Continuing Education Activity

Bladder prolapse (cystocele) is a chronic condition during which a bladder herniates to the anterior vaginal wall. Due to the condition's progressive nature, if left untreated it can significantly impact a woman's well-being, mental, and sexual health. It can be managed by pelvic exercises, vaginal pessaries, or with a surgical procedure. This activity describes the evaluation and management of bladder prolapse and reviews the role of the interprofessional team in improving care for patients with this condition.

Objectives:

• Explain the pathophysiology of bladder prolapse (cystocele).
• Summarise the evaluation of bladder prolapse (cystocele).
• Outline the management options available for bladder prolapse (cystocele).

Introduction

 A cystocele, otherwise known as a protrusion of the bladder, occurs when the bladder descends into the vagina.[1] The bladder bulges through the anterior wall of the vagina, with which it is anatomically associated. There are multiple underlying causes for the development of cystocele resulting in weakness of the muscles and the connective tissue surrounding the bladder and vagina.

Pelvic floor muscles and endopelvic fascia provide anatomical support of pelvic viscera in women. This pelvic support consists of three muscles: pubococcygeus, puborectalis, and iliococcygeus, which form a complex called the levator ani muscle group. In addition, the cardinal and uterosacral ligaments provide additional support and stabilization. A prolapsed or herniated bladder can have a negative impact on the quality of life, affecting daily functioning and sexual activity. In some women, symptoms may be mild and require no treatment and, in some cases, prolapses regress following menopause.[2] On the other end of the spectrum, there are cases with slow progression of the condition, where the bladder can eventually completely herniate beyond the hymen.

Etiology

Cystoceles result from a weakness of the pelvic-floor support system. The main associated risk factors are obesity, increasing age, and parity. They can also occur due to chronically increased intra-abdominal pressure, collagen abnormality, family history of cystocele, and following pelvic surgery.

Obesity

Giri et al., in their systematic review, reported that women with BMI >25 had a risk ratio of 1.36 (95% confidence interval) for developing prolapse, while women with BMI >30 had a risk ratio of 1.47 (95% confidence interval).[3] Another study suggested that in overweight and obese women, the risk of progression of a cystocele increased by 32% and 48%, respectively, compared with participants with normal BMI.[4] However, few studies have shown that weight loss did not lead to symptoms resolution or regression of the prolapse. In particular, in some of them, weight loss was associated with a borderline worsening of uterine prolapse, indicating that the damage to the pelvic floor is irreversible.[5][4]

Advancing Age

A number of studies have shown a strong link between aging and vaginal prolapse.[6][7] It is suggested that age-related changes in pelvic anatomy, innervation, and vasculature cause weakness in pelvic floor strength.[8] A study of vaginal tissue biopsies discovered that collagen in the vaginal wall changes its structure over time, which might explain the link between aging and cystocele development.[9]

Parity and Other Childbirth-related Factors

Vaginal delivery carries a high risk for pelvic floor weakness.[10] The attenuation of the pelvic floor muscles has been shown to increase with parity. Nygaard et al. showed that the prevalence of pelvic floor disorders increases by 12.8%, 18.4%, 24,6%, and 32.4% for 0, 1, 2, and 3 deliveries, respectively.[11] Moreover, it was found that forceps delivery plays a critical role in levator ani muscle avulsion.[12] Mant et al. specifically suggest that the first stage of labor is responsible for developing a vaginal prolapse.[13]

Increased Intra-abdominal Pressure

Increased intra-abdominal pressure seems to have a weak correlation with anterior vaginal prolapse. Several studies indicated a correlation between cystocele development and constipation, chronic cough, and obstructive pulmonary disease, which are all associated with chronically increased abdominal pressure.[14][15][16]

Collagen Abnormality

The predominant type of collagen found in the vaginal wall is type III, designed to be resistant to sudden pressure changes, which is essential in tissues that require elasticity. In women with vaginal prolapse, the amount of collagen III in the vaginal tissue was higher than in healthy women, possibly due to the underlying remodeling.[9] Women with congenital conditions affecting collagen production, such as Marfan and Ehlers-Danlos syndrome, are predisposed to developing cystocele.[17][18] Up to a third of women with Marfans and three-quarters of women with Ehlers-Danols have a history of vaginal wall prolapse.[17]

Family History

Even though there are no known specific genes responsible for the development of vaginal prolapse, a review of sixteen studies has revealed that women with pelvic prolapse are highly likely to have a relative suffering from the same condition.[19]

Pelvic Surgery

Surgery of the pelvis, especially hysterectomy, causes damage to the endopelvic fascia and nerves. This, in turn, results in a greater risk of vaginal prolapse and herniation of the bladder.[20]

Epidemiology

It is challenging to accurately estimate the number of women affected by anterior vaginal wall prolapse. This derives from the fact that a large percentage of these patients have minimal or no symptoms, and therefore never present to medical professionals. Secondly, many patients feel reluctant to seek medical advice because of social embarrassment.

The Women's Health Initiative study estimated that the prevalence of bladder prolapse is 34.3% for women with a uterus and 32.9% for women who have undergone a hysterectomy.[6]

A cross-sectional analysis of 1961 non-pregnant women above 20 years old revealed that 2.9% of the participants had a degree of pelvic organ prolapse.[11] Symptoms were found to be more severe in populations of women from lower socio-economic backgrounds. It has also been shown that approximately 11.1% of women will require an operative procedure for prolapse management by the age of 80, with about a third of them needing a repeat procedure.[21]

Pathophysiology

Vaginal prolapse includes prolapse of the bladder (cystocele), bowel (rectocele), or uterus. Prolapse occurs when structures of the levator ani are weakened, with the pelvic fascia subsequently becoming overstretched. There are four main support sites; damage to these areas leads to a descend of pelvic organs through the walls of the vagina. According to the anatomical site, cystoceles can be classified as apical, medial, and lateral.

An apical defect is localized in the upper segment of the vagina and is caused by a defect of the endopelvic fascia. They contribute to the development of stress urinary incontinence (SUI) because of the interruption of the urethra-vesical junction.[22]

A medial defect is caused by the separation of the pubocervical fascia from connective tissue around the cervix and damage to uterosacral ligaments. This can present as a large cystocele.

A lateral defect results in vaginal wall separation from the arcus tendinous, causing a reduction of the lateral vaginal sulcus on one or both sides.

History and Physical

Complaints related to bladder prolapse may be divided into vaginal pressure, urinary symptoms, sexual dysfunction, and, rarely, defecatory symptoms.

To aid history taking, a set of questions called the Pelvic Floor Impact Questionnaire (PFIQ) can be used to assess pelvic prolapse related symptoms.[23]

Women may complain of a feeling of pressure or sensation that something is bulging or about to come out of the vagina. Usually, this symptom develops when the prolapse is at the level of the hymen or beyond. With advanced stages of bladder prolapse, discharge, bleeding, or vaginal pain may be present.

Urinary symptoms may include stress incontinence (SUI) or symptoms such as frequency and urgency associated with an overactive bladder.[24] Patients may have trouble initiating urination, have a feeling of incomplete evacuation, and in later stages, experience bladder outlet obstruction due to bending of the urethra. Some women may report a need to press on the anterior vaginal wall in order to void successfully.[25]

Sexual dysfunction may be due to physical, psychological, or partner-related factors. Prolapses can results in dyspareunia, urinary incontinence during intercourse, obstruction, and dryness.[26]

It is reported that sexual dysfunction is associated with fear and embarrassment due to the possibility of urinary incontinence during intercourse.[27]

Defecatory symptoms are rare but most commonly include constipation and incomplete emptying. These symptoms are more common with posterior and apical vaginal wall prolapses.

A vaginal examination should be carried out with the patient in the dorsal lithotomy position. A cystocele is diagnosed and staged using the Pelvic Organ Prolapse Quantification System (POPQ) which provide an objective description tool and measure severity.[28] If the vaginal walls are seen beyond the vaginal opening, mucosal tissues should be inspected for ulcerations or other lesions. The examination should be repeated with the woman asked to strain or “bear down” and cough with attention made to any episodes of urinary incontinence or flatulence.

Subsequently, examination with a Sims speculum is performed to better visualize the vaginal walls. Simulated apical support may also be performed to establish whether a pessary may be of benefit. This is achieved by using forceps or a cotton swab and pressing the vaginal apex. To conclude, a bimanual examination is performed to exclude any other masses or pelvic pathology.

Evaluation

The most objective and standard tool for evaluating the severity of the anterior wall prolapse is the POPQ system, which was introduced in 1996. This system is recognized by The American College of Obstetricians and Gynecologists and consists of 4 stages.

• Stage 0 – no prolapse
• Stage 1 – most distal part of prolapse is -1cm (above the level of the hymen)
• Stage 2 – most distal part of prolapse is >= -1cm but <= +1cm (<=1cm above or below the hymenal plane)
• Stage 3 – most outside portion of the prolapse >+1cm but <+(total vaginal length -2)cm (beyond the hymen; protrudes no farther than 2cm less than the total vaginal length)
• Stage 4 – complete eversion of the vagina; most distal portion of the prolapse >= +(total vaginal length -2) cm.[29]

Three stages are used for patients after removal of the uterus and four if the uterus is present.

The POPQ system uses six measuring points of the vagina (two at the front, two at the bottom, and two in the apex) to create a map of the prolapse in the sagittal section. All the measurements are recorded in centimeters, with the level of the hymenal plane serving as a point of reference. Negative numbers are used to express points above the hymen, and positive numbers are used for points below the hymen.

The anterior wall in the POPQ system has two points. Point Aa is in the middle part of the anterior wall. It can have a value varying from -3 to +3 cm, depending on the severity of the prolapse. Point Ba is the distance between Aa and the apex of the vagina. Another important measurement made is total vaginal length (TVL), which is the length from the cervix (or posterior fornix) to the hymen. Staging classification will be discussed in the staging section.[28]

Another frequently used system is Baden-Walker Halfway Scoring System. The system's downside is a lack of clear demarcations; thus, this system is not as precise as POPQ and is not recommended by leading medical societies. It consists of three grades:

• 0 – Normal position for each respective site
• 1 – Descent halfway to the hymen
• 2 – Descent to the hymen
• 3 – Descent halfway past the hymen

Apart from physical evaluation, imaging and other tests serve to identify issues associated with bladder function or for the further evaluation of the prolapse. For example, medical photography may be used to record changes in the prolapse, especially pre-operatively. Perineal floor ultrasound scan is used to identify the evulsion of the perineal muscles from the symphysis pubis, which can increase the risk of cystocele development three to four times.[30] Other studies include urodynamics, such as a cystourethrogram, in order to further assess urinary complications. If signs and symptoms suggest a urinary tract infection, culture, and microscopy of urine samples may be helpful to guide management.

Treatment / Management

Treatment of cystocele is only suggested for women who report symptomatic anterior wall prolapse.[31] It has been established that it is not uncommon for a Stage 1 prolapse to regress.[32]

Broadly, management of the condition can be divided into expectant, conservative, and surgical. All the options should be offered to the patient and thoroughly discussed as part of a treatment plan. Better outcomes are noted if surgical objectives and the patient's expectations are discussed before treatment.[33]

Cystocele management requires careful consideration of several factors such as a women's age, physical & sexual activity, future reproductive wishes, the nature and extent of the symptoms, the degree of the prolapse, associated uterine, or posterior wall prolapse, and incontinence symptoms. It also depends on surgical expertise & previous management outcomes.

Expectant Management

A ‘watch and wait’ approach may be a good option for a patient who is asymptomatic with low-grade cystoceles or for those who are able to tolerate mild symptoms. Some patients may not wish to have treatment for various reasons. In this case, high-grade cystoceles will require frequent assessments of their symptoms to ensure there are no complications or changes in symptom burden.

Conservative Management

There are two main types of conservative management, vaginal pessaries, and pelvic muscle exercises.  The benefit of conservative management is that it does not impose operative risks, such as infection, bleeding, pain, or a failed procedure, or anesthetic risk in a high-risk patient with co-morbidities.

Vaginal pessaries are the most popular conservative management option. Pessaries are plastic or silicone devices that are inserted into the apex of the vagina. They lift and support the vaginal walls, reducing the symptoms of pelvic organ prolapse. They are contraindicated with acute infection of the vagina or pelvis, in those who have allergies to pessary materials and in non-compliant women.

Kegel exercises (pelvic muscle exercises) can be advised for women with stage 1 or 2 prolapse. It is found that these exercises improve prolapses by 1-2 cm on average. A systematic review and meta-analysis of the effectiveness of Pelvic Floor Muscle Therapy (PFMT) showed that women involved in pelvic muscle training showed better outcomes regarding symptoms and reduction of the size of the prolapse compared to control groups.[34] Supervised muscle training for at least 12-16 weeks can be considered for such women to measure the improvement.[35] The exercises should be continued if they are proved to be beneficial for the patient.

Hormone Replacement Therapy is not a treatment for cystocele. There is no evidence that estrogen's topical or systemic use reduces the size of cystocele; the creams or estrogen-containing vaginal pessaries can still be used for women with cystocele for treating signs of vaginal atrophy, which may occur concurrently.[36] Another study has shown the pre-operative use of topical estrogen creams improve the synthesis of collagen, preventing thinning of the vaginal wall, and reducing the activity of degrading enzymes.[37]

It is essential to encourage the patient to work on modifiable risk factors, such as a high BMI (>30), smoking, heavy lifting, chronic cough, or constipation.

Surgical Management

Surgical management is the next step for symptomatic women, those who require immediate relief, those who have declined conservative treatment, or for whom the conservative approach has failed to provide benefit. It should be noted that surgical management should follow the completion of the patient’s family as the pelvic support system can be further damaged during labor.

Surgical planning depends on whether the anterior vaginal prolapse is isolated or is combined with apical or posterior vaginal prolapse. A careful examination is required as a part of preoperative planning.

Anterior colporrhaphy

Anterior repair is performed trans-vaginally to repair central vaginal wall defects and to lessen the size of the anterior vaginal wall.

For this procedure, a patient is placed in the lithotomy position and catheterized; a Sims speculum is inserted to achieve a better view of the defect. An Allis forceps are placed at the midline of the anterior wall 1cm proximal to the urethra and two more forceps on each side next to the cervix or the vaginal cuff. Local infiltration with an adrenaline/lidocaine solution is commonly used to achieve hydro-dissection, analgesia, and to minimize intraoperative bleeding. With the use of Metzenbaum scissors, dissection of vaginal mucosa from the underlying vesicovaginal fascia is performed. When the mucosal layer is entirely free, a folding of the muscular layer and adventitia using figure-of-eight sutures is performed. Careful placement of the sutures is crucial in order not to damage the bladder.

2-0 Vicryl or PDS sutures are most often used. After successful plication, the excessive vaginal mucosa is removed, and the wound is closed with absorbable sutures.  The surgeon should be careful not to reduce the diameter of the vagina too much, as later it may cause pain during sexual intercourse. One study has reported the success rate of surgical approach ranging from 63% to 76.5%, depending on the procedure followed.[38]

Sacral Colpopexy

The other way to repair a bladder prolapse is to perform a sacral colpopexy, which is usually done laparoscopically. This procedure aims to place a permanent mesh to the anterior and posterior walls of the vagina and then attach it to the anterior longitudinal ligament below the sacral promontory. The operation can be performed together with anterior colporrhaphy or on its own. The benefit of sacral colpopexy is that it avoids vaginal incisions and scarring, which results in a lower risk of vaginal shortening or dyspareunia. The success rate of this procedure is 60% to 89%.[39] A randomized trial indicated that laparoscopic sacral colpopexy has a higher success rate and a lower chance of repeat procedure for both anterior and posterior vaginal prolapses.[40]

In many countries, including the US and the UK, the use of mesh for cystocele repairs has been suspended since 2019, pending an investigation into their use.[41]

Differential Diagnosis

There are many different conditions that could mimic the symptoms of bladder prolapse and should be included in the differential diagnosis such as rectal or uterine prolapse, ovarian or uterine benign and malignant tumors, vulvar malignancy, or benign vulvar lesions such as Bartholin’s or Skene’s cyst, urethral diverticulum and other causes of incontinence, urinary retention or hyperreactive bladder.

Prognosis

A cystocele is not a life-threatening condition on its own. However, it is progressive, and if left without proper management, it can cause a myriad of symptoms and conditions. Due to the protrusion of the bladder wall into the vagina, women might experience urinary symptoms and voiding dysfunction, which might be implicated with urinary tract infections and kidney damage. If the prolapse is beyond the vaginal opening, the mucosal tissue of the vagina can develop ulcers, and it is more prone to bleeding and infection. The psychological burden stemming from sexual dysfunction and urinary incontinence can also be significant.

Complications

Complications related to cystocele can be categorized depending on the type of management the patient is receiving. If a woman refuses or is non-compliant with treatment, the disease's natural course may lead to a complete vaginal prolapse (procidentia).

Conservative management has its pitfalls. For example, vaginal pessaries can cause pain, erosion of the vagina, bleeding, or infection.[42]

Surgical procedures carry the most significant number of complications. The most common is the recurrence of the prolapse and a need for further repair. Around 40% of women require a repeat procedure after an anterior colporrhaphy due to symptom recurrence.[43] Other complications include postoperative bleeding, hematoma, damage to the surrounding pelvic organs, infection of the operative site and dehiscence of the wound, infection of the urinary tract, pain during intercourse, urinary retention, and the formation of a vesicovaginal fistula.

There is also a higher rate of complications when using transvaginal mesh repair than using native tissue repair, predominantly in the form of chronic pelvic pain.[44]

Deterrence and Patient Education

The Association of Pelvic Organ Prolapse Support provides up to date information regarding vaginal prolapses, including anterior vaginal wall prolapse, and the POP (Pelvic Organ Prolapse) Risk Factor Questionnaire is also available on their website.

The International Urogynecological Association offers helpful informational leaflets for patients regarding cystocele and different management approaches in different languages. These leaflets should be given to women during urogynecological appointments for pelvic organ prolapse.

The American Urogynecologic Society (AUGS) offers an interactive POPQ tool designed to show different stages of vaginal wall prolapse. Its visual features could be incredibly beneficial during consultations with patients regarding pelvic organ prolapse expectations and management.

One study has shown that educational leaflets and a face-to-face conversation, when used together, provide a better understanding of the condition and improve women's knowledge of the care offered, regardless of their education.[45]

Enhancing Healthcare Team Outcomes

Due to the complex nature of anterior vaginal prolapse and its progressing effects on women's physical, mental, and sexual health, a multidisciplinary team's involvement is essential. Getting a broad group of specialists engaged in inpatient care provides support and significantly improves management outcomes.

According to the 2019 guidelines from the National Institute for Health and Clinical Excellence, the multidisciplinary team for women with a vaginal prolapse should include a specialist level doctor with experience in pelvic floor prolapse, a urogynecology specialist, a urogynecology nurse, and a pelvic floor specialist physiotherapist.[46]

Additional members may include a member of the geriatric team, an occupational therapist, and a colorectal surgeon with interest in pelvic floor surgery and expertise in operating in the obturator region in cases of concurrent rectoceles. For some cases, a radiologist with expertise in pelvic floor imaging, a pain team member, and a clinical psychologist might be required.[47][48] [Level 2]