A cystocele is often associated with conditions such as stress urinary incontinence and pelvic organ prolapse. These often prevent women from leading active and productive lives. Thus it is important to treat them effectively and restore a high quality of life to the sufferers.
Conservative Management
If the cystocele is of a mild grade and does not produce any troublesome symptoms, many doctors may opt for a watchful approach without any active intervention. During this time, some steps may help to prevent deterioration of the prolapse and may, in fact, alleviate the symptoms.
First and foremost, modifications of lifestyle that include changes in one’s daily routine are undertaken, such as:
- Losing weight if the patient is overweight or obese, as the excessive kilograms put added strain on the pelvic supports of the uterus and the urinary bladder, especially in the upright position
- Treatment of chronic cough which creates constant and extra pressure on the pelvic floor muscles
- Quitting smoking
- Avoiding constipation by eating high-fiber foods, drinking plenty of clear fluids and getting enough physical activity
- Not lifting heavy weights, including at work or at home
- Avoiding all activities which produce a high stress on the pelvic floor
Pelvic Floor Exercises
These are also called Kegel’s exercises, after their inventor, and help to tone the pelvic floor supports by constant practice. A strong pelvic floor holds up the attached organs, including the uterus, vagina and urinary bladder.
Pelvic floor exercises consist simply of contracting and relaxing these muscles several times a minute, for about 15 reps each, as many times a day as is possible. These are the same muscles that control bladder and bowel evacuation, so the same motions may help the patient learn how to control their contraction at will.
These exercises take a couple of weeks to help build up strength in the pelvic floor, but are often all that are needed in mild cases of cystocele or stress incontinence. They must be continued over the long term.
Biofeedback or weighted vaginal cones may also help the patient with low degrees of cystocele to strengthen the pelvic floor. A woman with such device in place can observe (by means of the analog dial) the intensity and efficiency of the pelvic floor contractions.
Pessaries
Vaginal pessaries are supportive devices of different shapes and sizes that hold up the pelvic floor from inside the vagina, utilizing the natural elasticity of the vaginal wall. The most common shape is the ring pessary. Pessaries are usually made of rubber or silicone.
Pessaries are suitable for women who:
- are unwilling to have surgery
- have not completed their families
- are at high risk for surgery
- have a prolapse only of the bladder (cystocele) and/or the uterus, but not of the posterior vaginal wall
The correct pessary size should be selected, usually by trial and error. Regular and thorough removal and cleaning of the pessary, as well as checking of the vaginal vault and walls for infection or trauma, are also important parts of pessary use. The presence of a pessary does not interfere with intercourse in most cases. Estrogen creams may be prescribed for use with a pessary, and may help in preventing or healing vaginal trauma, if present.
Such vaginal estrogen-containing creams may also be helpful for postmenopausal women with mild prolapse, as their vaginal mucosa may be thin and atrophic, contributing to the descent. The principal use of these creams is to increase the vaginal mucosal thickness and restore its supportive role to the bladder.
Surgical Management
Surgical techniques for the treatment of a cystocele are aimed at providing proper bladder support and treating the symptoms, without interfering with the normal functions of the vagina. Surgical management is suggested to take place after the woman has completed her family, as natural childbirth may damage the repairs that are made in the vaginal wall. If pregnancy occurs later, a Caesarean section may be the best mode of delivery in such patients.
The various types of vaginal operations for cystocele depend on:
- The type of prolapse
- The symptoms
- The age of the patient
- Any comorbid medical conditions
- Whether the family is of desired size or not
- Whether the patient is sexually active
Most surgeries for cystocele are performed vaginally, but may involve an incision in the lower abdomen, especially if laparoscopy or mesh insertion is in view. In view of all these, various options are available.
Types of Surgeries
If there is associated prolapse of other organs, a vaginal repair is usually done by incising and opening the anterior vaginal wall in a surgical approach known as anterior colporrhaphy. Before sewing them together, the intervening thin supporting fascia is plicated and buttressed. Mesh may be inserted into the supporting tissue of the vaginal wall to strengthen it. It is important that you know the risks of using a mesh, however, before you have such an operation, as they are not insignificant.
Sacrocolpopexy or sacrospinous fixation procedures are used to strengthen the bladder supports by attaching the uterus or the vaginal vault to one of the bones at the lower end of the spine (the sacrum) or to the strong ligaments overlying the sacrum. These may be done via open or laparoscopic procedures.
Vaginal hysterectomy with pelvic floor repair is performed in most cases of cystocele which require such approach, or in mild cases if there is an associated descent of the uterus. At this time a pelvic floor repair is also done.
The most radical technique is obliterating the vagina (known as colpocleisis), but this obviously puts an end to sexual intercourse through the vagina. It is therefore reserved for treating very frail patients, or if several previous procedures have proved unsuccessful.
Any surgery for vaginal repair may be extended to include other areas of laxity which become more obvious under the relaxation of anesthesia. This should be discussed in detail with the patient before embarking on the surgery.
Benefits of Surgical Interventions for Prolapse
At present, the recurrence of prolapse in women who have undergone surgical repair ranges from 25-30%. The risk of recurrence is higher in those whose etiologic factors remain unchanged, such as overweight or a chronic cough. Identification and proper repair of both lateral and central defects in the vaginal supports are crucial in preventing cystocele recurrence.
Though the cystocele is repaired, the weakness of the pelvic diaphragm may manifest elsewhere (as the bulging and descent of another pelvic organ) in the future.
After the surgery, the duration of hospitalization depends on the approach and the woman’s previous health. In general, the patient may go home in a few days. Nevertheless, heavy lifting, severe coughing and sexual intercourse should all be avoided for a couple of months at least.
Further Reading