Do you have an uncomfortable feeling that something is dropping down from your vagina? Do you feel a vaginal bulge? If yes, you may be suffering from a type of prolapse called as a cystocele.

Cystocele is a condition in which your bladder drops into the front wall of the vagina causing a vaginal bulge. Cystocele is the herniation of the bladder into the vagina (“cyst” refers to the bladder as the bladder is fluid filled and “cele” stands for herniation).

Cystocele is the most common type of prolapse. It is often associated with the prolapse of the urethra into the front wall of the vagina and in this case, it is called as a cystourethrocele.

What causes cystocele?

There is a supporting layer of tissue in between the bladder and the front wall of the vagina. It is called as the “fascia” and it holds the bladder in place. Any weakening of this tissue can cause the bladder to bulge into the vagina. The location of the bulge depends on where the fascia gets weakened. The weakening of the central part of the fascia leads to a “central cystocele’. The weakening of the sides of the fascia can cause the bladder to tear off from its attachment to the pelvic wall on either side. This is called as a ‘paravaginal defect’.

Cystocele results from the damage to the pelvic floor caused by excessive stretching during childbirth as discussed in the overall article on prolapse. It can be associated with prolapse of the other compartments of the pelvis simultaneously.

What are the symptoms of the cystocele?

Often a woman with cystocele will have no symptoms. When symptoms are present, they are most commonly

  • A feeling of bulge in the vagina or something dropping into the vagina
  • A dragging sensation in the pelvis and a lower backache
  • Pain with sexual intercourse or vaginal bleeding can also occur.

A cystocele is often accompanied by urinary symptoms such as a slow urinary stream, a feeling of incomplete bladder emptying, urinary frequency or urgency and stress urinary incontinence. You can read more about stress urinary incontinence here.

How is a cystocele diagnosed?

Most commonly, a cystocele is found incidentally during a pelvic examination by the doctor. It is important to undergo a complete physical and pelvic examination to determine whether the symptoms are due to a cystocele alone or due to other co-existent problems. The urogynecologist will grade the severity of the cystocele during the pelvic examination.

When the patient has co-existing urinary symptoms, it may be important to undergo urodynamic testing to determine the exact cause of the symptoms.

If on vaginal examination, the doctor feels that the patient has paradoxical contraction of the pelvic floor muscles (she is pushing down on the pelvic floor muscles when asked to squeeze), an ultrasound examination of the pelvic floor may be necessary to confirm the diagnosis and to demonstrate conclusively the improper contraction of the pelvic floor muscles.

How is cystocele treated?

Non-surgical management

  • Pelvic floor exercises (Kegel exercises) help to improve pelvic muscle tone. If you do not know how to exercise the right group of muscles, the physiotherapist will work with you to ensure that you learn to identify the right muscles.
  • A patient with cystocele may benefit from a course of pelvic floor physiotherapy if she has the paradoxical contraction of the pelvic floor muscles. The physiotherapist will work with the patient to help identify the right group of muscles and contract them properly. The physiotherapist may use tools such as biofeedback to train the patient. In biofeedback, a small pressure probe is inserted into the vagina and connected to a visual or sound display. The signals given by the display help the patient identify the right muscles and contract them better.

Vaginal estrogen therapy: Estrogen applied locally to the vagina helps reduce atrophy of the vaginal lining and helps to slow the progression of cystocele. In women with severe atrophy of the vaginal lining, a three month course of estrogen therapy to make the vagina healthier may be beneficial before performing any surgery.

Surgical management: Surgery should be considered in patients in whom symptoms interfere with daily activities. In a woman who has opted for medical management initially, surgery may be considered if the non-surgical treatment options fail. Surgery is usually performed through the vaginal route. The weakened fascia in between the bladder and the front wall of the vagina is strengthened. If there is a paravaginal defect, the bladder is reattached to the pelvic sidewalls. If there is a big paravaginal defect, it may have to be repaired through an abdominal incision. In the later case, we perform a laparoscopic surgery.

You need to properly discuss with the doctor the option that is best for you. It is important to know that no matter how efficient the surgeon or how well the surgery was performed, the success rates are generally 80 – 85%. Hence performing the proper procedure for your type of cystocele and choosing a doctor trained in pelvic floor reconstructive surgery is very important to assure the best surgical outcomes.

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