What are the types of pelvic prolapse. How is pelvic prolapse diagnosed. What imaging techniques are used for evaluating pelvic prolapse. What are the treatment options for pelvic prolapse. How does pelvic anatomy contribute to prolapse. What are the limitations of different imaging modalities for pelvic prolapse.

Understanding Pelvic Prolapse: Types and Prevalence

Pelvic prolapse is a condition where pelvic organs herniate through the perineum. It’s a common issue, particularly among multiparous women over 50, affecting approximately 50% of women in this age group. The condition can be categorized based on the involved pelvic organ and compartment:

• Anterior compartment: Urinary bladder (cystocele)
• Middle compartment: Uterus or vagina (uterine or vaginal prolapse)
• Posterior compartment: Small bowel loops (enterocele) or rectum (rectocele)

How does pelvic prolapse impact patients’ lives? Symptoms can range from stress fecal or urinary incontinence to uterine prolapse, constipation, or incomplete defecation. Beyond these physical symptoms, pelvic prolapse can significantly affect a patient’s body image and sexuality, leading to decreased quality of life.

Diagnostic Approaches: From Clinical Examination to Advanced Imaging

What is the primary method for diagnosing pelvic prolapse? In most cases, a clinical diagnosis through physical examination and medical history is sufficient. However, imaging plays a crucial role in complex cases involving multiple compartments and organs.

Role of Imaging in Pelvic Prolapse Diagnosis

When are imaging techniques most valuable in pelvic prolapse evaluation? Imaging becomes particularly useful in complex cases involving multiple compartments and pelvic organs. The two primary imaging modalities used are:

1. Translabial ultrasound
2. Dynamic pelvic MRI (MR defecography)

These imaging techniques not only aid in diagnosis but also provide valuable information for pre-operative planning in complex cases.

Pelvic Anatomy: The Foundation of Understanding Prolapse

To comprehend pelvic prolapse fully, it’s essential to understand the anatomy of the pelvic region. How is the pelvis divided anatomically? The pelvic anatomy consists of three compartments:

• Anterior compartment: Contains the bladder and urethra
• Middle compartment: Houses the vagina and uterus
• Posterior compartment: Includes the sigmoid colon, rectum, and anal canal

What structures prevent pelvic organ prolapse? The pelvic muscles, ligaments, and fascia play a crucial role in supporting the pelvic organs and preventing prolapse. Key components include:

• Endopelvic fascia: Supports the uterus and vagina
• Pubocervical fascia: Supports the bladder
• Rectovaginal fascia: Supports the rectum
• Pelvic muscles: Iliococcygeal, pubococcygeal, and puborectal muscles

In healthy individuals, these structures work together to keep the rectum, vagina, and urethra elevated near the pubic symphysis, preventing prolapse.

Imaging Modalities: Strengths and Limitations in Pelvic Prolapse Evaluation

Various imaging techniques can be employed in the assessment of pelvic prolapse, each with its own strengths and limitations. Let’s explore the most common modalities:

Plain Films and Barium Defecography

Are plain films useful in evaluating pelvic prolapse? Generally, plain films are not appropriate for pelvic prolapse assessment. Barium defecography, once used as part of pelvic floor dysfunction evaluation, has become largely obsolete with the advent of newer, non-ionizing radiation techniques like MR defecography.

Computed Tomography (CT)

Is CT a preferred method for pelvic prolapse imaging? Due to concerns about radiation exposure and the superior soft-tissue resolution of MRI, CT is usually not the first choice for pelvic prolapse evaluation. However, sagittal abdomen and pelvis CT images can provide hints of pelvic floor prolapse by drawing a pubococcygeal line and observing for overt prolapse. In such cases, a dynamic MRI pelvis (MR Defecogram) is typically recommended for further evaluation.

Magnetic Resonance Imaging (MRI)

Why is MRI considered the gold standard for pelvic prolapse imaging? Dynamic magnetic resonance imaging (MRI) offers several advantages:

• Accurate assessment of pelvic prolapse
• Superior anatomic detail compared to translabial ultrasound
• Useful as a preoperative planning tool
• No bowel preparation required
• No sensitive pelvic exposure needed

How is an MRI examination for pelvic prolapse conducted? The patient lies supine in the MRI scanner, typically using a 1.5 or 3.0 Tesla magnet. Warm ultrasound gel is administered per rectally to make the rectum more prominent. Patients are encouraged to retain some urine in the bladder to aid in diagnosing urinary incontinence.

Despite these advantages, what are the limitations of MRI in pelvic prolapse evaluation? MRI is not widely available, can be expensive, and is contraindicated in patients with MRI-incompatible devices or hardware. Additionally, while pelvic prolapse is most prominent in the upright position, obtaining images in the supine position does not significantly compromise diagnostic accuracy.

Treatment Approaches: From Conservative Management to Surgical Interventions

What treatment options are available for pelvic prolapse? The management of pelvic prolapse ranges from non-surgical approaches to various surgical procedures. Treatment choices depend on the severity of the condition, patient preferences, and overall health status.

Non-Surgical Management

What are the primary non-surgical treatments for pelvic prolapse?

• Kegel exercises: These pelvic floor muscle exercises can help strengthen the muscles supporting the pelvic organs.
• Pessary: A removable device inserted into the vagina to support prolapsed organs.
• Lifestyle modifications: Including weight loss, smoking cessation, and avoiding heavy lifting.

Surgical Interventions

When is surgery considered for pelvic prolapse? Surgical options are typically explored when conservative measures fail to provide adequate relief or in cases of severe prolapse. Surgical procedures may include:

• Reconstructive surgery: Aims to restore the normal position of pelvic organs
• Obliterative surgery: Closes off the vaginal canal (typically for women who are no longer sexually active)
• Minimally invasive procedures: Such as laparoscopic or robotic-assisted surgeries

How effective are surgical interventions for pelvic prolapse? While surgical outcomes can vary, many women experience significant improvement in symptoms and quality of life following surgery. However, it’s important to note that there’s a risk of recurrence, and some women may require additional procedures in the future.

Economic Impact: The Cost of Pelvic Prolapse Management

What is the economic burden of pelvic prolapse treatments? The management of pelvic prolapse contributes significantly to healthcare costs in the United States. From 2005 to 2006, it was estimated that approximately $300 million was spent on pelvic prolapse treatments.

Why are pelvic prolapse treatments so costly? Several factors contribute to the high costs:

• Diagnostic procedures, including advanced imaging techniques
• Surgical interventions, which may involve expensive equipment and specialized skills
• Post-operative care and follow-up
• Management of potential complications
• Ongoing conservative treatments for those not undergoing surgery

How can healthcare systems address the economic impact of pelvic prolapse? Strategies may include:

1. Emphasizing preventive measures and early intervention to reduce the need for costly treatments
2. Developing more cost-effective diagnostic and treatment protocols
3. Improving surgical techniques to reduce complications and recurrence rates
4. Enhancing patient education to promote self-management and adherence to conservative treatments

Future Directions: Advancing Pelvic Prolapse Diagnosis and Treatment

What advancements can we expect in pelvic prolapse management? As medical technology and understanding of pelvic floor disorders continue to evolve, several areas show promise for future improvements:

Imaging Innovations

How might imaging techniques for pelvic prolapse improve in the future?

• Development of more accessible and affordable high-resolution imaging modalities
• Integration of artificial intelligence for more accurate and efficient image analysis
• Advancements in 3D and 4D imaging technologies for better visualization of pelvic anatomy

Novel Treatment Approaches

What new treatment options might become available for pelvic prolapse?

• Tissue engineering and regenerative medicine techniques to strengthen pelvic floor tissues
• Improved minimally invasive surgical techniques with faster recovery times
• Development of new materials for pessaries and surgical mesh with reduced complication rates
• Advancements in neuromodulation therapies for better control of pelvic floor muscles

Personalized Medicine

How might personalized medicine impact pelvic prolapse management?

• Genetic profiling to identify individuals at higher risk of pelvic prolapse
• Tailored treatment plans based on individual patient characteristics and preferences
• Development of targeted therapies based on specific pathophysiological mechanisms

As research in these areas progresses, we can anticipate more effective, less invasive, and more personalized approaches to managing pelvic prolapse, potentially leading to improved patient outcomes and reduced healthcare costs.

Patient Education and Support: Empowering Women with Pelvic Prolapse

Why is patient education crucial in managing pelvic prolapse? Empowering patients with knowledge about their condition can lead to better outcomes, improved adherence to treatment plans, and enhanced quality of life. What are the key components of effective patient education for pelvic prolapse?

Understanding the Condition

How can healthcare providers help patients understand pelvic prolapse?

• Explaining the anatomy and physiology of the pelvic floor in simple terms
• Discussing the different types of prolapse and their symptoms
• Addressing common misconceptions about pelvic prolapse

Preventive Measures and Self-Care

What self-care strategies can patients employ to manage pelvic prolapse?

• Proper technique for Kegel exercises and pelvic floor muscle training
• Lifestyle modifications, including maintaining a healthy weight and avoiding heavy lifting
• Dietary changes to prevent constipation, which can exacerbate prolapse symptoms

Treatment Options and Decision-Making

How can patients be involved in treatment decisions for pelvic prolapse?

• Providing clear information about conservative and surgical treatment options
• Discussing the potential benefits and risks of each treatment approach
• Encouraging patients to express their preferences and concerns

Psychological Support

Why is psychological support important for women with pelvic prolapse? Pelvic prolapse can significantly impact a woman’s self-esteem, body image, and sexual function. Providing psychological support can help address these issues and improve overall well-being. What forms of support can be beneficial?

• Referral to support groups or counseling services
• Addressing concerns about sexuality and intimacy
• Providing resources for coping with the emotional aspects of pelvic prolapse

By focusing on comprehensive patient education and support, healthcare providers can empower women to take an active role in managing their pelvic prolapse, potentially leading to better outcomes and improved quality of life.

Pelvic Prolapse Imaging – StatPearls

Ilsup Yoon; Nishant Gupta.

Author Information and Affiliations

Last Update: May 1, 2023.

Introduction

Pelvic floor prolapse is the herniation of the pelvic organs through the perineum. Depending on the pelvic organ involved, pelvic prolapse further categorizes into the anterior compartment containing urinary bladder(cystocele), the middle compartment containing uterine or vaginal prolapse (uterus or vagina), or the posterior compartment containing either the small bowel loops (enterocele) or rectum (rectocele). Pelvic prolapse is very common among multiparous women over 50, affecting approximately 50% of women over age 50.[1] The patients present with symptoms of stress fecal or urinary incontinence, uterine prolapse, constipation, or incomplete defecation. Besides, pelvic prolapse can negatively impact the patient’s body image and sexuality. Pelvic prolapse treatments range from non-surgical approaches like Kegel exercise and pessary to various surgical procedures. [2] Treatments of pelvic prolapse significantly contribute to the healthcare cost in the United States, estimated at approximately $300 million from 2005 to 2006.[3]

Pelvic floor prolapse is most often clinically diagnosed through physical exams and medical history. Imaging plays a limited role in evaluating mild cases of pelvic prolapse that involve a single pelvic compartment and organ. Nonetheless, translabial ultrasound and dynamic pelvic MRI (MR defecography) serve as valuable tools in diagnosing pelvic prolapse in complex cases involving multiple compartments and multiple pelvic organs. Also, pelvic MRI provides pre-operative planning for complex cases. The article will discuss translabial ultrasound and dynamic pelvic MRI in the evaluation of pelvic prolapse.[4]

Anatomy

The pelvic anatomy divides into three compartments: anterior, middle, and posterior. The anterior compartment contains the bladder and urethra. The vagina and uterus are within the middle compartment. Finally, the posterior compartment contains the sigmoid colon, rectum, and anal canal.[5]

The pelvic muscles, ligaments, and fascia prevent prolapse of the pelvic organs in each compartment. The most crucial pelvic fascia is endopelvic fascia, and it supports the uterus and vagina. Endopelvic fascia is composed of the uterosacral ligament, parametrium, and paracolpium. Pubocervical fascia is between the anterior vaginal wall and pubis; it supports the bladder. Lastly, the rectovaginal fascia supports the rectum. It situates between the posterior vaginal wall and rectum. The primary supporting pelvic muscles include iliococcygeal, pubococcygeal, and puborectal muscles. These are clearly visible on the pelvic MRI. On the other hand, the pelvic ligaments and fascia are less well appreciated on the MRI, but their dysfunctions can be inferred from the prolapse of pelvic organs in each compartment. In healthy patients, the pelvic muscles, ligaments, and fascia prevent the prolapse of pelvic organs and keep the rectum, vagina, and urethra elevated near the pubic symphysis.

Plain Films

Plain films are usually not appropriate for the evaluation of pelvic prolapse.[6] Barium defecography is in use at some places as a part of the assessment of pelvic floor dysfunctions, however, with the advent of newer and non-ionizing radiation imaging techniques like MR defecography, barium defecography has become largely obsolete. 

Computed Tomography

Due to concern for radiation exposure and availability of MRI, which provides a better soft-tissue resolution, computed tomography (CT) is usually not appropriate for the evaluation of pelvic prolapse; however, one should look on sagittal abdomen and pelvis images for hint of pelvic floor prolapse by drawing a pubococcygeal line and see for overt prolapse and then recommend a dynamic MRI pelvis (MR Defecogram) for further evaluation.[6]

Magnetic Resonance

Dynamic magnetic resonance imaging (MRI) provides an accurate assessment of pelvic prolapse. MRI provides a better anatomic detail compared to the translabial ultrasound and is also useful as a preoperative tool. Furthermore, the MRI examination does not require bowel preparation and does not involve sensitive pelvic exposure. Despite its benefits, the MRI is not widely available, expensive, and contraindicated in patients with MRI incompatible devices or hardware.

The patient lies supine in the MRI scanner. This examination utilizes a 1.5 or 3.0 Tesla magnet. Despite the fact pelvic prolapse is most prominent in the upright position, obtaining the images supine does not significantly compromise the diagnostic accuracy.[7] The study is performed following the administration of warm ultrasound gel per rectally, as this makes the rectal more prominent. The patient is encouraged to retain some urine in the urinary bladder as this will help diagnose cystocele. The duration of the scan is approximately 15 minutes. However, the length of the examination can be longer if additional images are necessary. Typical MRI protocol involves a large field of view in the sagittal plane and a small field of view in the axial plane. Images are obtained during the resting phase, the squeezing or kegel phase, with the Valsalva maneuver (straining phase) and defecation or evacuation phases. Coronal plane images are optional and usually not obtained.[7]

The interpretation of the images involves drawing the following lines: pubococcygeal line, M-Line, H-Line, and the anorectal angle.[8][9] Pubococcygeal line demarcates the level of the pelvic floor. The line is drawn between the inferior border of the pubic symphysis and the last intercoccygeal joint. Pelvic organ prolapse is subjectively assessed at rest, squeezing, or kegel phase, with the Valsalva maneuver, as well as the defecation phase. The degree of pelvic prolapse can be graded based on the depth of the descent below the pubococcygeal line as mild (less than 3 cm), moderate (3 to 6 cm), and severe (greater than 6 cm).[10] H- line defines the anterior-posterior width of the levator hiatus. The line is drawn between the inferior border of the pubic symphysis and the anterior wall of the rectum at the anorectal junction. The normal H- line should measure less than 5 cm. Finally, M-line measure the descendants of the levator hiatus. It is drawn perpendicular to the pubococcygeal line and intersects the inferior portion of the H-line. The normal M-line should measure less than 2 cm. H-line greater than 5 cm and M-line greater than 2 cm at rest or with the Valsalva indicates pelvic muscle weakness. The anorectal junction is an important landmark and helps in measuring the anorectal angle. The anorectal angle is the angle between the anal canal central axis and the posterior border of the distalmost portion of the rectum. The normal anorectal angle is between 108 and 127 degrees during the resting phase and denotes the functioning of the puborectalis muscle. Normally, the angle should open or become more obtuse with straining/Valsalva and defecation by approximately 20 degrees.[8][9] Chronic functional constipation is a significant symptom and can adversely affect one’s social and personal life. The technical term for this is dyssynergic defecation or spastic pelvic floor syndrome. This condition characteristically presents by an inappropriate lack of relaxation of the puborectalis and external anal sphincter, leading to the urge of defecation without actual fecal emptying. Treatment includes biofeedback therapy, which uses psychophysiological tracings to improve physiological responses. Biofeedback therapy has proven to be very useful in these cases. 

Ultrasonography

Translabial ultrasound is a relatively inexpensive way of evaluating pelvic prolapse and is widely available. Besides, the ultrasound does not produce ionizing radiation and allows dynamic evaluation of the pelvic floor. However, the diagnostic quality of the ultrasound exam depends on the sonographer’s skill level and interpreting radiologist familiarity with the examination. The examination also requires bowel preparation before the start of the exam due to fecal content in the rectum impairing the diagnostic accuracy. Furthermore, the translabial ultrasound is considered a sensitive exam involving genitalia and rectum. 2).[10]

Nuclear Medicine

Nuclear medicine studies are usually not appropriate for the evaluation of pelvic prolapse.[6]

Angiography

Angiography is usually not appropriate for the evaluation of pelvic prolapse.[6]

Patient Positioning

As discussed above, the patient lies supine on the MRI examination. During the translabial ultrasound, the patient is in the dorsal lithotomy position (hip flexed and abducted).

Clinical Significance

Pelvic prolapse is a common condition affecting approximately 50% of parous women above 50.[1] The treatments for pelvic prolapse significantly contribute to the health care cost in the United States.[3] Pelvic prolapse is a clinical diagnosis. However, the dynamic MRI and translabial ultrasound are valuable tools for complicated multicompartment pelvic prolapse when the physical examination is often difficult. 

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Figure

Pelvic Prolapse. Contributed by Ilsup Yoon, MD

Figure

This sagittal image from MR Defecography shows severe perineal descent syndrome involving the posterior compartment. Also note the moderate to severe anterior rectocele. No intrarectal intuscusseption or internal prolapse was seen. This image also demonstrates (more…)

References

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Maher C, Feiner B, Baessler K, Schmid C. Surgical management of pelvic organ prolapse in women. Cochrane Database Syst Rev. 2013 Apr 30;(4):CD004014. [PubMed: 23633316]

2.

Woodley SJ, Boyle R, Cody JD, Mørkved S, Hay-Smith EJC. Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database Syst Rev. 2017 Dec 22;12(12):CD007471. [PMC free article: PMC6486304] [PubMed: 29271473]

3.

Sung VW, Washington B, Raker CA. Costs of ambulatory care related to female pelvic floor disorders in the United States. Am J Obstet Gynecol. 2010 May;202(5):483.e1-4. [PMC free article: PMC2866792] [PubMed: 20227673]

4.

Baeßler K, Aigmüller T, Albrich S, Anthuber C, Finas D, Fink T, Fünfgeld C, Gabriel B, Henscher U, Hetzer FH, Hübner M, Junginger B, Jundt K, Kropshofer S, Kuhn A, Logé L, Nauman G, Peschers U, Pfiffer T, Schwandner O, Strauss A, Tunn R, Viereck V. Diagnosis and Therapy of Female Pelvic Organ Prolapse. Guideline of the DGGG, SGGG and OEGGG (S2e-Level, AWMF Registry Number 015/006, April 2016). Geburtshilfe Frauenheilkd. 2016 Dec;76(12):1287-1301. [PMC free article: PMC5193153] [PubMed: 28042167]

5.

DeLancey JO. What’s new in the functional anatomy of pelvic organ prolapse? Curr Opin Obstet Gynecol. 2016 Oct;28(5):420-9. [PMC free article: PMC5347042] [PubMed: 27517338]

6.

Pannu HK, Javitt MC, Glanc P, Bhosale PR, Harisinghani MG, Khati NJ, Mitchell DG, Nyberg DA, Pandharipande PV, Shipp TD, Siegel CL, Simpson L, Wall DJ, Wong-You-Cheong JJ. ACR Appropriateness Criteria pelvic floor dysfunction. J Am Coll Radiol. 2015 Feb;12(2):134-42. [PubMed: 25652300]

7.

Fielding JR. Practical MR imaging of female pelvic floor weakness. Radiographics. 2002 Mar-Apr;22(2):295-304. [PubMed: 11896220]

8.

Picchia S, Rengo M, Bellini D, Caruso D, Pironti E, Floris R, Laghi A. Dynamic MR of the pelvic floor: Influence of alternative methods to draw the pubococcygeal line (PCL) on the grading of pelvic floor descent. Eur J Radiol Open. 2019;6:187-191. [PMC free article: PMC6527906] [PubMed: 31193423]

9.

Lakeman MM, Zijta FM, Peringa J, Nederveen AJ, Stoker J, Roovers JP. Dynamic magnetic resonance imaging to quantify pelvic organ prolapse: reliability of assessment and correlation with clinical findings and pelvic floor symptoms. Int Urogynecol J. 2012 Nov;23(11):1547-54. [PMC free article: PMC3484313] [PubMed: 22531955]

10.

Chamié LP, Ribeiro DMFR, Caiado AHM, Warmbrand G, Serafini PC. Translabial US and Dynamic MR Imaging of the Pelvic Floor: Normal Anatomy and Dysfunction. Radiographics. 2018 Jan-Feb;38(1):287-308. [PubMed: 29320316]

Disclosure: Ilsup Yoon declares no relevant financial relationships with ineligible companies.

Disclosure: Nishant Gupta declares no relevant financial relationships with ineligible companies.

Bladder prolapse – Better Health Channel

Bladder prolapse or cystocele is when the bladder bulges into the front wall of the vagina. This is also referred to as anterior vaginal wall prolapse.

Bladder prolapse usually happens because of weakening and stretching of the vaginal walls and pelvic floor muscles, due to childbirth or repetitive straining. Risk factors include pregnancy, childbirth and anything else that puts pressure on the pelvic floorExternal Link, including some high-impact gym exercises.

Bladder prolapse can occur by itself, or it may happen along with another prolapse, such as a rectocele (when the bowel bulges into the back wall of the vagina) or a uterine prolapse (when the uterus and cervix drop down into the vagina).

Symptoms of bladder prolapse

The symptoms of bladder prolapse depend on the severity of the prolapse, your level of physical activity and the presence of any other type of prolapse.

They include:

• urinary stress incontinence – leaking urine when coughing, sneezing, laughing, running or walking, or urge incontinence, which is urgently needing to go and leaking on the way
• needing to empty your bladder more frequently
• inability to completely empty your bladder when going to the toilet
• recurrent urinary tract infections
• difficulty keeping a tampon in place during menstruation
• straining to get urine flow started
• a slow flow of urine that may stop and start
• a sensation of fullness or pressure inside the vagina
• a bulge or swelling felt at the vaginal opening
• discomfort with intercourse
• leaking urine with intercourse
• protrusion of the vaginal wall out through the vaginal entrance (in severe cases)
• needing to go back to the toilet immediately after finishing passing urine.

Risk factors for bladder prolapse

Risk factors for bladder prolapse include anything that puts pressure on the pelvic floor and affects its function, such as:

• pregnancy and childbirth
• regularly straining on the toilet to pass bowel motions or empty the bladder
• being overweight
• chronic cough secondary to smoker’s cough or chronic lung diseases
• repetitive lifting of children or heavy weights at work or in the gym, or any exercises where there is excessive downward pressure on the pelvic floor
• pelvic or gynaecological surgery
• strong family history
• connective tissue disease, in which the tissues in the body are not able to hold the weight of the organs
• menopause.

Postmenopausal women are more susceptible to bladder prolapse because they have reduced levels of oestrogen (the female sex hormone). Oestrogen helps to keep the vaginal tissues and muscles in good tone. When oestrogen levels drop after menopause, these tissues become thinner and less elastic, which may allow the bladder to bulge into the vagina.

Diagnosis of bladder prolapse

Bladder prolapse is diagnosed by:

• medical history – including checking for possible risk factors
• physical vaginal examination (internal examination) – to allow assessment of the degree of prolapse, pelvic floor muscle function, presence of any other prolapse and other abnormalities in the pelvis, such as tumours or masses.

Tests for bladder prolapse

Tests that may be carried out to confirm or reject a diagnosis of bladder prolapse, depending on your symptoms, are:

• 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
• a bladder scan to measure residual urine – urine left in the bladder after emptying
• a midstream urine test to exclude urinary tract infection
• magnetic resonance imaging (MRI) – in some cases.

Stages of bladder prolapse

The severity of bladder prolapse can be measured in several ways. Terms such as ‘mild’, ‘moderate’ and ‘severe’ are not always completely accurate, as they depend on a person’s opinion, but are often used in day-to-day conversations to help people understand the severity of the prolapse.

A more commonly used grading is:

• Stage 1 – the bladder protrudes a little way into the vagina
• Stage 2 – the bladder protrudes so far into the vagina that it’s close to the vaginal opening
• Stage 3 – the bladder protrudes out of the vagina
• Stage 4 – most severe form, in which all pelvic organs including the bladder protrude out of the vagina.

Many gynaecologists now use the Pelvic Organ Prolapse Quantification (POP-Q) system, which measures in centimetres where the prolapse is in relation to the vaginal entrance to ascertain the ‘stage’ of prolapse.

Treatment for bladder prolapse

Treatment for bladder prolapse depends on how ‘bothersome’ the prolapse is (how much trouble it gives you) and its stage. The more advanced the prolapse, the more likely it is to be bothersome. During your consultation, you and your gynaecologist will discuss the most bothersome aspects of the symptoms and how they are affecting your life. A treatment plan can be tailored based on the severity of symptoms and stage of prolapse.

Treatment for asymptomatic bladder prolapse

If you have no symptoms of bladder prolapse, you may not need treatment. This may be the case with stage 1 or stage 2 prolapse. In fact, you may not be aware of the bladder prolapse at all. It may be picked up by your GP during a routine examination, such as during a cervical screening test.

Lifestyle changes and physiotherapy are the key aspects of managing such cases. There are things you can do to help prevent the condition from getting worse, which may include:

• weight loss
• management of constipation
• stopping smoking
• correction of position when sitting on the toilet
• avoiding heavy lifting
• pelvic floor exercises, which have been proven to reduce the symptoms of an early stage bladder prolapse and prevent any worsening
• seeking treatment and management for chronic cough and lung disease.

Seeing a pelvic floor physiotherapist is always recommended so that they can assess your pelvic floor function properly and show you the correct technique for doing pelvic floor exercises. The best published evidence supports supervised pelvic floor muscle exercises for the management of prolapse and urinary incontinence.

Treatment for symptomatic bladder prolapse

If you have symptoms of bladder prolapse it is recommended that, as for people with no symptoms, you make the same lifestyle changes, do pelvic floor muscle training and treat any chronic cough. Make them part of your routine.

However, sometimes prolapse can be more severe and these measures may not be enough on their own to relieve symptoms.

For these cases, there can be two different approaches:

1. Non-surgical approach – vaginal pessaries

A pessary is a device made mostly of silicone. It is inserted in the vagina to support the bladder prolapse and front vaginal wall. Pessaries come in different shapes and sizes.

You do not need surgery to put in a pessary. It can be done in the rooms of a pelvic floor physiotherapist, continence nurse or your gynaecologist.

Some women may prefer this option if they wish to avoid or delay surgery, and it may be the safest option for women who are unfit for surgery.

You will need regular check-ups with your healthcare professional if you are using a vaginal pessary long-term.

2.Surgical approach

In some cases, when all other management options have failed to help with the symptoms, or when a woman does not want to use a pessary, surgery may be necessary.

The type of surgery used will depend on your combination of prolapse and urinary tract symptoms. Your doctor will discuss the available surgical techniques with you.

It is common to have a urinary catheter inserted during the operation to rest your bladder for a day after surgery, but this will depend on the procedure you have.

Recovery from surgery takes about six weeks. You doctor will advise you about how to look after yourself during the recovery period, and a physiotherapist can recommend appropriate exercises.

Suggestions may include:

• avoiding any lifting
• avoiding constipation
• walking – this is the best exercise during bladder prolapse surgery recovery
• doing pelvic floor exercises
• resting each day.

Self-care for bladder prolapse

Your doctor may advise you to make a few lifestyle changes to prevent bladder prolapse from worsening (or recurring after surgery). They may suggest:

• not lifting objects that weigh more than 5kg, including children
• daily exercise to help keep your bowel movements regular, but avoiding heavy weight training, sit-ups and high-impact exercise. This may include choosing lighter weights that can be easily lifted without straining; core strengthening on an exercise ball; and cardiovascular exercises such as walking, swimming or bike riding (rather than running, jumping or high-impact aerobics)
• when exercising in the gym, avoiding weight-training that causes you to hold your breath or strain. It’s best to reduce the weight size and increase repetitions. Walking on a treadmill, with or without an incline, is a suitable exercise
• increasing the fibre in your diet to prevent constipation – 30g of fibre daily is recommended. Just one instance of straining can worsen bladder prolapse
• drinking six to eight glasses of fluid each day. Not drinking enough can make stools hard, dry and difficult to pass
• avoiding straining on the toilet for either bowel or bladder, as this will worsen a prolapse. Leaning forward with knees apart, forearms on thighs, a straight back and relaxed tummy will help
• doing pelvic floor exercises daily to strengthen the muscles supporting your pelvic organs. Instruction on how to do this correctly may come from a doctor, pelvic floor physiotherapist or continence nurse. These exercises may also reduce symptoms of urinary incontinence, which may be associated with a bladder prolapse
• squeezing up or bracing 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 vaginal oestrogen preparations, such as a cream, pessary or vaginal tablet) to improve vaginal secretions and blood flow and help tone the skin and muscles supporting your vagina and bladder
• seeing a doctor 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 a bladder prolapse
• keeping within a healthy weight range. Being overweight is known to make symptoms worse.

Having sex when you have a bladder prolapse doesn’t make it worse. You may wish to choose a more comfortable position if there is some discomfort.

Where to get help

• Your GP (doctor)
• Gynaecologist
• Pelvic floor physiotherapistExternal Link
• Jean Hailes for Women’s HealthExternal Link Tel. 1800 JEAN HAILES (1800 532 642)
• Continence Foundation of Australia HelplineExternal Link Tel. 1800 33 00 66

Cystocele in women – degrees, causes, symptoms and treatment.

Cystocele is a combined prolapse of the bladder along with the anterior wall of the vagina, which occurs due to the failure of the supporting apparatus of the pelvic floor, which holds the genitourinary organs in the anatomical position. Under the action of intra-abdominal pressure, the organs are squeezed out of the pelvic floor towards the entrance to the vagina. If left untreated, bladder prolapse occurs over time.

Among all gynecological diseases, cystocele accounts for 14%. Most of the pathology is diagnosed in older women, half of them are patients who have reached menopause. Depending on the size of the prolapse, three degrees of cystocele are distinguished:

• I – mild – the bladder is lowered to the middle of the vagina, the pathology can be determined during examination with straining;
• II – moderate prolapse of the bladder, which is located in the lower part of the vagina, often reaching the entrance; pathology is determined during examination without straining;
• III – the bladder descends beyond the entrance to the vagina, remaining in this position and at rest, at this stage there are complications associated with disruption of the genitourinary organs.

Causes

A cystocele develops due to weakening of the muscles and ligaments that hold the bladder, resulting in a hernia-like defect. There are a number of predisposing factors that lead to vaginal prolapse and cystocele. First of all, we are talking about a change in the hormonal background with a decrease in the level of estrogen, which, as a rule, is observed in women with the onset of menopause.

The peculiarity of the connective tissue of a hereditary nature is also important, in this case both hereditary anomalies and hernias of other localization are diagnosed; either in the patient herself or in close relatives. The failure of the muscles and ligaments that hold the urinary organs can also be associated with frequent childbirth, the birth of a large child, ruptures or rapid labor.

Vaginal prolapse and cystocele are promoted by an increase in intra-abdominal pressure, which occurs during physical exertion, persistent constipation, straining and prolonged coughing, as well as obesity or the presence of tumors in the abdominal cavity.

Clinical manifestations

The symptoms of a cystocele in women depend on the degree of the disease and are associated with a violation of the outflow of urine, while the localization of the defect also affects the sensations. With a mild degree, pollakiuria or urinary incontinence occurs. Also, stress incontinence is observed with a central, paravaginal and distal defect of the pubocervical fascia, an increase in the volume of residual urine is characteristic of a transverse defect. As it progresses, imperative urges appear, with acute urinary retention, pain appears in the lower abdomen.

When the bladder is lowered, the presence of a foreign body in the genital tract is almost constantly felt, discomfort and heaviness in the perineum, which can be given to the lower abdomen. After rest, discomfort may decrease. Most patients experience sexual dysfunction and dyspareunia.

Stagnation of urine, vesicoureteral reflux can cause infection, the development of hydroureteronephrosis, the risk of urolithiasis increases, in which a number of symptoms appear. In advanced cases, if there is a complete prolapse of the organ, severe pain appears, even if the patient remains motionless.

Diagnostics

The diagnosis is made on the basis of the results of the examination, ultrasound of the pelvic organs, the Valsalva test are very informative for cystocele, according to indications, a complex urodynamic study is prescribed, effective for assessing the function of urination based on modeling the process of accumulation and drainage of urine.

The diagnosis of cystocele must be differentiated from other types of genital prolapse (eg, uterine prolapse, rectocele) or other diseases (myoma, diverticulum, cyst, etc.), so the patient may need to consult other specialists. In our clinic, experienced urologists, urogynecologists, oncologists, gastroenterologists, proctologists, etc. can be involved for diagnostics.

Treatment of cystocele

For a free written consultation, in order to determine the stage of the disease, as well as to choose the right tactics for surgical treatment, it is necessary to send me to my personal email address [email protected] [email protected] a complete description of the ultrasound of the pelvic organs, if possible, a copy of the examination by the gynecologist on the chair, indicate age and main complaints. Then I can give a more accurate answer for your situation.

With a mild degree of prolapse of the bladder – a cystocele caused by a lack of hormones, hormone therapy is prescribed. Also, the patient is recommended special exercises aimed at strengthening the muscles of the supporting apparatus. If there is an infection, antibiotics are prescribed.

In more complex cases, the correction of the position of displaced organs is possible only with the help of surgical treatment. As a rule, the indication for surgery is a moderate and severe degree of protrusion. The purpose of the operation is to correct the existing defect by forming new supporting structures with the restoration of bladder function.

The tactics of treatment provides for reliable fixation of the vaginal walls – vaginopexy, as well as the correction of existing functional disorders. With stress urinary incontinence, urethropexy is performed, with incompetence of the pelvic floor muscles, colpoperineolevathoroplasty is indicated, according to indications, sphincteroplasty.

Facilitated laparoscopic promontofixation is an effective method for treating pelvic organ prolapse. If the cause of the prolapse is connective tissue dysplasia, and this occurs in 40% of patients with prolapse of the pelvic organs, then in the correction I use this particular technique using a mesh implant, which further minimizes the risk of recurrence. In this case, the prosthesis is installed in such a way that the appearance in the future of bedsores and the inflammatory process is excluded.

When planning the tactics of treatment and an adequate amount of surgical intervention, for each patient I combine certain techniques, taking into account the stage of the disease, the results of the examination, age, the presence of complications, etc. At the same time, I use more than 20 stages, from which I choose 5-10.

I have been dealing with pelvic prolapse for over 20 years. Feeling responsible for the condition of my patients, I carefully select the method (and there are several dozen of them today) that will be most effective for a particular patient. I have developed a unique author’s method of facilitated laparoscopic promontofixation, for which a patent has been received, which allows to restore the natural functioning of the reproductive system as much as possible. The results of the treatment of women with pelvic prolapse are summarized in three monographs, as well as in more than 20 scientific publications published in peer-reviewed publications.

More information about genital prolapse:

genital prolapse,
uterine prolapse,
Surgery for prolapse of the uterus and vaginal walls,
rectal prolapse,
Laparoscopic lightweight promontofixation with vaginal plasty,
Surgery for cystocele
Urinary incontinence,
rectocele,
Surgery for rectocele
The prolapse of the walls of the uterus,
Complete prolapse of the uterus
What to do with uterine prolapse?
Prolapse of the uterus after childbirth,
Consequences of uterine prolapse
Degrees of uterine prolapse,
Prolapse of the uterus 2 degrees,
Prolapse of the uterus 3 degrees,
Prolapse of the uterus in old age
Urinary incontinence in women after childbirth,
Tracheloplasty

Watch the video of operations performed by Professor Puchkov K.V. You can visit the site “Video operations of the best surgeons in the world. ”

Author of the article

Professor, MD Puchkov K.V.

Certified in the specialties: surgery, gynecology, urology, proctology, oncology.
Experience: 32 years

Cystocele – symptoms, causes, signs, diagnosis and treatment in “SM-Clinic”

Cystocele or hernia of the anterior vaginal wall is considered a common pathology among women. More often the disease affects the fairer sex of post-menopausal age. The frequency of detection of cystocele is constantly increasing, which is associated with an increase in the average life expectancy of women.

Without timely diagnosis and proper treatment, the pathology gradually progresses, which is accompanied by a decrease in the patient’s quality of life, and sometimes leads to disability. Often, a cystocele precedes prolapse of the uterus and vagina.

Types of cystocele

Bladder protrusion is classified into stages:

• First. Bladder prolapse is observed during a gynecological examination with straining. The organ reaches the middle of the vagina and in a calm state returns to its place. A mild form of cystocele is amenable to conservative therapy.
• Second. During gynecological examination, protrusion of the bladder is detected without straining. The organ reaches the lower third or entrance to the vagina. Moderate cystocele is treated conservatively or surgically.
• Third. The bladder comes out of the vagina. Omission is observed in a state of complete rest. Urinary complications are often found. Severe cystocele is treated exclusively with surgery.

Cystocele symptoms

The initial stages of cystocele development are asymptomatic. As the defect in the anterior wall of the vagina increases, the woman has a sensation of a foreign body in the perineum. Discomfort often appears towards the end of the day, with straining, lifting weights, during coughing and sneezing.

Dysuric disorders appear at the second stage of cystocele development. The patient may be disturbed by:

• frequent urge to urinate;
• urinary retention;
• imperative (imperative) urges;
• intermittent micturition;
• feeling of incomplete emptying.

The feeling of a foreign body in the vagina becomes permanent. Due to discomfort, a woman cannot have sex. With defecation and physical exertion, there is a feeling of a large rounded formation in the vagina.

In severe vesical prolapse, there is urinary incontinence, pulling and aching pains in the lower abdomen and lower back, radiating to the inguinal region. Patients complain of the constant presence of a foreign body, discomfort while sitting and walking.

Causes of cystocele

Cystocele develops with functional failure of the pubocervical vesical fascia. Predisposing factors recognized:

• Natural childbirth. Delivery injures the ligaments of the pelvic floor. Each subsequent birth further weakens the pelvic diaphragm. The risk of cystocele increases after the birth of a large child, ruptures and the use of auxiliary techniques (obstetric forceps, vacuum extraction).
• Increased intra-abdominal pressure. Excessive stress on the pelvic floor muscles occurs against the background of some chronic diseases. Cystocele is more often detected in women with obesity, bronchial asthma, a tendency to constipation, ascites, and large tumors in the abdominal cavity.
• Hormonal disorders. A decrease in the tone of the pelvic ligaments is observed with a lack of female sex hormones estrogen. The risk of prolapse increases after menopause or spaying at an earlier age.
• Collagenopathy. Weakness of the ligaments may be due to connective tissue dysplasia. Such disorders are mainly due to genetics. Almost a third of cases of cystocele are characterized by an unfavorable family history.
• Microcirculatory disorders. A sedentary lifestyle and chronic congestion contribute to trophic disorders of the pelvic floor muscles and a decrease in their tone.

Diagnosis of cystocele

Cystocele is determined during a gynecological examination without mirrors. The doctor asks the patient to strain or cough to assess the degree of prolapse of the anterior vaginal wall. To objectively confirm the diagnosis, an ultrasound scan of the pelvic organs and a comprehensive urodynamic study are performed. If urinary retention is detected and an infection is suspected, bakposev is performed. If necessary, the examination is supplemented with cystoscopy and cystography. During the examination, the condition of other pelvic organs is studied and evaluated, since a cystocele rarely occurs in isolation.

Expert opinion

Ignoring the problem is a serious mistake for women. Pelvic organ prolapse does not develop overnight, but most patients go to the doctor in a deplorable state, when the only treatment is surgery. Already at the second stage of the development of the disease, a woman has urination disorders. Stagnation of urine creates favorable conditions for the reproduction of bacteria, the development of cystitis and pyelonephritis. However, by contacting a doctor, a woman can get rid of unpleasant symptoms. To cope with a cystocele, you need to talk about your problem and contact a gynecologist at the first symptoms.

Mavromatis Ellada Pavlovna,
obstetrician-gynecologist of the 1st category

Methods of treatment of cystocele

Treatment of cystocele is aimed at eliminating bladder protrusion and normalizing the natural excretion of urine. It is also necessary to eliminate the defect of the ligaments of the vagina in order to prevent further prolapse of the organs. An important role is played by the identification and treatment of concomitant diseases that can provoke an increase in pressure inside the abdominal cavity. Complex treatment is used, which includes drug therapy, non-drug methods, as well as surgical methods of correction. Therapeutic tactics are selected based on the stage of development of the disease and its cause.

Non-surgical treatment of cystocele

Non-surgical techniques are used in stages 1-2 of cystocele development. Patients are advised to reduce weight (if it is overweight), follow a diet to prevent constipation, and avoid heavy lifting. The muscles of the pelvic floor are not directly related to the formation of cystocele, however, performing exercises to strengthen them improves microcirculation in the small pelvis and trophism of connective tissue structures.

Older menopausal women are given hormone replacement therapy. According to indications, with mild and moderate severity, physiotherapeutic procedures and laser techniques are carried out.

If conservative therapy fails, consider surgical treatment. If a woman is contraindicated in surgery, a pessary is installed. This is a silicone ring that is fixed inside the vagina for the purpose of mechanical support of the organs. The method can slow the progression of the disease and improve the patient’s quality of life.

Surgical treatment of cystocele

Reconstructive surgery for cystocele is aimed at restoring the function of the pubocervical fascia. In the absence of its defects, anterior colporrhaphy is performed – suturing the anterior wall of the vagina. In more complex cases, laparoscopic vaginopexy is performed using mesh prostheses. In case of urinary incontinence, plastic surgeries are supplemented with sling surgeries, in which a mesh implant is also inserted under the urethral canal.

Prevention of cystocele

To prevent prolapse of the bladder, a woman should regularly perform Kegel exercises and lead a moderately active lifestyle, avoid heavy physical labor and weight lifting. It is advisable to adhere to the rules of rational nutrition, to exclude the use of foods that provoke constipation and excessive gas formation. If you are overweight, you should follow a hypocaloric diet. It is necessary to regularly undergo preventive examinations by a gynecologist for the purpose of early diagnosis of diseases. It is also worth paying attention to the treatment of chronic respiratory diseases accompanied by cough.

Rehabilitation of cystocele

The period of hospital follow-up after reconstructive surgery is 2-3 days. During the rehabilitation period, a woman must observe sexual rest, avoid physical exertion and weight lifting. It is undesirable to take a bath, you can not swim in open water. Until full recovery, you should follow a diet to prevent acute constipation.

Questions and Answers

Significant prolapse of the bladder, rectum, uterus and vagina is possible with significant prolapse. In the later stages, the organs go out through the vagina, but this is observed only in advanced cases, when a woman does not pay attention to her condition for a long time. At the same time, other internal organs are also displaced, which is manifested by multiple functional disorders.

If a woman has to set the bladder manually, this indicates a severe prolapse of the organ. Increasing the tone of the pelvic floor muscles in such a situation will not have an effect. Comprehensive treatment is necessary, taking into account the causes of prolapse.

The use of a pessary is a palliative therapy. The ring does not have a direct therapeutic effect on the ligaments of the vagina. The pessary only supports the internal organs in a stable position. As the prolapse worsens, the method loses its effectiveness. Many patients complain of discomfort in the vagina due to the use of a pessary (irritation, redness, dryness), which is why they are forced to refuse to use it. Therefore, it is better not to start the problem, and at the first symptoms, contact a gynecologist.

Already in the second stage of the disease, women experience urinary outflow disorders and infectious complications. Pathogenic bacteria can rise up, causing pyelonephritis. Omission of organs makes sexual life impossible, causes discomfort during ordinary household chores. With severe prolapse, a woman constantly suffers from aching pelvic pain. Neurotic disorders and depression join.