Bladder prolapse

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 floor, 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 physiotherapist
• Jean Hailes for Women’s Health Tel. 1800 JEAN HAILES (1800 532 642)
• Continence Foundation of Australia Helpline Tel. 1800 33 00 66