Cystocele

A cystocele is a downward bulge of the bladder into the front wall of the vagina.


Causes/associated factors
The bladder, uterus and other pelvic organs in the lower abdomen are supported by muscles, ligaments and connective tissue (strong sheets of fiber). Weakness in this area may cause the bladder to protrude into the vagina. Throughout much of a womanevels decline with age, however, these supportive structures may weaken as well. Excessive stretching during childbirth is another common cause of pelvic weakness. On occasion, even younger women who have never given birth may develop a cystocele.
Other possible causes include anything that increases pressure inside the abdomen, such as prolonged heavy lifting, chronic coughing, obesity, chronic constipation or pelvic tumors, and an inherited weakness in connective tissue or muscle strength.


Signs and symptoms
There may be no symptoms early on. If the cystocele enlarges and puts additional pressure on the vaginal wall, you may experience:
a feeling of pelvic heaviness or fullness, much like the sensation of sitting on a ball
low backache
incontinence (the inability to control the release of urine), often when you sneeze, cough, laugh, lift something or walk
incomplete emptying of the bladder
painful vaginal intercourse
If the cystocele allows urine to pool, you may notice symptoms similar to a bladder infection -- a burning sensation when you urinate, more frequent urination and an increased urgency to urinate. In more severe cases, a cystocele may actually cause an infection.

Symptoms of a cystocele are typically much worse after standing for long periods of time and at the end of the day. The symptoms usually go away when you lie down.


Diagnosis
The doctor will ask questions about your medical history and do a physical exam, including a pelvic exam. The doctor may feel the bulge in your vaginal wall, especially if you have a full bladder during the exam. To check for infection or determine if urine is being retained, catheterization (draining urine from your bladder through a special tube) and a urinalysis may be necessary. Typically, the doctor is able to make a diagnosis based on the physical exam, but sometimes an X-ray of your bladder or other specialized tests are needed.

Treatment
Conservative treatment -- such as making healthy lifestyle choices, doing Kegel exercises and perhaps using a pessary -- may be recommended if you:
have no symptoms
have only minor symptoms
may want to bear children in the future
are not a good surgical candidate
Lifestyle measures
Avoid heavy lifting and straining. If you smoke, quit. It's also helpful to maintain a normal weight. Finally, take steps to prevent constipation. For example, drink plenty of fluids and make sure there's enough fiber in your diet.

Kegel exercises
Regular Kegel exercises may provide some relief for mild symptoms. For these exercises, squeeze your vaginal and anal muscles as though you were stopping the flow of urine. Your stomach and buttocks should not move. Hold each squeeze for four seconds, then relax. Work up to eight to 10 seconds per squeeze. Repeat the exercise 10 to 20 times, at least three times a day. For younger women, improvement may be apparent within two to three months of consistent exercise.

Pessary
Sometimes, a pessary -- a device inserted into the vagina to support the protruding bladder wall -- is recommended. Pessaries are typically made of rubber or silicone and resemble a contraceptive diaphragm. The most common pessaries are shaped like a ring or doughnut in a variety of sizes. The pessary must be removed regularly for cleaning, which will help prevent vaginal discharge and pressure sores. Follow-up visits are important.

If conservative treatments aren't effective, your doctor may recommend hormone replacement therapy or, in some cases, surgery.

Hormone replacement therapy
Hormone replacement therapy (HRT) has been used to try to improve the tone and quality of the pelvic muscles and supportive tissues for cystoceles that appear after menopause. A recent study has shown possible risks associated with HRT, however. Be sure to discuss the risks and benefits of HRT with your doctor.

Surgery
Surgery may be necessary for severe or particularly bothersome symptoms or when non-surgical treatment fails. Surgical procedures vary, depending on the particulars of your cystocele and whether you need treatment for any other conditions. Surgery is done most often through the vagina, but it can also be done through the abdomen. With a vaginal hysterectomy and anteroposterior colporrhaphy, for example, the uterus is removed and the vagina is elevated and attached to a higher point in the pelvis. The elevation is essential in repairing the cystocele.


Complications
Pessaries may lead to pressure sores or infection, particularly if theyications of surgical repair may include bleeding, infection, accidental injury to neighboring organs, or problems related to the anesthesia.

Pregnancy-specific information
Again, childbirth is a risk factor for developing a cystocele. The risk increases with each pregnancy. Kegel exercises are often recommended during pregnancy to help strengthen the vaginal and perineal muscles (the area between the vagina and rectum) for delivery and postpartum recovery.
After the fourth month of pregnancy, do the exercises in a standing or sitting position to help alleviate the pressure your expanding uterus places on your major blood vessels.


Senior-specific information
As described above, aging is associated with the loss of estrogen and connective tissue strength. How fast this happens depends on your personal health status and the condition of your connective tissue. For example, chronic coughing or extensive lifting may contribute to the progressive weakening of your pelvic structures.
For older women, Kegel exercises rarely provide more than partial relief. If you're a poor surgical candidate, your doctor may recommend using a pessary until your health improves enough for surgery.


Prevention
Minimizing risk factors and following the conservative treatment suggestions described above can help prevent a cystocele. Do Kegel exercises routinely. Routine exercise can also strengthen the supportive tissue, as well as help prevent obesity. It's helpful to quit smoking and control allergic symptoms to prevent chronic coughing. Regular bowel movements can help prevent straining and constipation, which increase abdominal pressure. To minimize unnecessary risks, ask your doctor for lifting recommendations.