Cystocele is the lowering of the bladder into the vagina due to the failure of the pelvic diaphragm. It is manifested by the sensation of a foreign body in the vagina, urinary retention, urinary incontinence, dyspareunia, pain in the lower abdomen and lower back. It is diagnosed by vaginal examination, ultrasound of the urethra and bladder, complex urodynamic, video urodynamic studies. Conservative treatment of cystocele includes pelvic muscle training, hormone replacement therapy, and the installation of a vaginal pessary. During surgical correction, anterior colporaphy, vaginopexy with or without the installation of a synthetic prosthesis, sling operations are performed.
ICD 10
N81.1 Cystocele
Meaning
Cystocele (protrusion, prolapse, prolapse of the bladder) is the most common type of genital prolapse, detected in 34% of women with pelvic dysfunction syndrome. It is almost always combined with ureterocele. The term “cystocele” to describe a hernia of the anterior wall of the vagina was first used in the 1600s. The incidence increases with age, reaching 55-60% in postmenopause.
Despite the successes of preventive medicine, a constant decrease in birth injuries, a reduction in the employment of women in heavy industries, the frequency of cystocele in the population remains high and continues to increase, which is associated with an increase in average life expectancy. The urgency of timely diagnosis and adequate treatment of bladder prolapse is due to a significant deterioration in the quality of life, and in severe cases, disability of patients.
Causes
Prolapse of the bladder is one of the manifestations of the pelvic floor insolvency syndrome and develops under the influence of the same factors as the prolapse of other organs (rectum, uterus, vagina). The immediate cause of the cystocele is the weakening and formation of hernia-like defects of the musculoskeletal fascial apparatus supporting the bladder, primarily the pubic-cervical vesicular fascia. Specialists in the field of modern urology and urogynecology identify a number of predisposing factors that increase the risk of pelvic dysfunction:
- Frequent childbirth. The probability of a cystocele increases after each subsequent natural delivery. According to the results of observations, in women who gave birth 4 times or more, the risk of urinary prolapse is 3.3 times greater than in single births. The high-risk group includes patients who carried a large fetus, underwent rapid labor, vaginal and perineal ruptures, obstetric operations.
- Dishormonal states. Estrogenic insufficiency contributes to the weakening of muscle-fascial structures, which is associated with an increase in cases of cystocele during perimenopause and after oophorectomy. The probability of bladder prolapse increases from 6.6% in 20-29-year-old women to 55.6% in 50-59-year-olds. The relationship between the prevalence of pathology and the level of estrogens is confirmed by a decrease in morbidity when prescribing hormone replacement therapy.
- Hereditary connective tissue dysplasia. The frequency of the familial form of cystocele reaches 30%. Both genetic anomalies (Marfan syndrome, Ehlers-Danlos disease) and undifferentiated forms of collagenopathy, manifested by hernias of other localization, juvenile osteochondrosis of the spine, varicose veins, hemorrhoids, myopia, flat feet and other disorders contribute to the weakening of the pelvic diaphragm.
- Increased intra-abdominal pressure. Hernial protrusion of the bladder into the vaginal cavity is facilitated by heavy physical exertion and diseases in which the pressure in the abdominal cavity increases. Cystocele occurs more often in women suffering from persistent constipation, bronchial asthma. The risk of vesical protrusion increases in the presence of ascites, obesity, volumetric neoplasms of the abdominal cavity (subserous fibroids, ovarian cysts).
Pathogenesis
The basis for the occurrence and progression of cystocele is the discrepancy between the strength of the pelvic diaphragm and the pressure it experiences. After prolonged ischemia of the anterior vaginal wall during childbirth, with ruptures of muscle-fascial and ligamentous structures, hereditary weakness of connective tissue fibers, a hypoestrogenic decrease in the overall tone of the perineal muscles and relaxation of ligaments, the functional viability of the ligamentous apparatus holding the genitourinary organs deteriorates.
As a result, with an increase in intra-abdominal pressure, the bladder is squeezed out through the pelvic floor defect into the vagina, while the anterior vaginal wall is lowered. Violation of the outflow of urine leads to an increase in its residual amount and an increase in intravesical pressure. As a result, a vicious circle is formed that supports a further increase in the volume of hernial protrusion.
Classification
The systematization of clinical forms of cystocele is based on the degree of omission of the organ. To date, two variants of the classification of the severity of urogenital protrusion have been proposed. International gynecological and urogynecological associations have recommended a standardized systematization of genital prolapse POP-Q, according to which the length of the vagina and the anatomical position of the marker point Ba on its anterior wall in relation to the plane of the hymen are estimated. Domestic urologists and gynecologists often use a simplified clinical version of determining the forms of cystocele, which allows choosing the optimal treatment tactics:
- Protrusion of the I degree. With a slight prolapse, the bladder descends to the middle part of the vagina and is determined by a gynecological examination with straining. In most cases, it is sufficient to use conservative non-drug and drug methods to correct the violation.
- Protrusion of the II degree. In patients with moderate bladder prolapse, hernial protrusion is found in the lower half of the vagina and can reach its entrance. It is detected during gynecological examination without straining. Surgical treatment is more effective, although a conservative approach is acceptable.
- Protrusion of the III degree. The bladder extends beyond the genital slit. Prolapse persists at physical rest. Against the background of cystocele, complications from the genitourinary organs often develop. Conservative elimination of the pelvic floor defect is impossible, reconstructive plastic surgery is recommended.
Cystocele symptoms
With a small prolapse, there are no clinical symptoms. As the hernial protrusion increases, the urinary protrusion begins to manifest itself with sensations of pressure, the presence of a foreign body in the vagina, which increase during urination, defecation, coughing, lifting weights. As the disease progresses, the urine stream weakens up to an acute delay, due to an increase in the volume of residual urine, there is a feeling of an overflowing bladder, imperative urge to urinate.
The sensation of a large foreign object in the genital tract persists constantly. In 30% of patients, sexual function is impaired due to soreness during sexual intercourse. With severe cystocele, urinary incontinence is observed in stressful situations. There is heaviness, a feeling of compression, dull aching pains in the lower abdomen, lower back, which can radiate into the groin area.
Complications
An increase in the amount of residual urine contributes to the development or exacerbation of cystitis, the formation of stones in the bladder cavity. Prolonged obstructive violation of natural urination increases the risk of the formation of infectious pyelonephritis, hydroureteronephrosis, urolithiasis, which may subsequently be aggravated by chronic renal failure. Due to a significant deterioration in the quality of life in women with cystocele, subdepressive states and astheno-neurotic disorders (insularity, tearfulness, irritability, fatigue) are more common.
Diagnostics
When diagnosing a cystocele, data from physical examination and instrumental studies are used to verify the prolapse of the bladder into the vagina. To choose the optimal treatment method, it is recommended to evaluate the integrity of the pubic-cervical fascia. The most informative in diagnostic terms are:
- Examination on the chair. Vaginal examination is recommended to be performed in a lithotomic position with the introduction of a single-leaf mirror along the posterior vaginal wall. The prolapsed bladder is usually found along the anterior wall in the form of a soft, reversible tumor-like formation, which increases in volume and thickens when the patient is strained.
- Echography. Signs of a cystocele according to bladder ultrasound are displacement of the posterior urogenital wall below the level of the pubis at rest and when straining (coughing), its deformation in the form of an acute triangle. Hypermobility and dislocation of the urethra, determined by ultrasound of the urethra, indicates a central defect of the cervical-pubic fascia.
- Comprehensive urodynamic study (CUDS). Carrying out uroflowmetry, filling cystometry, tension cystometry can reveal a violation of the closing function of the urethrovesical sphincter and a decrease in the contractility of the detrusor. The addition of CUDS with a video-dynamic study makes it possible to refine the data based on the results of contrast extraction.
- Endoscopic diagnostics. Performing a cystoscopy is usually difficult. With endoscopic examination, it is usually possible to visualize only the cervical areas of the bladder and the downward longitudinal folding on its back wall. Examination of the mouths of the ureters becomes possible after intravaginal insertion of cotton or gauze swabs, while the bottom in the form of a hill is pushed into the cavity of the bladder.
- X-ray diagnostics. Cystography in the diagnosis of cystocele is mainly used as an auxiliary method
Cystocele is differentiated from other types of genital prolapse (prolapse of the uterus and vagina, rectocele, enterocele), urethral diverticulum, paraurethral cyst, skineitis, bartolinitis, uterine inversion, prolapse of the myomatous node, cervical cancer. According to the appointment of a urologist, gynecologist or urogynecologist, the patient is advised by a proctologist, gastroenterologist, surgeon, oncologist.
Cystocele treatment
Conservative treatment
At the initial stages of the formation of prolapse, the main therapeutic task is the correction of urogenital protrusion. With pronounced omission, in order to normalize the function of the bladder, adjacent organs, it is necessary to restore the anatomical integrity of the pelvic diaphragm. Patients with mild and moderate degrees of cystocele are recommended lifestyle correction with the exception of heavy physical exertion, treatment of concomitant pathology contributing to the formation of genital hernias, etiopathogenetic and symptomatic conservative therapy of urethrovesical prolapse:
- Strengthening the pelvic floor muscles. With a decrease in muscle tone after childbirth, against the background of involutive or postoperative hypoestrogenism, it is effective to perform Kegel exercises or Atabekov’s exercise therapy complex. Training is less effective in the presence of anatomical tissue defects, although in this case it is possible to reduce the severity of protrusion and urination disorders.
- Hormone replacement therapy. Women with cystocele symptoms that have arisen against the background of menopause or postcastration syndrome are recommended to prescribe estrogen-containing or phytoestrogenic drugs. Hormone therapy can increase the tone of the pelvic muscles and strengthen the ligaments, reducing prolapse and related disorders.
- Installation of the pessary. The introduction of a special supporting device into the vagina prevents further lowering of the walls and provides mechanical fixation of the fallen bladder. The method is considered palliative and is recommended for women who refuse surgical treatment or cannot be operated on for health reasons.
- Physical therapy. Physiotherapy techniques (laser therapy, electromyostimulation) are also used in the complex conservative treatment of cystocele.
Surgical treatment
With the ineffectiveness of therapeutic approaches, patients with severe or complicated cystocele are shown to perform reconstructive operations. The choice of the type of surgical intervention depends on the condition of the cervical fascia.
In the absence of an anatomical defect in the fascial tissue, the best results are observed after vaginopexy, anterior colporaphy. If the integrity of the fascia connecting the bladder to the pubic joint is violated, synthetic mesh prostheses are installed. To eliminate urinary incontinence, plastic surgery is supplemented with minimally invasive sling (loop) interventions — TVT, TVT-O.
Prognosis and prevention
The use of conservative methods of therapy in the absence of gross anatomical defects of the pelvic floor can significantly improve the quality of life of the patient, postpone the operation. The effectiveness of surgical treatment for anterior colporaphia ranges from 45 to 91%, positive results with vaginopexy are observed in 95-97% of operated women.
For the prevention of cystocele in the postpartum and perimenopausal period, it is recommended to strengthen the pelvic floor muscles with Kegel exercises, physiotherapy procedures, follow a diet to prevent constipation, limit lifting weights to no more than 3 kg. In the presence of extragenital pathology capable of provoking urinary prolapse, timely adequate therapy of the underlying disease is required. An important role in preventing cystocele is played by reducing obstetric injuries due to careful management of childbirth, anatomical restoration of the integrity of the birth canal after ruptures, thread tightening of the vagina with weakening of the pelvic diaphragm.