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Cystocele
By Mayo Clinic staffMayo Clinic Health Manager
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Definition
A cystocele occurs when the wall between a woman's bladder and vagina weakens and stretches, allowing the bladder to bulge into the vagina. A cystocele may also be called a prolapsed bladder.
A cystocele may occur from excessive straining, such as during childbirth, chronic constipation or heavy lifting. It may also occur after menopause, when estrogen decreases. Therefore, older women and those who've given birth to several children are more likely to develop a cystocele.
For mild and moderate cystoceles, self-care measures or nonsurgical treatments are often effective. In more severe cases of cystocele, surgery may be necessary to keep the vagina and other pelvic organs in their proper positions.
Symptoms
In mild cases, it's possible to not even notice a bulge. When cystocele symptoms do present themselves, they may include:
- A feeling of fullness or pressure in your pelvis and vagina — especially when standing for long periods of time.
- Increased discomfort when you strain, cough, bear down or lift.
- A bulge of tissue that, in severe cases, protrudes through your vaginal opening. The resulting soft bulge may feel walnut- or even grapefruit-sized, and often goes away when you lie down.
- A feeling that you haven't completely emptied your bladder after urinating.
- Loss of urinary control with coughing, laughing or sneezing (stress incontinence). In severe cases, you may not be able to control urination at all.
- Recurrent bladder infections.
- Pain or urinary leakage during sexual intercourse.
When other organs join the bladder in moving into the space in the front part of the vagina, the condition is called an anterior prolapse.
Causes
Your pelvic floor consists of a sheet of muscles and ligaments that support your bladder, uterus, colon and small intestine — organs that fill your pelvic cavity. If these supporting tissues stretch or weaken, some of your internal organs may sink lower in your body, or prolapse.
Most common causes
Pregnancy and childbirth are the most common causes of a cystocele. This is because the muscles and ligaments that support and hold your vagina in place may become stretched and weakened during labor and delivery. For this reason, cystoceles are more common after multiple pregnancies.
Not everyone who has had a baby develops a cystocele. Some women have very strong supporting muscles and ligaments in the pelvis and may never have a problem. Women who have only Caesarean section deliveries usually do not develop prolapse.
Other causes
Prolapse may also be caused by straining your pelvic floor muscles through:
- Being overweight or obese
- Repeated heavy lifting
- Straining with bowel movements
- A chronic cough or bronchitis
Risk factors
The following factors may increase your risk of experiencing a cystocele:
- Childbirth. Women who have vaginally delivered one or more children have a higher risk of having prolapse.
- Aging. Your risk of experiencing prolapse increases as you age because you naturally lose muscle and nerve function as you grow older, causing muscles to become stretched or weakened. This is especially true after menopause, when estrogen — which helps keep pelvic muscles strong — decreases.
- Having a hysterectomy. Having your uterus removed may contribute to weakness in your pelvic floor.
- Genetics. Some women are born with weaker connective tissues in their pelvic areas, making them naturally more susceptible to a cystocele.
When to seek medical advice
In mild cases, a cystocele may not require medical attention. In fact, in such cases, you might not even know you have a cystocele.
In moderate and severe cases, however, prolapse can be bothersome, uncomfortable and, rarely, painful. It can make emptying your bladder difficult, and lead to bladder infections. Make an appointment with your doctor if you experience:
- A feeling of fullness or pressure in your pelvis and vagina, especially when you bear down
- A soft bulge that protrudes through your vaginal opening
- A feeling that you're unable to completely empty your bladder
- Urinary incontinence
- Repeated bladder infections
- Pain during sexual intercourse
Tests and diagnosis
To diagnose a cystocele, your doctor will conduct a pelvic exam. During the pelvic exam, your doctor:
- Will look for the telltale bulge in your vaginal wall that usually makes prolapse easy to diagnose
- May ask you to bear down and push as if you are having a bowel movement so he or she can see how far the bladder or other organs protrude into the vagina
- May instruct you to contract the muscles of your pelvis (as if you are stopping the stream in the middle of urinating) to check the strength of your pelvic floor muscles
Treatments and drugs
Cystocele treatment depends on the severity of the condition. Mild cases — those with few or no obvious symptoms — may require no treatment or simple self-care measures such as special exercises to strengthen your pelvic floor muscles. If self-care measures aren't effective, treatment may include:
- Pessary. A vaginal pessary is a plastic or rubber ring that's inserted in the vagina to support the bladder by pushing it up and back into place. In some cases, your doctor may recommend using a large tampon or vaginal diaphragm instead of a pessary. Most women who use pessaries do so as a temporary alternative to surgery. But some women may use pessaries for years.
- Estrogen therapy. Your doctor may recommend using estrogen — either orally or in a vaginal cream — if you've already experienced menopause. This is because estrogen, which helps keep pelvic muscles strong, decreases after menopause.
When surgery is necessary
Severe or especially uncomfortable cases of cystocele may require surgery. This surgery is elective and designed to relieve symptoms related to the cystocele.
In most cases, surgery consists of a vaginal repair. In this procedure, a surgeon elevates the prolapse back into place and tightens the muscles and ligaments of your pelvic floor. This procedure may require the removal of some stretched tissue. While the benefits of this type of surgery can last for many years, there's some risk of recurrence. This is partly because pelvic muscles and nerves continue to weaken as you age.
If the cystocele recurs, you may need surgery again — although it's more difficult to get a good result the second time. In some cases, especially where the tissues needed to support the vagina are unusually thin, using a special type of tissue graft helps thicken the vaginal tissues and increases support. If the cystocele is associated with a prolapsed uterus, your doctor may recommend removing the uterus (hysterectomy) to help correct the problem and prevent recurrence.
When possible, avoid surgical treatment if you have a large cystocele until you're done having children. If the prolapse is so uncomfortable that you need a vaginal repair, you can still have children — though a Caesarean delivery is recommended.
Dealing with incontinence
Your doctor may recommend one of a number of procedures to elevate the junction between the urethra and bladder (urethral suspension) to help with incontinence. Or, your doctor may recommend collagen injections in your urethra, the tube from your bladder through which urine exits your body, to treat incontinence caused by a cystocele. During a collagen injection, the protein is injected through a narrow tube (cystoscope) into the lining of your urethra. This helps add bulk to the tissues of your urethra, helping to close the gap that allowed urine to leak.
Prevention
You can help prevent prolapse with the following measures:
- Do special exercises called Kegels. These exercises are designed to strengthen your pelvic floor muscles. This is especially important after you have a baby.
- Treat and prevent constipation. High-fiber foods can help.
- Avoid heavy lifting, and lift correctly. When lifting, use your legs instead of your waist or back.
- Control coughing. Treat a chronic cough or bronchitis, and don't smoke.
- Avoid too much weight gain. Talk to your doctor to determine your ideal weight.
Lifestyle and home remedies
Depending on the severity of the condition, self-care measures may provide the relief you need.
Kegel exercises, exercises designed to strengthen your pelvic floor muscles, can help both prevent and treat incontinence. To perform Kegel exercises:
- Pull in your pelvic floor muscles — the muscles you use to stop urinating.
- Hold them for a count of three and then relax for a count of three.
- Work up to 10 to 15 repetitions at a time.
- Repeat three times daily.
Kegel exercises may be most successful when they're taught by a therapist using biofeedback. Biofeedback uses information from a variety of pain-free monitoring devices to help teach you to control certain involuntary body responses, such as muscle tension. In this case, biofeedback can help ensure you're contracting the proper muscles, and that the intensity and duration of the muscle contractions are optimal.
Other measures
Other self-care measures can help you reduce the strain on your pelvic organs. Follow these recommendations:
- Avoid heavy lifting.
- Avoid straining with bowel movements.
- Avoid constipation by eating high-fiber foods.
- Lose weight if you're overweight or obese.
- Try to control coughing.
