopause, can result in a sudden worsening of symptoms, particularly if a woman chooses not to take hormone therapy. Many women who stop postmenopausal estrogen replacement find that pelvic organ prolapse is far more bothersome than the hot flashes.

How do you know if you have a cystocele?

Symptoms are generally related to the severity of the cystocele; in other words, how far the bladder has dropped. In a first-degree cystocele, the bladder is only slightly lower than its normal position and most women are totally unaware that something has shifted unless their gynecologist points it out. A further drop creates a second-degree cystocele, which is the point when some women become aware that something is not quite right. Still, many women with a second-degree prolapse have no symptoms. By the time the bladder drops low enough to protrude at the opening of the vagina or outside the vagina (third- and fourth-degree prolapse), most women are definitely aware there is a problem. 

The most common symptom that someone reports is the feeling that "something is bulging or falling down," which is not surprising since that is exactly what has happened.  Many women, in addition to constant pressure, actually feel a mass or bulge at the vaginal opening. A quick look in the mirror (a hand mirror with a long handle works really well) and you can see something pink bulging out.  Some women also suffer from incontinence, but that is not always the case. 

Does Anything Prevent It From Happening?

Women who have never been pregnant almost never have a significant cystocele. Women who labor but ultimately end up with a Cesarean section are at less risk than if they had delivered vaginally, but still at some risk.

Treatment Options

Surgery
A cystocele can be repaired as an outpatient procedure performed vaginally by reconstructing the roof of the vagina.  Prior to surgery, urodynamic testing is recommended to determine if a urethral sling for treatment or prevention of incontinence is needed.  Cystocele surgery is often performed in conjunction with other corrective procedures in the case of uterine prolapse, or a rectocele.

 

Non-Surgical Treatment of Cystocele 
Non-surgical options are available and useful in the treatment of a cystocele if the condition is not severe, or if a woman is a poor surgical candidate. Some women simply want to avoid surgery or need to delay surgery until a more convenient time.

 

Estrogen 
Vaginal tissues and supporting structures depend on estrogen for strength and elasticity. Women in low-estrogen states (menopause, breastfeeding moms) often are the most symptomatic. The use of estrogen in the form of vaginal rings, tablets or vaginal creams will often improve a mild prolapse such that no other treatment is needed. Severe cystoceles (third or fourth degree) will rarely respond to estrogen therapy alone, but can be useful as an adjunct to other therapy.

Menopausal women who are scheduled for surgery will have a better result if they are pretreated with estrogen for at least a few weeks before surgery. The tissue is much easier to work with and will be more supportive. Often, gynecologists will recommend continuing the use of vaginal estrogen creams after surgery to maintain surgical results, particularly if the vaginal tissues are dry and thin.

Exercises
Every woman who has ever had a problem with incontinence or prolapse has been instructed in the fine art of Kegel and other pelvic muscle exercises.

 Kegel exercises can strengthen the sides, but not the middle. The only way to strengthen the middle is by surgically repairing the loose area using stronger tissue. Pelvic physical therapy is helpful, but does not often provide adequate relief in severe cases. 

Does it make sense to wait it out? 
Surgical treatment should never be considered in a woman who recently had a baby. Tissues damaged during childbirth, once given the chance to heal, often improve. Many women panic when they discover that, in addition to all the other new surprises that come with motherhood, they are unable to make it to the bathroom without losing urine. Before running out and buying diapers in two sizes (newborn and adult), it's important not to overreact. A symptomatic cystocele in the first few weeks after delivery, especially in breast feeding moms who have lower than normal estrogen levels, is not an indication of a long-term problem. There is always improvement after nursing is concluded and hormones return to pre-pregnancy levels. Often the problem completely resolves.

If someone already has normal estrogen levels, and has eliminated smoking and high impact exercise from their routine, further spontaneous improvement is unlikely. What nobody can predict is: will it get worse? Therein lies the difficulty. Many women can endure the situation as it is, but are worried that as the years go on, the cystocele will progress to an intolerable point. They will then be in the position of needing surgery when they are much older and potentially too sick to safely undergo an operation. The vision of lying in a nursing home with diapers and a pessary is one scenario most people would like to avoid, but it is difficult to predict which women with moderate pelvic relaxation will ultimately end up with a severe problem. Another reason some women opt to do surgery before they absolutely need it is that pelvic reconstructive surgery (like a facelift) holds up better if it is done with younger, more elastic tissue.

Having said that, expectant management is appropriate if symptoms are tolerable and as long as the bladder is not actually hanging outside the vagina. Once that happens, treatment is no longer elective. When exposed to air, vaginal tissue dries out, breaks down, bleeds, and over time becomes macerated and potentially infected. That situation is potentially life-threatening and requires immediate surgery.

Women who choose to wait it out in hopes that things won't get worse should be seen at regular intervals to insure that the situation is not deteriorating. Most women, though, know when something has changed.

Pessaries
Pessaries are not new. In fact, devices placed temporarily in the vagina to lift up the uterus and bladder have been around long before modern medicine. There is documentation of a Roman medicated pessary as early as AD 30. Modern pessaries can be left in place for up to three months at a time with interval visits for cleaning and replacement. Younger women are usually able to clean and replace their pessaries themselves, allowing for less frequent visits.

In the past, pessaries were often recommended for women who were felt to be poor surgical candidates due to age or chronic illness. Pessary use is far less frequent in recent years since improved surgical and anesthetic techniques have made surgery a safer, more reasonable option for older and sicker patients. There are still some situations in which a pessary is useful and appropriate.

Some women simply don't want to go through surgery and are willing to live with the inconvenience and limited relief of a pessary. Some women are so elderly or sick that surgical intervention would be dangerous or inappropriate. If young women with symptomatic pelvic relaxation desires more children, a pessary is a good option to alleviate symptoms until her family is complete and she is ready for definitive surgery. Some women with slight cystocele are only symptomatic at certain times, such as when they are playing golf, or tennis, and find a pessary useful to use on an "as-needed" basis.

Short-term pessary use is appropriate for women to make them more comfortable if a planned surgery needs to be delayed.  

There are multiple types of pessaries and finding the right pessary, in the right size, is the key to success.

There are rings, rings with a rubber support (much like a diaphragm), cubes, donut shapes, and inflatable balls. The type of pessary is dependent on the degree of prolapse, and presence of other pelvic defects such as a uterine prolapse or rectocele. Each type of device comes in multiple sizes.  

Once the correct pessary is in place, most women can be taught to take out and replace it for cleaning. Some women are unable or unwilling to do this, in which case they must return at least every three months for cleaning and examination.

Most women that are motivated to use a pessary do well and are generally satisfied with the device, at least for the short term. One study showed that approximately fifty percent of women fitted for a pessary were still using it and satisfied sixteen months later.

 


(Excerpt from The Essential Guide to Hysterectomy)