Cystocele - (also known as “Dropped bladder”) defined as a hernia of the bladder in which the supportive tissue weakens and causes the bladder to fall into the vagina. If you imagine, the vagina to be a tunnel, it is sometimes helpful to consider that a cystocele occurs when the ceiling of your tunnel starts to bulge down into the tunnel. This tunnel analogy will also help us understand what happens with a rectocele, and with uterine prolapse.
Symptoms of a Cystocele
The first thing one may notice with a cystocele is a vaginal bulge. This can often be seen even before the patient feels anything. Over time the bulge may get bigger or lower in the vagina. The natural history of cystoceles is to get worse over time. As it does, the patient may experience a sense of vaginal pressure. But ofter, there may be no symptoms at all. Sometimes women may notice the bulge when they wipe after urinating. When a cystocele becomes very advanced, it may progress to the point of blocking the complete emptying of the bladder during normal urination. If this occurs, the patient may experience a feeling of never being completely empty, or she may notice that she cannot sleep through the night without getting up to urinate several times (this is called nocturia). She may also experience the frequent need to empty her bladder during the day (urinary frequency). The range of symptoms is extremely variable and may range from no symptoms at all to a major quality of life issue.
The treatment options available are numerous. Most importantly, an option that is many times overlooked or not discussed with gynecologic patients is the option of no treatment at all. I have seen many patients who have come to me for a second opinion because they have been recommended to have surgery. My approach to this problem is always to consider the most conservative option first. If there is no effect on bladder function and the patient has no bothersome symptoms, the best treatment is conservative (non-surgical) managment. In the office as part of the initial visit we will teach you pelvic floor exercises which may help slow the progression of your cystocele.
If a cystocele is symptomatic or if the dropping of the bladder is blocking adequate emptying of the bladder then the next option offered may be a pessary. A pessary is an object that is placed in the vagina which acts as a physical barrier for the bladder and vaginal wall, preventing or reducing the amount of bulge. A pessary for many women is a great option. Pessaries are often not offered because of physician bias against them. Many patient who come to me for a second opinion tell me, “yes, I have heard of the pessary option, but my doctor told me that it is not for me, that I am too young for a pessary”.
There are three options for the treatment of a cystocele:
- Conservative management (or no active treatment). This option can include pelvic floor exercises
- Pessary management. A pessary is a flexible device for which there are many different sizes and shapes. The device is placed in the vagina and acts as a physical dam, to hold up whatever part has fallen. It can be used successfully for cystocele, rectocele or uterine prolapse or any combination of dropped organs
- Surgery - there are many different surgical options for cystocele repair. The most commonly performed is a colporrhaphy, which is also the least successful. Colporrhaphies will fail in 30-40% of patients, sometimes within a year. This very poor track record and high failure rate is often not discussed with patients who are surprised to find the cystocele return.