What are the key aspects of pelvic prolapse imaging. How do different imaging modalities contribute to diagnosis. What are the common symptoms and treatment options for pelvic prolapse.

Understanding Pelvic Prolapse: Definition and Prevalence

Pelvic floor prolapse is a condition characterized by the herniation of pelvic organs through the perineum. This common health issue affects approximately 50% of women over the age of 50, particularly those who have given birth multiple times. The condition can involve different compartments of the pelvic area, including the anterior (bladder), middle (uterus or vagina), and posterior (small bowel or rectum) compartments.

The categorization of pelvic prolapse depends on the specific organ involved:

• Cystocele: Prolapse of the urinary bladder
• Uterine or vaginal prolapse: Descent of the uterus or vagina
• Enterocele: Prolapse of small bowel loops
• Rectocele: Prolapse of the rectum

Recognizing Symptoms and Impact of Pelvic Prolapse

Pelvic prolapse can manifest through various symptoms, significantly affecting a person’s quality of life. Common symptoms include:

• Stress urinary incontinence
• Fecal incontinence
• Uterine prolapse
• Constipation
• Incomplete defecation

Beyond these physical symptoms, pelvic prolapse can have profound psychological effects. Many patients experience a negative impact on their body image and sexuality, which can lead to decreased self-esteem and relationship difficulties.

How does pelvic prolapse affect daily life?

Pelvic prolapse can significantly disrupt daily activities. Patients may experience discomfort while standing or walking for extended periods. Some individuals may feel a constant sensation of pressure or fullness in the pelvic area. In severe cases, the prolapsed organs may protrude from the vaginal opening, causing pain and making activities like sexual intercourse challenging or impossible.

Diagnosis and Imaging Techniques for Pelvic Prolapse

While pelvic floor prolapse is often diagnosed through physical examination and medical history, imaging plays a crucial role in complex cases involving multiple compartments and organs. The two primary imaging modalities used for diagnosing pelvic prolapse are:

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

Translabial Ultrasound: A Non-Invasive Diagnostic Tool

Translabial ultrasound is a valuable, non-invasive technique for assessing pelvic prolapse. This method involves placing an ultrasound probe on the perineum to visualize the pelvic organs and their position relative to surrounding structures. Translabial ultrasound offers several advantages:

• Real-time imaging of pelvic organ movement
• No radiation exposure
• Widely available and cost-effective
• Can be performed in various patient positions

Dynamic Pelvic MRI: Advanced Imaging for Complex Cases

Dynamic pelvic MRI, also known as MR defecography, provides detailed images of the pelvic floor and its organs during various maneuvers. This technique is particularly useful in complex cases and for preoperative planning. Key aspects of dynamic pelvic MRI include:

• High-resolution imaging of soft tissues
• Ability to assess multiple compartments simultaneously
• Evaluation of pelvic organ movement during straining and defecation
• No radiation exposure

The MRI examination is typically performed using a 1.5 or 3.0 Tesla magnet, with the patient lying supine. While pelvic prolapse is most prominent in the upright position, obtaining images in the supine position does not significantly compromise diagnostic accuracy.

Anatomical Considerations in Pelvic Prolapse

Understanding the anatomy of the pelvic floor is crucial for accurate diagnosis and treatment of pelvic prolapse. The pelvic anatomy is divided into three compartments:

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

Several structures work together to prevent prolapse of pelvic organs:

• Pelvic muscles: Iliococcygeal, pubococcygeal, and puborectal muscles
• Ligaments and fascia: Endopelvic fascia, pubocervical fascia, and rectovaginal fascia

These supporting structures are visible on pelvic MRI, allowing for a comprehensive assessment of pelvic floor integrity.

Treatment Options for Pelvic Prolapse

The management of pelvic prolapse ranges from conservative approaches to surgical interventions. The choice of treatment depends on the severity of symptoms, the degree of prolapse, and the patient’s overall health and preferences.

Non-Surgical Approaches

Conservative treatments are often the first line of management for mild to moderate pelvic prolapse:

• Kegel exercises: Strengthen pelvic floor muscles
• Pessary: A removable device inserted into the vagina to support prolapsed organs
• Lifestyle modifications: Weight loss, avoiding heavy lifting, and managing chronic cough

Surgical Interventions

When conservative measures fail or in cases of severe prolapse, surgical options may be considered:

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

The choice of surgical approach depends on various factors, including the specific type of prolapse, the patient’s age, overall health, and desire for future pregnancies.

Economic Impact of Pelvic Prolapse

Pelvic prolapse imposes a significant economic burden on healthcare systems. In the United States alone, the cost of treating pelvic prolapse was estimated at approximately $300 million from 2005 to 2006. This figure encompasses various aspects of care, including:

• Diagnostic procedures
• Conservative treatments
• Surgical interventions
• Follow-up care and management of complications

As the population ages and awareness of pelvic prolapse increases, it is likely that these costs will continue to rise. This underscores the importance of early detection, effective management, and ongoing research into more cost-effective treatment options.

Future Directions in Pelvic Prolapse Management

The field of pelvic prolapse diagnosis and treatment is continuously evolving. Several areas of ongoing research and development show promise for improving patient outcomes:

Advanced Imaging Techniques

Researchers are exploring new imaging modalities and refining existing ones to enhance the accuracy of pelvic prolapse diagnosis. These include:

• 3D and 4D ultrasound imaging
• Functional MRI techniques
• Artificial intelligence-assisted image analysis

Novel Treatment Approaches

Innovative therapeutic strategies are being developed to address pelvic prolapse more effectively:

• Tissue engineering and regenerative medicine for pelvic floor reconstruction
• Minimally invasive surgical techniques with reduced recovery times
• Targeted pharmacological interventions to strengthen pelvic floor tissues

Personalized Medicine

The future of pelvic prolapse management lies in tailoring treatments to individual patients based on their specific needs and risk factors. This approach may involve:

• Genetic testing to identify predisposition to pelvic prolapse
• Biomarker analysis for early detection and prognosis
• Customized rehabilitation programs based on pelvic floor muscle function

As research in these areas progresses, it is anticipated that the diagnosis, treatment, and prevention of pelvic prolapse will become more precise and effective, ultimately improving the quality of life for millions of affected individuals.

Preventive Measures and Risk Factors for Pelvic Prolapse

While not all cases of pelvic prolapse can be prevented, understanding the risk factors and taking proactive measures can help reduce the likelihood of developing this condition or slow its progression.

Key Risk Factors

Several factors increase the risk of developing pelvic prolapse:

• Pregnancy and childbirth, especially multiple vaginal deliveries
• Age and menopause
• Obesity
• Chronic cough or constipation
• Heavy lifting or strenuous physical activity
• Family history of pelvic prolapse
• Connective tissue disorders

Preventive Strategies

Implementing certain lifestyle changes and practices can help maintain pelvic floor health:

• Regular pelvic floor exercises (Kegel exercises)
• Maintaining a healthy weight
• Avoiding constipation through proper diet and hydration
• Using proper lifting techniques
• Quitting smoking to reduce chronic cough
• Managing chronic health conditions that may contribute to prolapse

By addressing these risk factors and adopting preventive measures, individuals can potentially reduce their risk of developing pelvic prolapse or minimize its severity if it does occur.

Patient Education and Support for Pelvic Prolapse

Effective management of pelvic prolapse extends beyond medical interventions. Patient education and support play crucial roles in improving outcomes and quality of life for those affected by this condition.

Importance of Patient Education

Educating patients about pelvic prolapse can lead to several benefits:

• Early recognition of symptoms and timely seeking of medical attention
• Better understanding of treatment options and their potential outcomes
• Improved adherence to treatment plans and lifestyle modifications
• Reduced anxiety and improved psychological well-being

Support Systems and Resources

Various support systems can help patients cope with the physical and emotional challenges of pelvic prolapse:

• Support groups (both in-person and online)
• Pelvic floor physical therapy
• Counseling services for body image and sexual health concerns
• Educational materials and workshops
• Nurse navigators or patient advocates to guide through treatment processes

Healthcare providers play a vital role in connecting patients with these resources and ensuring they have the support needed to manage their condition effectively.

Addressing Stigma and Misconceptions

Pelvic prolapse is often surrounded by stigma and misconceptions, which can prevent individuals from seeking help. Efforts to address these issues include:

• Public awareness campaigns to normalize discussions about pelvic health
• Training healthcare providers to approach the topic sensitively and comprehensively
• Promoting open dialogue about pelvic prolapse in various healthcare settings

By fostering a more open and supportive environment, patients with pelvic prolapse can feel empowered to seek the care they need and improve their overall quality of life.

In conclusion, pelvic prolapse is a complex condition that requires a multifaceted approach to diagnosis, treatment, and management. From advanced imaging techniques to innovative treatments and comprehensive patient support, the field continues to evolve. As research progresses and awareness grows, individuals affected by pelvic prolapse can look forward to more effective, personalized care options and improved outcomes. By addressing this condition holistically – considering physical, emotional, and social aspects – healthcare providers can significantly enhance the well-being of those living with pelvic prolapse.

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

symptoms, causes, diagnosis and treatment in Moscow at the Center for Surgery “SM-Clinic”

Cystocele: symptoms, causes, diagnosis and treatment in Moscow at the Center for Surgery “SM-Clinic”

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General information

Cystocele is a prolapse of the anterior wall of the vagina and bladder in women (genital prolapse), which results in a direct violation of the functions of these organs. Loss of elasticity and functional viability of the muscles of the anterior wall of the vagina most often develops in women of the postmenstrual period, aged 40 years or more.

The disease may be preceded by complicated or multiple births, operations affecting the pelvic organs, traumatic perineal ruptures, hernias. Also, the causes of cystocele can be increased intra-abdominal pressure, some congenital pathologies and underdevelopment of muscle tissues, high sports loads of a specific nature. The risk of bladder prolapse increases with age against the background of general age-related muscle atrophy.

Stages of cystocele development

Depending on the observed topographic changes and functional disorders, the following degrees of pathology progression are distinguished:

• 1 degree. It is characterized by slight deviations from the physiologically normal position of the bladder. It proceeds almost asymptomatically, does not cause inconvenience and can be diagnosed during a routine examination if the doctor asks the patient to tighten the muscles of the small pelvis. The defect may be more pronounced towards the end of the day or after significant physical exertion.
• 2nd degree. Diagnosing pathology is not difficult without muscle tension. During a medical examination, a protrusion of a weakened vaginal wall is easily fixed, but the bubble does not yet go out through the genital gap, being within it.
• 3rd degree. There is a partial or complete extrusion of the anterior wall of the vagina into the perineum through the genital gap, noticeable even in a completely relaxed position without tension.

The disease often occurs in combination with other topographic disorders of the pelvic organs. In the Center for Surgery “SM-Clinic” its any stages and forms are successfully treated.

Bladder prolapse symptoms

The early stage of the disease is usually asymptomatic. With careful attention to herself, the patient may pay attention to frequent, sometimes slightly painful urination and a weakening of the pressure of the urine stream. As the disease progresses, the symptoms increase and become more pronounced.

The most characteristic of them is a feeling of heaviness, pressure, the presence of a foreign object in the perineum. The prolapse of the bladder also entails a displacement of the vagina, which can make sexual intercourse painful, and bacterial infections easily penetrate into the vagina itself. In the advanced stage, protrusion of the walls of the bladder can be observed from the genital slit. Possible minor bleeding.

Other pronounced symptoms of cystocele:

• Weak pressure when urinating.
• Impossibility of simultaneous emptying of the bladder, the need for gradual urination.
• Feeling of insufficiently complete emptying, in later stages up to the inability to do it yourself, without manual reduction of the defect.
• Frequent and sharp urges, incl. at night, forcing to get up during sleep.

Diagnosis of cystocele

Pathology is diagnosed by vaginal examination in a horizontal position without the use of mirrors. The doctor assesses the state and position of the organs both in a state of physical rest and under tension, asking the patient to strain or cough (cough test). To differentiate the disease from other pathologies that have a similar visual picture, the doctor may prescribe the following laboratory and hardware studies: Ultrasound of the pelvic organs, incl. for residual urine, cystography, or a complete comprehensive urodynamic examination (CUD).

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Surgical treatment of cystocele

If the stage of prolapse of the bladder is not subject to conservative treatment or it has proved to be ineffective, gynecologists recommend not to delay surgical intervention, since the pathology tends to progress. Surgeons perform the following operations:

• Anterior colporrhaphy. The essence of the operation is to remove part of the stretched sagging anterior vaginal wall, followed by suturing the wound. If a woman does not plan to have children in the future, the wall can be strengthened with a special medical implant, which removes the risk of a possible relapse. Access to the problem area is through the vagina.
• Laparoscopic plasty. The operation is performed through several small incisions in the abdominal cavity, which heal quickly and almost without a trace. The doctor has a good view of the surgical field on a large monitor with the help of video camera sensors inserted into the punctures. This method is the least traumatic and effective. It is used mainly in the case when the cystocele is combined with the prolapse of the uterus, pelvic floor and other concomitant pathologies that require more extensive surgical intervention.
• Sling operation. It is performed by open access with stress urinary incontinence when the bladder is displaced and, as a result, changes in the angle of the urethra. The operating surgeon passes a loop made of a special synthetic material under the canal and sets it in such a way as to fix the urethra in position at the required angle for natural controlled urination. The duration of the operation is about 60 minutes.

The optimal method of surgical intervention for each clinical case is chosen by the doctor based on the totality of available factors. Depending on them, one of the following surgical techniques is selected

Anterior Colporrhaphy

The operation is performed by vaginal access and is a plastic transformation (suturing) of the anterior wall of the vagina with cutting the flap from its sagging part. After that, the wound is sutured with the capture of the fascia (connecting membranes) of the bladder. If necessary, the anterior vaginal wall is strengthened with a mesh implant.

Laparoscopic plasty

The deformity is eliminated through small punctures in the abdominal cavity for the introduction of microsurgical instruments and sensors that provide visual and other control necessary for the quality of the operation. This is the least painful operation with a short rehabilitation period.

Sling operation

The essence of surgical intervention is to restore the correct angle of inclination of the urethra in order to eliminate the involuntary outflow of urine. To do this, a loop is placed under its middle part, made of a special medical synthetic material, which lifts the urethra and fixes it in the desired position. The operation is performed by access through the anterior abdominal wall.

The operation is performed under general endotracheal anesthesia. The choice of surgical tactics depends on the degree of prolapse of the bladder, its functional consequences, the age of the patient, the possible planning of pregnancy, the state of health and other individual factors that doctors must take into account.

Medical expert opinion

Rehabilitation period

Currently, the most minimally invasive surgical techniques are used, as far as a specific clinical case allows. This allows you to minimize the stay in the hospital to 1-2 days, depending on the type and extent of surgical intervention. In the postoperative period, the doctor without fail prescribes preventive antibiotic therapy, if necessary, painkillers are used. As a rule, the operation is well tolerated, but requires restriction of physical activity for a month.

If, based on the results of the examination, the doctor recognizes the need for surgical intervention, it is highly undesirable to postpone and refuse the operation due to the inevitable progression of the pathology and its transition to a more severe stage, which is more difficult to surgically correct.

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Urology: Prolapse of the pelvic organs

Under prolapse (omission) of the pelvic organs understand the displacement of the walls of the vagina and uterus into the lumen of the vagina and beyond.

Department of Urology – uroportal.ru

When it comes to the omission of the anterior wall of the vagina, most often we mean cystocele (omission of the bladder), the posterior wall – rectocele and enterocele (omission of the rectum and / or small intestine).

Classification of pelvic organ prolapse:

• I degree. Prolapse of the anterior and/or posterior walls of the vagina (walls do not extend beyond the entrance to the vagina).
• II degree. Prolapse of the anterior and / or posterior walls of the vagina (the walls are outward from the entrance to the vagina).
• III degree. Complete prolapse of the vagina, which is accompanied by prolapse of the uterus.

The most common types of pelvic organ prolapse are:

• cystocele (other Greek kystis – bladder, kēlē – protrusion) – prolapse of the bladder and the anterior wall of the vagina,
• rectocele (lat. – rectum – rectum, kēlē – protrusion) – prolapse of the rectum and the posterior wall of the vagina,
• uterine prolapse.

Most often, this condition is described as “omission of the walls of the vagina” or even “omission of the uterus.” Cystocele is the most common type of pelvic organ prolapse in women. The most characteristic complaints in cystocele: frequent urination, difficulty urinating, feeling of incomplete emptying of the bladder, heaviness in the lower abdomen.

The most characteristic complaints in rectocele: constipation, difficulty emptying the rectum (the need to “set the vagina”), feeling of a foreign body in the perineum.

Prolapse of the uterus is most often associated with prolapse of the bladder (cystocele) and/or rectum (rectocele), so there may be complaints that are characteristic of both diseases.

Factors contributing to the development of prolapse of the pelvic organs

• traumatic and prolonged labor,
• systemic dysplasia (deficiency) of connective tissue,
• estrogen deficiency (decrease in general and local levels of female sex hormones),
• chronic diseases accompanied by increased intra-abdominal pressure (bronchitis, asthma, constipation, etc.),
• violation of the processes of microcirculation of blood and lymph in the pelvis,
• obesity,
• sedentary lifestyle.

Basic methods for diagnosing prolapse

• vaginal examination,
• Ultrasound of the urinary system,
• urodynamic studies,
• urinalysis,
• cystoscopy.

Treatment

The immediate cause of the development of prolapse is an anatomical defect in the ligamentous apparatus of the pelvic floor (ruptures of the fascia). In this regard, the only effective method of treatment is the surgical restoration of the integrity of damaged structures. This can be done in two ways.

The first method involves “suturing” ligament defects (fascia) with a special surgical suture material. With proper determination of indications and good performance, such operations provide good results. Unfortunately, with pronounced forms of omission, “plastic” with one’s own tissues is extremely ineffective – relapses occur in 30-60% of cases.

Very often, patients with uterine prolapse are offered to remove this “useless and even harmful organ.” I would like to state with all responsibility: if the uterus is healthy (there are no polyps, discharges, smears for oncocytology are normal, etc.), removing it is an absolutely vicious operation!

The uterus is not the cause of uterine prolapse! The reason, as already mentioned, is defects in the ligamentous apparatus of the pelvic floor! Following the logic that “the prolapsed uterus must be removed”, it is not bad to remove the bladder for a cystocele and the rectum for a rectocele! When the uterus is removed, the risk of further prolapse does not decrease, but increases!

The second group of operations is the prosthesis of the incompetent ligamentous apparatus of the pelvic floor with synthetic endoprostheses (nets). With pronounced forms of prolapse, such operations provide incomparably better anatomical and functional results than traditional plastics. But they are fraught with a number of serious dangers! Synthetics require the surgeon to have a deep understanding of the anatomy of the pelvic floor and to master all the technical nuances of using “grids”. Practice has more than convincingly shown that these are not empty words. Insufficiently trained specialists have already pretty much messed up “synthetic firewood” … In case of complications, their “authors” usually scold the grids. But at 9In 0% of cases, problems are not related to the implant at all.

SURGICAL TECHNIQUE FOR VAGINAL PROFLECTION DEVELOPED AT OUR CENTER

Compared to traditionally performed methods, the technique we have developed does not involve the use of expensive equipment, is relatively simple to perform, is characterized by a short duration of an average of 35 minutes, and a low rate of complications.

PICTURE 3. A – SURFACE SUTURE TECHNIQUE: A – APICAL SLING FIXATION LIGATIONS, B – purse-string suture on the inner surface of the fascia, C – UROSLING-1, D – SUTURE PASSES OVER THE FIXER YOUNG LIGATURES; B – FORMATION OF NEOCERVIX: A – TIGHTENED purse-string suture, B – LIGATURES ARE TIED TOGETHER OVER A CONGLOMERATE OF TISSUES, C – NEOCERVIX; C — SCHEME OF THE POSITION OF THE APICAL SLING: A — UROSLING-1, B — SACURA-Spinous Ligament, C — VAGINA DOME

The above facts are confirmed by the data of a clinical study conducted on the basis of the North-West Center for Pelvic Perineology (Pelvic Floor Surgery) – not a single case of endoprosthesis erosion was detected, both as a result of the use of modern mesh material, and due to the unique method of fixing the vaginal dome to it. The main advantage of the proposed technique is the absence of direct contact between the sling and its fixation ligatures with the vaginal wall.

The neocervix formed with the help of a purse-string suture is used as a support structure for fixing the vaginal fornix to the endoprosthesis. Often, in posthysterectomy prolapse, there are concomitant defects of the endopelvic fascia, which forces surgeons to supplement the apical correction with the restoration of the anterior / posterior vaginal wall. However, traditionally performed colporrhaphy is accompanied by a high recurrence rate, reaching 70 percent in the case of cystocele correction, according to some authors.

Reconstructive pelvic floor surgery is a very specific field. If you are faced with the problem of prolapse of the pelvic organs – look for specialists who feel confident in it. Then the chance to return to a full life will be maximum.

Summarizing the above, we can state that a good anatomical result in all three compartments, obtained in our study, is achieved due to the creation of a single construct consisting of a neocervix (a conglomerate of tissues from the restored endopelvic fascia and other structures of the vaginal wall), fixed to a synthetic apical sling. Vaginal reconstruction according to our technique has all the advantages of traditional plasty (colporrhaphy) – (minimal risks for the patient) and the reliability of pelvic floor reconstruction using synthetic material.

Currently, on the basis of the urological department of the Clinic of High Medical Technologies named after. N.I. Pirogov St. Petersburg State University annually provides assistance to more than 2,000 patients with various pelvic floor pathologies from all regions of Russia, the CIS and neighboring countries.

Our clinic performs more than 600 surgeries per year for urinary incontinence in women and another 1400 for prolapse (omission) of the pelvic organs (also in combination with urinary incontinence).

Treatment at the VMT Clinic IM. N.I. Pirogov St. Petersburg State University

North-Western Center for Pelvioperineology (NWCCPP) , founded in 2011 on the basis of the Urology Department of the Clinic of High Medical Technologies named after N.