Cystocele or drooping bladder

The bladder is located behind the pelvis and in front of the rectum, and is located above the prostate and seminal vesicles in the case of men and over the vagina in the case of women. When the containment fails and due to the effect of gravity, the bladder can fall down on the vagina causing various symptoms producing the dropped bladder or cystocele.

What is cystocele?

Cystocele is a drooping of the bladder due to weakening of the pelvic muscles that support it. The pelvic muscles are responsible for supporting the bladder, which is separated from the vaginal canal by a fibromuscular wall that at any given time and for various reasons can weaken.

How is it produced?

Complicated delivery

The fall of the bladder due to weakness of the wall that separates it from the vagina is usually due to alterations that occur during or after childbirth, especially when it comes to long, complicated, and instrumentation-requiring deliveries, in cases of very large babies or due to the existence of multiple deliveries. Labor and the massive strain on the pelvic muscles causes the pelvic muscles to weaken.

Estrogen drop

In addition, estrogens, female sex hormones, are responsible, among many other things, for maintaining adequate muscle tone in the pelvic muscles, in order to hold the different structures in their correct anatomical position and prepare for an eventual childbirth. Upon reaching the decreased secretion of estrogens, so without them the pelvic muscle structures tend to weaken.

Muscular weakness

Other factors that can lead to weakening of these muscle groups and facilitate the appearance of a cystocele are the continuous load of weights that increase the pressure on the pelvic area, severe and prolonged constipation or chronic cough, maneuvers that increase abdominal pressure and, consequently, the one that is exerted on this pelvic musculature, being able to weaken it.

Sometimes cystocele can be caused by congenital alterations, such as spina bifida or malformations of the bladder, vagina or rectum, although these are rare cases.

Symptoms of dropped bladder

Cystocele is characterized by the presence of a sensation of mass or occupation at the level of the pelvis that can reach various degrees. When the bladder falls on the vagina, the pressure on it increases, which can cause symptoms of increased pressure, which causes the urinary sphincter to open.

When standing (due to gravity) or when performing maneuvers that increase pressure on this area (called Valsalva maneuvers), such as laugh, cough, sneeze, run, have a bowel movement, or carry weight, urine leakage is likely to occur as well.

Likewise, the very fact that the bladder falls can make it difficult to empty it, so that urination is not complete and there may be a constant urge to urinate and an absence of satisfaction with urination. The swollen urine that remains inside the bladder can lead to recurrence.

The cystocele can also cause difficulties to defecate by secondary compression of the rectum, and cause urinary tract infections.

Degrees of dropped bladder

Depending on the level of descent of the bladder, cystocele can be classified into:

• Grade I cystocele, mild, with a slight descent from its normal position.
• Moderate grade II cystocele, when the descent already reaches the opening of the vaginal cavity.
• Severe grade III cystocele when the bladder exits the body through the vagina.

How is it diagnosed?

The diagnosis will be based initially on the symptoms that the patient explains about urgency for urination, urinary incontinence (and in minor rectal occasions), sensation of and difficult or even painful sexual relations.

A complete exploration will be carried out, carrying out a vaginal examination and observing if there is an exit or protrusion of the bladder to the outside, both while the patient is standing or lying down. The patient will be asked to squeeze the abdomen in both positions to check for urine leakage.

Imaging tests can be performed to assess the shape and location of the bladder, by means of a computerized axial tomography (CT) or cystography, which allows to see the shape and position of the bladder and its emptying mechanism when taking serial radiographs while urinating . It is also advisable to carry out a urometric study to assess the preservation of the urination mechanisms.

Treatment: the famous Kegel exercises

Treatment for cystocele will vary depending on the grade. In mild cases, it can sometimes be enough to reinforce the pelvic muscles by means of a series of exercises that seek to contract the pubococcygeus muscle, which allows this muscle to recover its original tone and thus prevent a progression of the descent of the bladder.

It is not so easy to contract the correct muscles, so it is advisable to put yourself in the hands of a professional to perform the exercises properly. Sometimes, to be able to locate the muscles to be worked well, an electrostimulation of the area can be performed initially.

• Mild or moderate cases, a pessary can be used, that is, a body that is placed inside the vagina and that prevents the progression of the cystocele. This method, however, carries a lot of inconvenience.
• In moderate or severe cases, treatment is usually surgical. The surgery seeks to return the bladder to its initial position and hold it with straps or mesh so that it does not fall back, in a procedure with general anesthesia similar to the repair of an inguinal hernia. The intervention is usually successful.
• Occasionally, hormone replacement therapy with estrogens can be performed to strengthen the pelvic floor in menopausal patients.

How to avoid having cystocele?

Cystocele can be prevented as far as possible by strengthening the pelvic muscles throughout life, especially after childbirth and at the beginning of menopause. Kegel exercises are a good tool to prevent cystocele and urinary incontinence. In case of presenting these symptoms, it is advisable to put yourself in the hands of the urologist or gynecologist as soon as possible.

General Medicine Specialist