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All you need to know about Bladder Prolapse/Cystocele.

Introduction 

Question about bladder prolapse

Do you want answers to your questions of badder prolapse or cystocele ? I have answers to all your questions such as is bladder prolapse curable? If so how? and is it dangerous? What will happen if I do not get  any treatment? Can it be fixed with Physical therapy? What is surgery like? Will I need surgery? These and many more will be answered as you read this blog post.

Prevalence 

This is the most common of the 3 kinds of organ prolapse seen in associated with urinary incontinence seen in the older female population 60 years and older.

Anatomy 

The 3 main functions of the pelvic floor are  

The 2nd image is Bladder Prolapse .Image obtained from Google mages , no intention of copyright violation.
  • Bladder 
  • Bowel
  • Sexual function

The associated organ systems of the above listed functions are located in the pelvic floor. The bladder, the rectum and  the uterus are supported by tissues called the ligaments.Most of the time, these organs are held in place by a combination of strong ligament and pelvic floor muscles.When the supportive ligaments and muscles get weak the organs start slide from their places  to bulge  through the vagina.When there is a bladder prolapse the bladder starts to protrude through the front ( anterior ) vaginal opening.

Degrees of Bladder Prolapse : The degree of prolapse is measured in the extent of prolapse relative to the hymen.

  • 1st degree
  • 2nd degree
  • 3rd degree 

Symptoms of Bladder Prolapse:

Recurrent UTI and pain
  1. Urinary Incontinence- 
  2. Stress Incontinence : urinary leakage with coughing sneezing and laughing 
  3. Urge Incontinence :  Decreased ability to control and subside the urge to  urinate is felt.
  4. Incomplete bladder emptying 
  5. Recurrent urinary tract infections 
  6. Difficulty inserting a tampon and difficulty with keeping the tampon in during menstruation. Common patient statements are “ the tampon doesn’t stay inside for long or I have trouble inserting the tampon.“
  7. Difficulty initiating the urine steam.
  8. A feeling of bladder fullness which increases as the end of the day usually feels better when patient is laying down .
  9. A bulge can be seen and felt at the vaginal opening. Can be seen during  straining/ coughing in  lying down and  seen and felt in standing as well (in severe cases).
  10. Pain and discomfort with intercourse.

Causes /Risk Factors of Bladder prolapse

Chronic coughing and sneezing can be a risk factor for bladder prolapse
  • Childbirth( Vaginal delivery , especially instrument assisted )
  • Constipation
  • Chronic coughing as in C.O.P.D.( lung diseases)
  • Repetitive heavy lifting and strenuous exercises such as crossfit  
  • Postmenopausal. Estrogen is responsible to keep the vaginal tissues supple and in good tone hence post menopause the tissues (ligaments ) loose elasticity and are prone to bladder prolapse.
  • Any pelvic Surgery
  • Genetic factors 
  • Caucasian Ethnicity

Diagnosis of Bladder Prolapse

  • A Through History and Physical Exam to assess the degree of prolapse
  1. Test for Bladder prolapse : 
  • Urodynamics : to know the type of incontinence.
  • Urine test to check for UTI ( urinary tract infection )
Bridges with Kegel exercises

Treatment for Bladder prolapse

  • The treatment depends on the degree of prolapse. 
  • No treatment may be required if it’s not interfering with your daily activities or causing urinary issues.
  • Prolapse can remain asymptomatic until the organ descent has reached a certain point and hence it may not be recognized until advanced. In some women the prolapse progresses rapidly and some it remains stable for years .Handa et al ( 2004 ) found that spontaneous regression was seen in cases of mild prolapse.
  • Miedel et al (2011) found that only small % of women with POP worsen over 5 years. 
  • Bladder prolapse is not dangerous in mild cases. It’s an inconvenience interfering with daily activities  and in most of the less severe degrees of prolapse can be treated effectively with a combination of lifestyle change, pelvic floor therapy and medications.The severe degree of prolapse may require surgery.

1. Lifestyle changes :

  • Wt. loss ( if overweight )
  • Treating Chronic Cough
  • Avoiding straining and managing constipation
  • Pelvic floor muscle exercises Kegel exercises
  • Pessary .May require some practice to insert the Pessary.May require regular follow up with Dr .

A. Pelvic Floor Exercises :

A,PFMT ( Pelvic floor muscle training ) has been concluded to have a positive effect on POP (pelvic organ prolapse ) due to the following hypothesized reasons (Bo, 2004)

  1. Women learn to contract the pelvic floor before and with any increase in the intra abdominal pressure , such as bearing down when lifting heavy wts .
  2. Regular strengthening exercises build up the strength of the Pelvic floor and the structural support overtime .

      B.  The Knack

Squeeze before you sneeze
  1. The Knack is a technique that we pelvic PT’s call instruction to consciously contract the PFM before an activity that requires an increase in the intra abdominal pressure for eg lifting something heavy or before a cough or a sneeze (if you can predict it).
  2. I instruct my patients “ Squeeze before you sneeze “.
  3. This will take some practise but will prove to be effective, as reported by my patients about 3 to 4 weeks of regular pelvic floor exercises.

3. Medications:

    Estrogen Replacement Therapy

4.Surgery 

Surgical options may be considered as a means of treatment usually in severe degree of prolapse and when conservative management was not effective. Prolapse recurs in 70% of the women who had surgery.(Iglesia et al 2010) and 1/3rd of the operated women undergo one further surgical procedure for prolapse (Olsen et al 1997) 

  1. Types of Surgery 
  1. Reconstructive Surgery – restores organs to their original place.Normal activities can be resumed after recovery from surgery. 
  2. Obliterative Surgery -which narrows and closes off the vaginal to support the prolapse, sexual intercourse is not possible after this surgery. 

This can be done in one of the following ways.

Open Surgery

Laparoscopic Surgery

Robotic assisted surgery

Recovery time : Depends on the type of Surgery but the Dr usually recommends no heavy lifting, straining , and sexual activity for 6 weeks post surgery. 

Conclusion 

  1. Bladder prolapse is a treatable condition and patients can return to a good quality of life after the diagnosis of a bladder prolapse.
  2. Mild degrees of Prolapse, can be treated effectively and successful most of the time with Physical therapy , Pessary and lifestyle modification .
  3. Surgery is an option in advanced prolapse.

References :

1.www.urologyhealth.com

2.www.acog.org

3.Evidenced based Physical Therapy for Pelvic Floor 2nd edition

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Symptoms of Vaginal Prolapse, Medical and Physical Therapy Treatment

Introduction

Pelvic Organ Prolapse (P.O.P.)  is  very common and seen in 43% to 76% of women. This can be seen in young and older women. In younger populations childbirth related, Pelvic floor muscle trauma, this can occur after prolonged and hard labor and giving birth to a “big baby” (more than 9 to 10 lbs). In the older population this can occur due to the stretching out of supportive ligaments.

Picture from Google images ,No intention of copy write infringement.

P.O.P. or simply prolapse is the downward descent of the female pelvic organs, (Vagina,Uterus,Bladder and Rectum) . 

Prolapse Terminology:

Cystocele or Urethrocele :Bladder prolapse

Rectoclele or Enterocele: Rectum prolapse .Rectal prolapse is not the same as hemorrhoids.

Uterine Prolapse : The vaginal vault prolapse.

Urodynamics:Bladder function test that evaluates urinary incontinence or difficulty urinating.

Cystoscopy: A procedure that uses a camera to look and assess for any anatomical abnormalities that contribute to urinary symptoms.

Defecography: A radiological study that looks at  bowel function and prolapse symptoms. .

Risk factors for developing Prolapse:

  • The loss of uterine and bladder support, connective tissue lax and weak.Some women are genetically predisposed to lax tissues.
  • Chronic constipation.
  • Systemic disease, Ehlers-Danlos syndrome
  • Chronic coughing 
  • Obesity
  • Menopause
  • Heavy lifting and repetitive intense activities such as CrossFit
  • Smoking 

Degrees of Prolapse:

P.O.P. is said to be of 3 degrees  mild , moderate and severe.The degree of prolapse is graded by the organs descent in relation to the hymen.  

  1. Mild P.O.P. : Most women are asymptomatic , no complaints of symptoms are expressed until the organ be it uterus , bladder or rectum has prolapsed past the hymen.
  • In mild P.O.P. loss of this support results in urethral hypermobility and cystocele(bladder prolapse) which is thought to cause stress urinary incontinence (DeLancy 1994) hence these 2 ( ie bladder prolapse and stress incontinence) usually coexist especially with mild prolapse.
  1. Severe  P.O.P. : symptoms include vaginal bulge that can be seen and felt, and can be the uterus, bladder or rectum that can be causing it.
  • Urinary urgency, frequency and incontinence are common coexisting complaints along with Pelvic floor dysfunction and possibly  with constipation as well .The anterior vaginal wall supports the bladder and urethra.

When the prolapse is of a more severe degree P.O.P ,women complain of urinary hesitancy , intermittent flow , weak or prolonged stream , and also feeling difficulty with emptying or feeling the need to manually splint the prolapse to urinate.Possibly changing  the sitting position on the toilet  to facilitate completion or to start urination.

  • Symptoms of moderate and severe degree  are usually worse at the end of the day or with standing and exercises and improve with laying down .
  • Prolapse symptoms primarily impact the quality of life and symptoms are not “dangerous” to life or medically but symptoms gradually and usually progressively get worse.Prolapse generally does not heal itself.
  • Symptoms are usually better in gravity eliminated positions
  • Symptoms more prominent with straining ..

Symptoms can be divided into 

VaginalUrinary Bowel Sexual
Sensation of heaviness and pressure and Bulgein the vagina which may be visible when and or palpable.In mild prolapse urinary incontinence of stress ,urgency and frequency.In moderate prolapse Weak urine stream, incomplete emptying of bladder and urinary retention in severe prolapseFeeling incomplete emptying of bowel. 
Feeling an obstruction to defecation.		Dyspareunia (Painful sexual intercourse) 

Adapted from Jalovesk et al, 2007

Treatment for Prolapse:   

Conservative Treatment:

  • “Wait and Watch”(depending on the degree of prolapse)
  • Pessary
  • Physical Therapy.                         

Surgical Repair of Prolapse :Surgical repair of prolapse is performed by a Urogynecologist.

What can one expect when seen by the Dr.(Urogynecologist)

  • The Dr  would examine the symptoms to evaluate the degree of organ prolapse based on the prolapse grading system.
  • A vaginal exam will be performed and the patient asked to strain to produce the maximum extent of prolapse.Various instruments may be used.
  • Depending on the degree of prolapse and if weakness is found in the pelvic floor muscles, the patient may be referred to the pelvic floor therapist. A pelvic floor therapist is a physical therapist who undergoes additional specialised  training and board testing to treat patients with issues of the pelvic region related diagnosis.
  • When appropriate the patient may be fitted with a Pessary.

Pessary: 

  • A Pessary is an intravaginal device used to support the vaginal wall in women with P.O.P.
  • A Pessary is generally prescribed by the urogynecologist and they are made in various shapes and sizes.
  • They are mostly made of silicone.
  • Pessary is used as a safe alternative to surgery when appropriate.
  • There has been no high-level research based evidence of the effectiveness of pessaries to manage P.O.P.
  • Pessary seems to be effective in  improving the pelvic floor symptoms as evidenced by clinical trials  that showed significant symptom relief and improvement in the quality of life, satisfaction and sexual function.
  • Women fitted with pessaries are advised to remove and reinsert periodically to avoid complications of pessary use like, vaginal bleeding erosion and infection.Regular follow up with Dr. is recommended.
Pelvic Physical Therapy is the one of the effective way of management conservatively .

Physical Therapy and  Prolapse :

  • Women cannot change their genetic predisposition but can certainly do what can be done what is in their control which is exercise. Pelvic floor muscle strengthening exercises, Kegels  have been proven to help prevent the symptoms and even to improve the symptoms of urinary urgency frequency  if present.
  • Regular Pelvic floor muscle strengthening helps to strengthen and retain the muscles and nerves of the Pelvis.
  • Download my helpful instructions on Kegel Exercises.
  • If you suspect you have prolapse or have any questions please comment or contact me via email .I will be happy to answer your questions or point you in the right direction, if possible .

Resources :

Association for Pelvic organ Prolapse Support (APOPS)

Private Facebook Groups for Pelvic organ Prolapse

References :

Evidence-based Physical Therapy for Pelvic floor  2nd Edition.

Pelvic Floor Dysfunction and Treatment , Level 1 Herman and Wallace Pelvic Rehabilitation Institute

Declancy,J.O. 1994 Structural support of urethra as it relates to stress incontinence, the hammock hypothesis .AM. J .Obstet. Gynecol. 170 ,1713 to 1720