Cystocele - Causes, Symptoms, Diagnosis, and Treatment

Introduction

Cystocele is a common disorder seen in women. The weakening of the bladder ligaments and the muscles present between the urinary bladder and vagina characterizes this condition. As a result, the bladder falls into the vagina, so this condition is also known as the fallen bladder. The vagina is a muscular organ that forms an integral part of the female reproductive system and links the uterus to the outside of the body. The urinary bladder is a bag-like organ that acts as a storage site for urine.

What Is a Cystocele?

Cystocele is a condition that arises due to the weakening of the pelvic floor muscles resulting in excessive pressure upon it, ultimately causing the drop of the bladder into the vagina. The pelvis is a structure present in the lower part of the body between the legs and the stomach. The organs present within the pelvic cavity are listed below:

1. Organs that are involved in reproduction.

2. Urinary bladder (a bag-like structure that stores the urine).

3. Ureters (the tube-like structures responsible for carrying the urine from the kidneys to the urinary bladder).

4. Urethra (tubes responsible for carrying the urine outside the body).

The three grades of cystocele are listed in the table below:

The function of the pelvis is to provide support to the organs mentioned above so that they remain in their proper position. However, in conditions such as pregnancy, weight lifting, and constipation, pressure increases upon the pelvic floor, which causes the weakening of the muscles to present within the pelvis. This results in the wall between the pelvis and bladder collapsing, ultimately causing the bladder to fall into the vagina. Cystocele should not be confused with rectocele as the former occurs when the bladder slips into the vagina, and the latter arises when the rectum (the organ that holds the stool) falls into the vagina.

What Are the Causes and Risk Factors of a Cystocele?

There are certain conditions due to which pressure develops on the pelvic floor, causing the weakening of the muscles, connective tissues, and ligaments present within the pelvis. These conditions are also the risk factors for cystocele, and they are listed below:

• Vaginal Delivery: It is the most common and the safest mode of childbirth. The term that doctors often use is "normal delivery," which implies this vaginal delivery. It is the most preferred method of child delivery worldwide compared to a cesarean section or C-section. However, sometimes, due to trauma or multiple pregnancies, the muscles that form the pelvic floor and support the vagina get strained so that they cannot support the urinary bladder. As a result of which, the bladder sinks into the vagina. This situation most commonly arises in vaginal delivery and has been reported in more than 35 percent of women.

• Obesity: Excessive body weight (obesity) increases the risk of bladder prolapse because it increases the pressure within the abdomen resulting in the weakening of the muscles that comprise the pelvic floor. When the muscle becomes weak, there is no support left for the bladder, and it drops into the vagina.

• Weight Lifting: Women who lift heavy objects or weights repeatedly are always at the risk of uterine prolapse. Lifting weights more than the capacity of the body strains and weakens the muscles of the pelvic floor, which support the uterus causing it to slip into the vagina.

• Constipation: The condition in which the bowel moments are not regular, and the patient passes less than three stools a week. The stools remain within the body resulting in pressure on the floor of the pelvis.

• Coughing: During coughing, the muscles present within the stomach and pelvis contract vigorously. These contractions cause pressure on the bladder and the pelvic muscles.

• Menopause: It is the period in which the menstrual cycle (periods) ends in the life of a woman at the age of 45 to 50 years. The hormone level within the body changes, and mainly, the estrogen hormone levels go down. Estrogen is responsible for regulating the reproductive functions in females and provides strength to the pelvis muscles. The lowered estrogen levels weaken the pelvic muscles, increasing the risk of bladder prolapse.

What Are the Symptoms of a Cystocele?

Cystoceles do not present with symptoms in mild cases, but if the condition persists for a prolonged period, it can present with the following symptoms:

1. There is a constant feeling of heaviness in the vagina and lower part of the abdomen (near the pelvis). Also, a bulge in the vagina is both seen and felt.

2. There are several problems that a patient faces related to urinary flow, and they are listed below:

• Difficulty in the passage of urine.

• The patient rushes to the bathroom frequently for urination because of the constant feeling that the bladder is not empty.

• Difficulty in starting the flow of urine, and the flow of urine stops before the bladder becomes empty.

• Due to the frequent need to urinate, urine might leak, resulting in urinary incontinence. - Pressure is felt in the pelvic region throughout the day during activities like standing, coughing, or lifting something. -The patient might feel pain at the time of sex as there is discomfort within the vagina due to the bladder prolapse.

How Is a Cystocele Diagnosed?

The diagnosis of cystocele involves the following steps:

Medical History Form: The doctor asks the patient to fill out a medical history form to get an idea about the condition of the disease and the health of the patient. The questions are based on the following:

• Any symptoms of fullness or heaviness in the vagina or pressure felt in the lower abdominal region (pelvic region).
• History of pregnancy to further evaluate the condition because vaginal delivery is one of the risk factors for cystocele.
• Family history to check if anyone in the family has been diagnosed with this condition.
• Bladder and bowel habits to know if the patient has difficulty passing out urine or stools to rule out constipation.
• Information is also needed about the drugs the patient is consuming.

Physical Examination: The doctor examines the patient both in the standing and the supine (lying down) position. The physical examination involves the following:

• Examination of the vagina is done to check if there is any tissue bulging into it. For example, in the case of cystocele, the bladder bulges into the vagina so that the doctor will feel it upon examination.
• The doctor usually asks the patient to sit in a similar position during a bowel movement to check how far the bladder has slipped into the vagina.
• To assess the strength of pelvic muscles, the doctor asks the patient to tighten them, just like holding the flow of urine.

Urine Tests: One of the symptoms of cystocele or bladder prolapse is difficulty in the passage of urine as the urine remains retained within the bladder and the patient frequently rushes to the bathroom for urination. Therefore, the following tests are carried out as a urine examination:

• Post-void Residual Urine Test: The patient is asked to pass urine and empty the bladder. The doctor then evaluates the amount of urine remaining in the bladder by the following methods:
• Ultrasound: An imaging test in which X-ray images of the bladder and vagina are obtained on the screen. These images help the doctor understand the amount of urine present within the bladder.
• Catheterization: In this method, the doctor inserts a tube known as a catheter to drain the urine present within the bladder. The doctor then measures the amount of urine drained out from the bladder and compares it with the standard values.
• Voiding Cystourethrogram: An imaging test in which the bladder is filled with a particular type of liquid. X-ray images are used to see when the bladder is filled with liquid and when the patient passes out urine. In addition, it allows the doctor to check if the bladder and the kidneys are working correctly or not.

What Are the Treatment Options for Cystocele?

Not all cases of cystocele present with symptoms and need to require treatment urgently. The doctor will suggest the treatment only if the condition is severe and the patient is symptomatic. The treatment options include:

• Kegel Exercises: These exercises target the pelvic muscles (the muscles used to stop the urine flow) and strengthen them. The stronger the muscles of the pelvic floor, the better they support the bladder and other organs. It is important that the patient follows the instructions given by the doctor and only then performs these exercises. In these exercises, the patient must tighten the pelvic floor muscles and focus only on them for five to ten seconds, and they are relaxed again.

• Vaginal Support Device: The device inserted into the vagina for support is known as a pessary. The device is a plastic or rubber ring inserted by the doctor to support the bladder. It will only provide relief from the symptoms and in no way work to cure the disease.

Is It Required to Do Surgery?

Surgery is required in only those cases where the patient is under constant discomfort due to the symptoms, and the doctor might recommend the following surgical treatments:

1. Anterior Colporrhaphy: This procedure is meant to repair the cystocele. This method involves shifting the bladder back to the place and tightening the muscles that support the bladder with the help of stitches.

2. Urethral Suspension Surgery: This surgery mainly supports the urethra (tubes that carry urine outside the body) to prevent urine leakage.

3. Obliterative Surgery: In this procedure, the inner walls and all other parts of the vagina that support the bladder are closed to prevent it from bulging inwards.

Lifestyle Changes: The following lifestyle changes can help prevent the development of pressure upon the muscles of the pelvis:

1. Foods rich in fibers like bananas, apples, and beans help proper bowel movement and prevent constipation.

2. Coughing produces unnecessary pressure on the pelvic muscles, so the patient needs to manage the cough to prevent anterior bladder prolapse.

3. The patient should avoid lifting heavy objects or weights because that strains the pelvic muscles and weakens them.

4. It is important to maintain a correct body weight because obesity or excessive body weight increases the pressure upon the abdominal muscles.

What Are the Complications of a Cystocele?

The complications of cystocele mainly arise when the patient is not responding well to the treatment or the condition has progressed to an advanced stage. In the advanced case, the muscles supporting the pelvis become strained to such an extent that they cannot support the uterus, and it ultimately slips into the vagina or bulges out of the vagina. This condition is known as procidentia. One of the symptoms of bladder prolapse is urine retention; this increases the risk of urinary tract infection as the urine present within the body becomes a medium for bacterial growth. In rare cases, the condition recurs.

Conclusion:

Cystocele is not a life-threatening condition, but the condition can become severe if not treated at the right time. Women find it difficult to urinate and experience other symptoms related to the urinary system. The patient needs to consult the doctor as soon as any such symptoms are noticed to make a timely diagnosis, and the patient lives a healthy life ahead. An important point that needs to be remembered is that no treatment is required in mild cases, and only lifestyle modifications can help the patient cure the condition.