Bladder prolapse or cystocele is when the bladder bulges into the front wall of the vagina. Other names for this include ‘fallen’ bladder and anterior vaginal wall prolapse.Bladder prolapse usually occurs due to a weakening and stretching of the vaginal walls, resulting from childbirth or repetitive straining. Risk factors include pregnancy, childbirth and anything else that puts pressure on the pelvic floor, including inappropriate 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 and may protrude outside the vagina).
Symptoms of bladder prolapse
The symptoms of bladder prolapse depend on the severity of the prolapse, the person’s level of physical activity and the presence of any other type of prolapse.
- urinary stress incontinence – leaking urine when coughing, sneezing, laughing, running or walking, or urge incontinence, 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 holding a tampon in place during menstruation
- straining to get urine flow started
- a slow flow of urine that tends to stop and start
- a sensation of fullness or pressure inside the vagina
- a bulge or swelling felt at the vaginal opening
- discomfort with intercourse
- protrusion of the vagina out through the vaginal entrance (in severe cases).
Risk factors for bladder prolapse
Risk factors for bladder prolapse include anything that puts pressure on the pelvic floor, such as:
- pregnancy and childbirth
- regularly straining on the toilet to pass bowel motions or empty the bladder
- being overweight
- smoking and chronic lung diseases with coughing
- 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.
Some women have a strong family history of prolapse.
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 in good tone, so once 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 examination – to allow grading of the prolapse, assessment of pelvic floor muscle function and the presence of any other prolapse.
Tests for bladder prolapse
Tests that may be carried out to confirm or reject a diagnosis of bladder prolapse, depending on your symptoms, are:
- bladder and pelvic ultrasounds to exclude any masses or cysts putting pressure on the bladder and to assess muscle function
- 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.
Grades of bladder prolapse
The severity of bladder prolapses can be measured in several ways. ‘Mild’, ‘moderate’ and ‘severe’ are not always completely accurate, as they depend on a person’s opinion.
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 is close to the vaginal opening
- Stage 3 – the bladder protrudes out of the vagina.
Many gynaecologists now use the POP-Q system, which measures in centimetres where the prolapse is in relation to the vaginal entrance.
Treatment for bladder prolapse
Treatment for bladder prolapse depends on how severe it is.
Treatment for mild cases of bladder prolapse
When there are no symptoms of bladder prolapse, treatment may be unnecessary. Lifestyle changes can prevent the condition from getting worse, and may include:
- weight loss
- management of constipation
- correction of position when sitting on the toilet
- pelvic floor exercises.
Treatment of a chronic cough is also important.
Treatment for moderate cases of bladder prolapse
The lifestyle changes listed for mild cases, treatment of any chronic cough and pelvic floor physiotherapy are important, but surgery may also be indicated. Referral to a pelvic floor physiotherapist may be appropriate to assess pelvic floor function and to teach the correct technique for performing pelvic floor exercises.
In some cases, a pessary may be used to support the bladder. This can be used for women of all ages, and is a good option for women who are either unfit for surgery or who wish to delay or avoid surgery.
A pessary is inserted high into the vagina to support the bladder and can be fitted in the doctor’s rooms. Regular follow-up with a doctor is necessary in long-term use.
Treatment for severe cases of bladder prolapse
Surgery is usually required to repair a severe bladder prolapse. Different techniques are used, depending on the combination of prolapse and urinary tract symptoms. Your doctor can discuss the available surgical techniques with you.
It is common to have a urinary catheter inserted during the operation to rest your bladder after surgery, but this will depend on the procedure performed
Recovery from surgery takes about six weeks and during this time you should not do any lifting at all. Walking is the best exercise at this time and pelvic floor exercises can be commenced. You should have a rest every day. After this, gradually increase your activity as tissues continue to heal to their full strength over the first three months.
You should not lift anything heavier than 10 kg until this time, and avoid high-impact exercise, sit-ups and weight training. Your physiotherapist can advise appropriate exercises.
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). These suggestions may include:
- Don’t lift heavy objects over 10 kg, including children or grandchildren.
- Exercise daily to help keep your bowel movements regular, but avoid heavy weight training, sit-ups and high-impact exercise. Choose lighter weights that you can easily lift without straining, core strengthening on an exercise ball, and cardiovascular exercise such as walking, swimming or bike riding, rather than running, jumping or high-impact aerobics.
- When exercising in the gym, avoid weight-training that causes you to hold your breath or strain. It is preferable to reduce the weight size and increase repetitions. Walking on a treadmill, with or without an incline, is a suitable exercise.
- Increase the amount of fibre in your diet to prevent constipation and straining – 30 g of fibre daily is recommended. Just one instance of straining can worsen bladder prolapse.
- Drink between six and eight glasses of fluid each day. Not drinking enough can make stools hard, dry and difficult to pass.
- Avoid straining on the toilet for either bowels or bladder as this will worsen a prolapse. Leaning forward with knees apart, forearms on thighs, straight back and relaxed tummy will help.
- Perform pelvic floor exercises daily to strengthen the muscles supporting the pelvic organs. You may need instruction from your doctor, a pelvic floor physiotherapist or a continence nurse.
- Always squeeze up or brace 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.
- See your 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.
- Keep yourself within a healthy weight range. Being overweight is known to make symptoms worse.
- Having intercourse 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.
Pelvic floor exercises
Pelvic floor exercises help to increase the strength of the pelvic floor muscles. They have been shown to reduce the symptoms of a mild to moderate bladder prolapse and prevent any worsening. These exercises may also reduce symptoms of urinary incontinence, which may be associated with a bladder prolapse.
It is important to learn to do the exercises correctly to gain the most benefit. A one-on-one session with a specially trained pelvic floor physiotherapist will usually be required for women who have bladder prolapse symptoms.
Where to get help
This page has been produced in consultation with and approved by:
Jean Hailes for Women's Health
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