Cystocele

Cystocele, also known as prolapsed bladder or anterior vaginal wall collapse, is a condition where a woman's bladder bulges into her vagina due to weakened muscles and connective tissue. This condition often affects women over 50, and its prevalence increases with age.

Overview

Signs and Symptoms

A cystocele can manifest with various symptoms, including:

• Vaginal bulge
• Sensation of something falling out of the vagina
• Pelvic heaviness or fullness
• Difficulty starting urination
• Feeling of incomplete urination
• Frequent or urgent urination
• Faecal incontinence
• Frequent urinary tract infections
• Back and pelvic pain
• Fatigue
• Painful sexual intercourse
• Bleeding

These symptoms can significantly impact a woman's quality of life, leading to complications like urinary retention, recurrent urinary tract infections, and incontinence.

Causes and Risk Factors

Cystocele results from the weakening or detachment of muscles, fascia, tendons, and connective tissues between the bladder and vagina. Common causes and risk factors include:

• Childbirth
• Constipation
• Chronic cough
• Heavy lifting
• Hysterectomy
• Genetic predispositions
• Being overweight

Pelvic floor trauma, connective tissue disorders like Marfan syndrome and Ehlers-Danlos syndrome, and conditions causing increased intra-abdominal pressure such as COPD and obesity also contribute to the development of cystocele.

Diagnosis

Diagnosis of cystocele is based on symptoms and physical examination. Pelvic exams assess urine leakage during bearing down or coughing and measure the anterior vaginal wall's descent. Additional tests may include:

• Postvoid residual measurement using ultrasound
• Voiding cystourethrogram
• Urine culture and sensitivity test

Differential diagnosis includes Bartholin cyst, nabothian cyst, and urethral diverticulum.

Grading and Classification

Cystocele severity is graded using systems like the Pelvic Organ Prolapse Quantification (POP-Q) system and the Baden-Walker Halfway Scoring System. The condition can be classified as apical, medial, or lateral, depending on the location and nature of the defect.

Prevention

Preventive measures for cystocele include:

• Smoking cessation
• Weight loss
• Pelvic floor strengthening exercises
• Treatment of chronic cough
• Maintaining healthy bowel habits with high-fibre foods to avoid constipation

Treatment

Non-Surgical Treatment

Non-surgical options for cystocele include:

• Pessary: A removable device inserted into the vagina to support the bladder.
• Pelvic floor muscle therapy: Exercises to strengthen vaginal support.
• Dietary changes: High-fibre foods to promote bowel movements.
• Oestrogen therapy: Intravaginal administration to prevent pelvic muscle atrophy.

Surgical Treatment

Surgical options depend on the severity and location of the cystocele. Common procedures include colporrhaphy, which involves folding and suturing the vaginal tissue to strengthen support. Surgical mesh may be used to reinforce repairs, although it has a 10-50% failure rate.

Other surgical techniques include:

• Paravaginal defect repair: Laparoscopic surgery through the abdomen to repair lateral ligaments and supportive structures.
• Sacrocolpopexy: Attachment of the vaginal vault to the sacrum, often used for recurrent or severe cases.
• Colpocleisis: Closure of the vaginal opening for women who no longer desire vaginal intercourse.

Post-Surgical Care

Post-surgical care involves activity restrictions, monitoring for infection, and avoiding actions that increase intra-abdominal pressure. Complications can include anaesthesia side effects, bleeding, infection, painful intercourse, incontinence, constipation, and urinary tract infections.

Epidemiology

Cystocele affects approximately one-third of women over 50. In the US, over 200,000 surgeries are performed annually for pelvic organ prolapse, with cystocele accounting for 81% of these. The incidence of cystocele symptoms peaks between ages 70 and 79.

History

Historical treatments for cystocele date back to ancient Egypt and Greece, where various methods like inversion therapy and the use of astringent lotions were employed. Surgical advancements in the 19th and 20th centuries, including the introduction of anaesthesia and antisepsis, significantly improved outcomes for women with cystocele.

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Self-assessment MCQs (single best answer)

What is another name for cystocele?

Which of the following is NOT a symptom of cystocele?

What is a common risk factor for developing cystocele?

Which diagnostic test measures the amount of urine left in the bladder after urination?

What is the purpose of a pessary in the treatment of cystocele?

Which surgical procedure involves folding and suturing the vaginal tissue to strengthen support for cystocele?

What dietary change is recommended for preventing cystocele?

Which system is used for grading the severity of cystocele?

What is the estimated prevalence of cystocele in women over 50?

Which condition is included in the differential diagnosis of cystocele?