Anterior Prolapse (Cystocele) Treatment

Overview

There are various pelvis organs, namely the bladder, uterus, and intestines. The pelvic floor’s muscles and connective tissues hold these organs in place. Now, when the pelvic floor becomes weak, or when it experiences too much pressure it can result in a condition called an anterior prolapse. Here the pelvic organs slip down from their normal position into the vagina. This usually happens due to factors like vaginal childbirth, constant heavy lifting, chronic constipation, and violent coughing. Let’s understand the condition in detail.

What is meant by an Anterior Prolapse (Cystocele)?

Anterior vaginal prolapse is also known as a cystocele or a prolapsed bladder. It refers to a condition where the bladder drops from its original position in the pelvis and hence puts pressure on the wall of your vagina. The anterior wall of the vagina is supported by connective tissues and muscles. When these supporting structures are damaged or weakened, the bladder tends to descend into the vaginal space leading to the formation of a cystocele. This condition is more common in women who have gone through childbirth or menopause.
This condition can be treated with both non-surgical and surgical measures. Non-surgical measures include exercises and certain lifestyle changes. More severe cases would require surgical intervention.

What Causes an Anterior Prolapse?

As discussed, one’s pelvic floor consists of ligaments, muscles, and connective tissues, which all support the bladder and other pelvic organs. If these supporting structures weaken with time or due to certain stress-causing factors, the bladder may slip down and bulge into the vagina. These factors include:

• Pregnancy, vaginal childbirth
• Repeated heavy lifting
• Obesity or being overweight
• Straining during bowel movements
• Chronic cough, or bronchitis

Furthermore, there are several risk factors associated with anterior prolapse:

• Aging: The risk of anterior prolapse increases with age, especially post-menopause. This is because estrogen production at this time reduces, which is responsible for maintaining the strength of the pelvic floor.
• Hysterectomy: Uterus removal may sometimes weaken the pelvic floor.
• Obesity: Being overweight means a higher risk of anterior prolapse.
• Genetics: Women born with weaker connective tissues are also more susceptible to this condition.
• Pregnancy and childbirth: Your risk of anterior prolapse further increases with vaginal or instrument-assisted delivery, giving birth to infants with a high birth weight, and multiple pregnancies.

What are the Symptoms of an Anterior Prolapse?

In mild cases, there might not be any signs or symptoms. However, if they do occur, they include the following:

• Pressure or a feeling of fullness in your pelvis and vagina
• A bulge of tissue in the vagina, which is visible or one that you can feel
• Pelvic pressure at the time of coughing, straining, bearing down, or lifting
• Problems during urination such as difficulty in starting urination, having a feeling of an unemptied bladder after urination, frequently feeling the urge to urinate, or urinary incontinence (leaking urine) 

One may note here that the symptoms are especially noticeable after standing for long time periods. They may even go as you lie down.

How is an Anterior Prolapse Diagnosed?

Diagnosing an anterior prolapse may involve the following:

A pelvic examination: Here, the doctor examines you while you lie down and/or stand. The doctor will look for the presence of a visible tissue bulge in your vagina, which would be an indication of cystocele. The degree of prolapse will be found out by making you bear down as if during a bowel movement. Moreover, you’ll be asked to contract the pelvic floor muscles to check the muscle strength; this you can do by trying to stop the urine stream.

Filling out a questionnaire: This is to provide the examiner with information about your medical history, the degree of prolapse, and its effect on your life. 

Bladder and urine tests: In case of a prolapse, tests might be carried out to find out the degree to which your bladder empties and whether there also exists a bladder infection. The latter is done through a test on a urine sample.

What are the Treatment Options for an Anterior Prolapse?

Treating an anterior prolapse is dependent on your symptoms, the severity of the prolapse, and the presence of any related conditions (such as urinary incontinence, or more than one type of pelvic organ prolapse). Mild cases with few or no signs may not require immediate treatment. They can be monitored over time. If symptoms are noticeable, the first-line treatment will involve the following options:

Non-Surgical Measures

• Exercises for the pelvic floor muscle (also known as Kegels or Kegel exercises): You can do these under instructions from a physical therapist. They help strengthen the pelvic floor muscles to make them better support the bladder and other pelvic organs.
• A supportive device (a pessary): It’s a plastic/rubber ring that is inserted into the vagina, hence supporting the bladder. It will not cure the prolapse, but will relieve symptoms and hence prove as a temporary alternative to surgery. You’ll be instructed on how to clean and reinsert the pessary on your own.

Surgical Measures

• Anterior Colporrhaphy: This is a common surgical procedure for repairing a cystocele. During an anterior colporrhaphy, the surgeon makes an incision in the vaginal wall and repositions and tightens the connective tissues that support the bladder.
• Vaginal surgery: The prolapsed bladder is lifted back in place with stitches and through removal of extra vaginal tissue. A special tissue graft might also be used to reinforce the vaginal tissues and enhance support for such thin tissues. 
• Hysterectomy: Uterus removal is recommended when there is a prolapsed uterus. This is also followed by repairing damaged pelvic floor muscles, ligaments, and other tissues.
• Sacrocolpopexy: This procedure involves attaching the top of the vagina to a ligament on the sacrum (the bone at the base of the spine). Sacrocolpopexy is often performed using minimally invasive techniques, such as laparoscopy or robot-assisted surgery. 

It may be noted here that if you are pregnant and having a cystocele, you’ll need to delay surgery until childbirth.

Preventive Methods

Cystocele can be prevented by controlling the associated risk factors. Some of the preventive measures are:

• Maintaining a healthy weight
• Pelvic floor exercises or Kegel’s exercises
• Avoiding heavy lifting 
• Avoiding constipation through healthy bowel habits
• Protecting the muscles of your pelvic floor during heavy physical activities by practicing the correct technique.

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