A range of causes

Risk factors include vaginal childbirth, regularly straining on the toilet to pass bowel motions, unhealthy weight, smoking and chronic lung diseases with coughing. Repetitive lifting of heavy weights such as children or in the gym may also cause cystocele. Some women have a strong family history of prolapse.

Postmenopausal women are more susceptible to cystocele. This is because the sex hormone, oestrogen, helps to keep the muscles supporting the vagina and bladder – the pelvic floor muscles – in good tone. Once oestrogen levels drop, after the menopause, these muscles become thinner, weaker and less elastic. The vaginal skin stretches, which may allow the bladder to bulge backwards into the vagina.

A cystocele can occur by itself or it may happen along with other abnormalities such as a rectocele (when the bowel bulges forward into the back wall of the vagina) or a uterine prolapse (when the uterus and cervix drop down into the vagina and may protrude outside the vagina.)

Symptoms

The symptoms of cystocele depend on individual factors, such as the severity of the prolapse, level of physical activity and any other associated prolapse. They include:

• Stress incontinence – leaking urine when coughing, sneezing, laughing, standing up, running or walking. It may occur without a cystocele.
• Inability to completely empty the bladder after going to the toilet.
• Straining to get urine flow started or a slow flow of urine that tends to stop and start.
• A sensation of fullness or pressure inside the vagina.
• A bulge or swelling felt in the vagina.
• In severe cases, the vagina and bladder may protrude outside the vaginal entrance.

Grades of severity

Cystoceles can be graded in several ways. Mild, moderate and severe are descriptive but are subjective. Commonly used is:

• Stage 1 – the bladder protrudes a little way into the vagina.
• Stage 2 – the bladder protrudes so far into the vagina that it is close to the vaginal opening.
• Stage 3 – the bladder protrudes out of the vagina.

Gynaecologists with a special interest in prolapse now use a grading system called the POP-Q system which measures the degree of prolapse in centimetres in relation to the hymen. This system is thought to be more reproducible and standardised so that everyone involved in prolapse care is talking about the same thing.

Diagnosis

Cystocele is diagnosed by:

• Medical history – including checking for possible risk factors
• Physical examination – to allow grading of the cystocele, assessment of pelvic floor muscle strength and presence of other prolapse

Tests that may be indicated are:

• Bladder and/or pelvic ultrasound to exclude any masses or cysts putting pressure on the bladder.
• Urodynamics – a test of bladder function and to assess different types of incontinence
• Bladder ultrasound to measure residual urine – urine left in the bladder after passing urine
• A mid-stream urine test to exclude bladder infection

Treatment

Treatment for cystocele depends on the severity of the condition, but can include:

• Mild cases – when there are no symptoms, treatment may be unnecessary. Advice should be given to include lifestyle changes to prevent the condition from getting worse. Weight loss, management of constipation and correct position for sitting on the toilet, treatment of chronic cough and pelvic floor exercises to strengthen the pelvic floor muscles are all important.
• Moderate cases – all of the above lifestyle changes and pelvic floor physiotherapy are still important but surgery may also be indicated. Referral to a pelvic floor physiotherapist to assess pelvic floor and to teach the correct exercise technique is appropriate. For women who have symptoms and are either unfit for surgery or who wish to delay surgery, a ring pessary may also be used. The ring pessary is a device that is inserted high into the vagina to support the bladder. With long term use, there is a risk of ulceration of the vagina, regular follow up with a gynaecologist is necessary.
• Severe cases – surgery is usually required to repair a severe cystocele. There are different surgical techniques available.

Pelvic floor physiotherapy

Pelvic floor exercises help to increase the strength of the pelvic floor muscles. They may reduce the symptoms felt as the result of a mild to moderate cystocele and prevent any cystocele from worsening. These exercises may also reduce symptoms of stress incontinence, which may be associated with a cystocele. It is important to learn to do the exercises correctly to gain the most benefit. Most pilates or ‘get fit’ classes for women will include pelvic floor awareness as part of the program, however a one-on-one involvement with a specially trained pelvic floor physiotherapist will usually be required for women who have a symptomatic cystocele.

Surgery

Surgery for cystocele repair is usually done under general anaesthesia. Under specific circumstances, it may be done under spinal or epidural anaesthesia.

Different surgical techniques are now available, depending on the particular combination of prolapse and urinary tract symptoms.

Traditionally, the vaginal wall is opened, the bladder is separated from the vagina and the excess vaginal tissue is removed. The bladder is supported with buttressing sutures and then the vagina is closed.

Current techniques may also involve the use of supporting mesh, tissue graft or a tape to support the bladder and urethra in place.

Additional surgery will depend on the presence of other prolapse or vaginal weakness.

A urinary catheter to rest the bladder after surgery is common. The length of time will depend upon the particular operation. It is usually between hours and 3 days. Some operations now are day procedures.

Full recovery, during which time avoidance of lifting straining or overexercise is important, usually takes around 6 weeks.

Self-care suggestions

Your doctor may advise that you make a few lifestyle changes to prevent the cystocele from worsening (or recurring after surgery, which can happen). These suggestions may include:

• Don’t lift heavy objects over 10kg.This includes children and grandchildren!
• Exercise daily to help keep you regular but avoid heavy weight training, sit-ups and high impact exercise. Opt for lighter weights that you can easily lift without straining, core strengthening on an exercise ball and cardio-vascular exercise such as walking, swimming or bike riding rather than running, jumping or high impact aerobics.
• When exercising in the gym, avoid weight-training which causes you to hold your breath or strain. It is preferable to reduce the weight size and increase repetitions. Walking on a treadmill, with or without an incline, is a suitable exercise.
• Increase the amount of fibre in your diet to prevent constipation and straining. Once instance of straining can worsen the cystocele. You should have 30g of fibre daily.
• Drink between six and eight glasses of water each day. Not drinking enough water makes stools hard, dry and difficult to pass.
• Avoid straining on the toilet for either bowels or bladder; use the hissing or sighing technique.
• Perform pelvic floor exercises daily to strengthen the muscles supporting the pelvic organs. You may need instruction from your doctor or other health care professional, such as a pelvic floor rehabilitation physiotherapist.
• Always squeeze up your pelvic floor muscles before you lift, cough, laugh or sneeze.
• If you are postmenopausal, your doctor may recommend hormone therapy, usually in the form of local oestrogen preparations such as a cream, pessary or a vaginal tablet, to help tone the muscles supporting the vagina and bladder.
• Seek medical advice for any condition that causes coughing and sneezing such as asthma, chest infections and hay fever as repetitive sneezing and coughing may cause or worsen cystocele.
• Keep yourself within a healthy weight range. Being overweight is known to worsen symptoms.

Where to get help

• Your doctor
• Gynaecologist
• A specialist pelvic floor physiotherapist or health professional
• The Jean Hailes Foundation - www.jeanhailes.org.au
• National Continence Helpline Tel. 1800 33 00 66

Things to remember

• A cystocele is when the bladder bulges out into an overstretched vagina.
• Risk factors include vaginal childbirth, repetitive heavy lifting and regularly straining on the toilet to pass bowel motions.
• Severe cases of cystocele need surgical repair.

Further resources

Related articles

• Bladder and bowel health
• Incontinence

Books

• Incontinence: the hidden epidemic

Websites

• Continence Foundation of Australia - www.continence.org.au
• Australia Physiotherapy Association - www.physiotherapy.asn.au/

Content Updated March 18, 2011