Cystocele (Prolapsed Bladder)

What a cystocele is

The bladder rests on the front wall of the vagina, supported by a layer of tissue (the pubocervical fascia) and the pelvic floor muscles. When these supports stretch or tear, the bladder drops and pushes the vaginal wall downward and inward. A cystocele is one form of pelvic organ prolapse. It often occurs alongside other types, such as a rectocele (the rectum bulging into the back wall) or uterine prolapse.

Grades of cystocele

Doctors also use the POP-Q system, which measures specific points in centimeters relative to the hymen.

Symptoms

Mild cystoceles often cause no symptoms. When present, symptoms include:

• a feeling of pelvic pressure, heaviness or fullness in the vagina
• a bulge you can see or feel at the vaginal opening
• symptoms worse after standing, lifting, coughing or at the end of the day, and better lying down
• leaking urine with coughing, laughing or exercise (stress incontinence)
• a weak or slow stream, or feeling the bladder has not emptied
• needing to push the bulge back (splinting) to pass urine
• frequent urination or urgency
• repeated urinary tract infections
• discomfort during sex

Some women with larger cystoceles have hidden stress incontinence: the bulge kinks the urethra and stops leaks, which appear only after the prolapse is corrected.

Causes and risk factors

• vaginal childbirth, especially large babies, long pushing stages or forceps delivery
• menopause: lower estrogen weakens pelvic tissues
• aging
• chronic straining: constipation, chronic cough, heavy lifting
• obesity
• hysterectomy
• genetic factors and connective tissue disorders

Diagnosis

A doctor or urogynecologist will ask about your symptoms and examine the pelvis, often while you lie down and while you strain or cough, sometimes also standing. Additional tests may include:

• urine test for infection
• bladder scan to measure urine left after voiding
• urodynamic testing to measure bladder function, especially before surgery
• ultrasound or cystoscopy in some cases

Treatment

Treatment depends on how much the cystocele bothers you, not just its size.

Watchful waiting

Mild, symptom-free cystoceles do not need treatment. They do not damage health and often do not get worse.

Pelvic floor muscle training

Kegel exercises strengthen the pelvic floor and can reduce symptoms, especially in mild to moderate prolapse and stress incontinence. A pelvic floor physical therapist ensures the right muscles are used. Aim for at least 3 months of regular practice.

To do a Kegel: squeeze the muscles you would use to stop passing urine or wind, hold for up to 10 seconds, relax for 10 seconds, and repeat 10 times, three times a day.

Lifestyle measures

• treat constipation and avoid straining
• lose excess weight
• avoid heavy lifting, or lift with proper technique
• stop smoking to reduce chronic cough

Vaginal estrogen

Low-dose estrogen cream, tablets or rings can improve tissue health in postmenopausal women and make pessaries more comfortable.

Pessary

A pessary is a removable silicone device placed in the vagina to support the bladder. It comes in many shapes and sizes and is fitted by a clinician. It is a good option for women who want to avoid or delay surgery, are pregnant, or are not fit for surgery. It needs periodic cleaning and checkups.

Surgery

• Anterior colporrhaphy (anterior repair): the most common operation. The surgeon tightens the supporting tissue between the bladder and vagina through the vagina.
• Apical support procedures: when the top of the vagina or uterus has also dropped, such as sacrocolpopexy or uterosacral ligament suspension.
• Incontinence procedures, such as a midurethral sling, if stress incontinence is present.
• Vaginal mesh for prolapse repair through the vagina was withdrawn from the US market in 2019 because of complications. Mesh is still used in abdominal sacrocolpopexy and in slings for incontinence.

Prolapse can recur after surgery, and future pregnancies may affect results, so many women delay surgery until they have finished having children.

Frequently asked questions

What does a cystocele feel like?

Many women describe a feeling of pressure, heaviness or something falling out of the vagina, often worse at the end of the day or after standing or lifting. You may see or feel a soft bulge at the vaginal opening. Urine leaks and difficulty emptying the bladder are also common.

Can a cystocele heal on its own?

A cystocele does not usually reverse on its own, but mild ones often stay stable and cause no problems. Pelvic floor exercises, weight loss and treating constipation can improve symptoms and may stop it from worsening.

Is a prolapsed bladder dangerous?

Usually not. It affects quality of life rather than health. Rarely, a severe cystocele can block urine flow, causing infections or kidney problems, or ulcerate if it protrudes outside the body. These need prompt treatment.

Can I exercise with a cystocele?

Yes. Walking, swimming and cycling are generally fine, and pelvic floor exercises help. High-impact exercise and heavy lifting can worsen symptoms, so a pelvic floor physical therapist can advise you on safe exercise and techniques.