The pelvic organs are held in place by the pelvic floor muscles, ligaments and layers of connective tissue. When this support weakens, the organs can drop into or out of the vagina; this is called pelvic organ prolapse. In a cystocele, the supporting layer between the bladder and the vagina weakens and the bladder pushes the front wall of the vagina inward. Many women have prolapse in more than one area at the same time; prolapse of the uterus and of the back wall of the vagina is covered on the Uterine Prolapse and the Rectocele and Enterocele pages.
Causes
The main cause is pregnancy and vaginal birth. Menopause, aging, frequent heavy lifting, excess weight, straining because of constipation and a long-lasting cough caused by smoking, asthma or other conditions also contribute to prolapse. Some people have an inherited tendency related to the structure of their connective tissue.
Symptoms
A mild cystocele often causes no symptoms and is noticed during an examination. When there are symptoms, they may include:
- A feeling of fullness, pressure or dragging in the vagina
- A bulge that can be felt in the vagina or that comes out of the vaginal opening
- A slow or interrupted urine stream and a feeling that the bladder has not emptied completely
- Frequent urination, a sudden urge to urinate and recurrent urinary tract infections
- Leakage of urine when coughing or during exertion
Assessment
Complaints related to urinary, bowel and sexual function are asked about in detail. The examination is carried out lying down and, if needed, standing; the degree of prolapse and any leakage of urine are checked while straining and coughing. The degree of prolapse in the front, middle (uterus or vaginal vault) and back compartments of the vagina can be recorded with a standard measuring system called POP-Q. The strength of the pelvic floor muscles and any thinning of the vagina related to menopause are also assessed. The amount of urine left in the bladder after urinating can be measured with ultrasound. If prolapse is found on examination, imaging is usually not needed. If surgery for incontinence is also being considered, urodynamic testing is performed before the operation; this test is described on the Urinary Incontinence page.
Non-surgical options
A cystocele that causes no complaints may not need treatment and is monitored with check-ups. If there are complaints, non-surgical options are discussed first:
- Lifestyle: losing weight if the body mass index is over 30, reducing heavy lifting and preventing or treating constipation are recommended.
- Pelvic floor muscle exercises (Kegel exercises): for mild to moderate prolapse that causes symptoms (POP-Q stage 1–2), a program supervised by a specialist and continued for at least 16 weeks is considered as a first option.
- Pessary: a device, usually made of silicone, that is placed in the vagina to support the prolapsed organs; it can be used alone or together with exercises. Its use is described in detail on the Uterine Prolapse page.
- Vaginal estrogen: if there is vaginal dryness and thinning related to menopause, estrogen applied in the vagina may be recommended.
Surgical treatment
Surgery is discussed for people whose complaints have not improved with non-surgical treatment or who do not want it. The operation used for a cystocele is anterior repair (anterior colporrhaphy): through an incision in the front wall of the vagina, the weakened supporting layer between the bladder and the vagina is repaired with dissolving stitches and the vaginal wall is closed. NICE, the body that issues national clinical guidance in England, recommends that this repair be carried out with the person’s own tissue, without synthetic mesh. If there is also prolapse of the uterus or the vaginal vault, anterior repair may be combined with an operation that supports this area. The operation can be performed under general or spinal anesthesia and, in some cases, local anesthesia.
For people who do not have incontinence, it is discussed beforehand that incontinence may appear after anterior repair and that further treatment may be needed. NICE recommends that a separate operation not be performed in these people to prevent incontinence. If stress incontinence is also present, the benefits and risks of treating both problems in the same operation or separately are compared.
Use of transvaginal mesh
Placing synthetic mesh through the vagina to reinforce a prolapse repair has been restricted in many countries because of serious complications such as exposure of the mesh in the vagina, pain, infection and injury to the bladder or bowel. In April 2019, the US Food and Drug Administration (FDA) ordered manufacturers to stop selling the remaining mesh products intended for transvaginal repair of prolapse; these products were intended for repair of anterior prolapse (cystocele). The order does not cover slings used for incontinence or mesh placed through the abdomen. NICE also recommends that transvaginal mesh for anterior or posterior vaginal wall prolapse be used only in the context of research. These meshes have been withdrawn or their use has been restricted in countries such as the US, the UK, Australia and New Zealand. Prolapse operations that use mesh placed through the abdomen are a separate group and are covered on the Uterine Prolapse page.
After surgery
After the operation, there may be a urinary catheter and a vaginal pack for a short time. As the stitches in the vagina dissolve, a creamy discharge and brownish spotting may occur for a few weeks; foul-smelling discharge should be assessed. During recovery, heavy lifting, straining, strenuous exercise and constipation are avoided. The return to daily activities is gradual; when intercourse can be resumed is decided at the follow-up examination. A check-up that includes a vaginal examination is recommended six months after surgery.
Possible risks
Bleeding, infection, urinary tract infection, blood clots and problems related to anesthesia may occur. Injury to the bladder or the ureter (the tube that carries urine from the kidney to the bladder) is an uncommon risk. Stress incontinence may appear after surgery, and there may be difficulty passing urine and constipation. Some women develop pain during intercourse. The prolapse may come back in the same area over time, or prolapse may develop in another part of the vagina. Even when the operation corrects the prolapse, not all complaints may go away.