The urinary bladder is a pelvic organ that both stores and releases the urine formed in the kidneys. It is located towards the lowest part of the abdominal wall, in front of the uterus. In most women, the uterus actually rests on the bladder.
The vaginal wall is a primary support for the urinary bladder, with the supporting fascia in between them blending with the capsule of both organs. The fascia is a sturdy fibrous sheet, and is thickened at various places to form strong ligaments connecting the vagina and bladder to the pelvic bones. These form strong suspension supports for the pelvic organs, namely, the bladder, uterus and rectum. When these supports weaken, it results in sagging of the vaginal wall and the bladder. This is called a fallen bladder.
The fascia between the vagina and urinary bladder is weakened in many conditions, such as:
- a difficult or protracted childbirth
- hypo-estrogenic state following menopause
- deteriorating connective tissue strength of old age
- chronic downward stress on the fascia and other pelvic ligaments, such as in:
- severe habitual cough
- carrying heavy headloads
- congenital weakness of the fascia in rare cases
Failure of the pelvic supports results in the bladder dropping down with the vagina, which is called a cystocele. This appears as a bulging of the vaginal wall in front. It is graded according to the degree of bulging. When the whole of the vagina sags outside the vaginal opening, it is called a complete prolapse.
The symptoms of a fallen bladder range from none in mild cases, to severe inability to empty the bladder. Most often, these women complain of:
- a mass or bulge coming down the vagina
- difficulty at the start of urination
- incomplete urination
- stress incontinence, which refers to the leakage of urine on sneezing, coughing, lifting a heavy weight or even laughing heartily
- urgency, or leakage of urine if the woman is unable to use the bathroom as soon as the urge comes
- increased frequency of urination
- a dragging low backache
- pain or discomfort during intercourse
- frequent urinary infections.
Diagnosis and treatment
Diagnosis depends on the presence of a dropped bladder on pelvic examination. This may be less obvious when the woman is lying down, and may have to be induced by special maneuvers. The sagging vaginal tissues may look red and inflamed, and sometimes gets infected.
Other tests may be required to identify the presence of other complications, such as retention of urine. Treatment is always necessary, as dropped bladders usually worsen with time.
Treatment is based on the extent of prolapse, the strength of the pelvic muscles, the woman’s general health and her symptoms. Non-surgical treatment consists of:
- avoiding aggravating factors such as heavy lifting or straining downwards
- treatment of chronic cough or constipation
- strengthening of the pelvic floor muscles in mild cases, by
- Kegel’s pelvic floor exercises
- electrical stimulation of the pelvic muscles
- biofeedback techniques to monitor pelvic muscle strength and help with prescribing the right exercise
- estrogen creams to firm up the pelvic supports
- pessary use
Estrogen creams have several benefits, such as improving the strength of the pelvic muscles, reducing the severity of urinary symptoms, and improving the thickness and health of the vaginal and urethral mucosa. Pessary application with or without estrogen cream is another option. Pessaries are small removable devices which can be inserted into the vagina to bolster the pelvic supports, and thus hold the bladder in place. They are used either as stopgap treatment till surgery can be done, or as permanent treatment of a dropped bladder when surgery is contraindicated or undesirable for any reason.
Surgical management consists of repairing the vaginal supports and tighten the anterior vaginal wall. This is called an anterior colporrhaphy. Sometimes artificial or natural material is used to fashion a sling for the bladder as well. The use of mesh to strengthen the vaginal wall is controversial at this time but may be necessary if the vagina is very weak. While a dropped bladder is not life-threatening, it severely affects the quality of life and should be treated appropriately.