WHAT IS A CYSTOCOELE?
A cystocoele is a prolapse or ‘falling down’ of the bladder, which is slipping into the vagina. It is actually a problem with a weakness of the front wall of the vagina which prolapses, carrying with it the bladder, which lies directly in front of the vagina. Other types of prolapse may also be present, especially in cases of large cystocoeles. The uterus or bowel can also prolapse. It is not uncommon for patients to also have stress incontinence e.g. leakage of urine with activities such as coughing.
WHAT SYMPTOMS MIGHT A CYSTOCOELE CAUSE?
- a lump in the vagina
- urinary incontinence or leakage
- pelvic pain, discomfort or a dragging sensation
- recurrent urine infection
- back pain
- incomplete bladder emptying
- difficulty passing urine
- pain with intercourse
- urinary leakage with intercourse
HOW IS IT DIAGNOSED?
By vaginal examination either lying down or standing whilst you are straining or bearing down. It can also be seen on the X-ray during Fluoroscopic Urodynamic Studies (FUDS). Your surgeon may order a urine test for infection and an ultrasound scan to see if you empty your bladder completely when you pass urine.
OTHER TESTS MAY BE RECOMMENDED
A cystoscopy – an inspection of the inside of the bladder with a telescope may be recommended to exclude other bladder diseases as a cause for your symptoms. In severe prolapse the kidneys can be affected and a blood test for kidney function and ultrasound scan of the kidneys may be ordered.
WHAT CAUSES A CYSTOCELE?
Tearing of supports to the bladder and vagina may occur during childbirth, or with chronic straining form coughing, constipation or heavy lifting. Tissues may be weakened after the menopause and by aging or obesity. Damage to the nerves to the supporting pelvic floor muscles may also occur with childbirth, other injuries or pelvic surgery.
WHEN SHOULD A CYSTOCELE BE TREATED?
Generally if it causes symptoms treatment options will be discussed. If it is not causing any symptoms is may just be checked on periodically. We can’t predict whether or not it will get any worse with time.
WHAT ARE THE TREATMENT OPTIONS?
Avoiding heavy lifting or straining can be recommended for all patients.
Pelvic Floor Exercises
These strengthen the muscles surrounding the openings of the urethra, vagina, and rectum. They can help reduce stress incontinence, urgency to pass urine and protect against prolapse.
Constipation should be treated to avoid straining. Caffeine found in coffee, tea, and soft drinks may aggravate bladder symptoms and should be reduced.
A pessary is a device that may be inserted into the vagina to support the bladder and other pelvic organs, holding them in place. Pessaries must be removed, cleaned, and reinserted on a regular basis, usually about every 3 months. If it is not cleaned, they can cause a badsmelling discharge or infection and ulcers in the vagina. If used correctly, a pessary can last for years. Your surgeon will need to fit you with the right size so it is comfortable. A pessary can be a good option in women who do not want surgery or are not suitable for surgery.
Oestrogen as a cream or pessary inserted into the vagina, can improve and strengthen the tissues around the bladder and vagina and improve symptoms of stress incontinence and urge to pass urine.
This can be done through the vagina. It may also be combined with other prolapse repair or stress incontinence surgery. Surgical correction is usually put off until a woman has completed her family.
Will it work?
Early results are good with about 90% success but your bladder prolapse may recur. The risk of this can be quite high, up to 50% recurring within 5 years. Again treatment is only required if there are bothersome symptoms.
What are the risks with surgery?
- If you decide to have surgery, you should be aware of the risks:
- The operation may fail to correct your symptoms, and more surgery may be needed later.
- A new prolapse may occur at another site.
- Chronic pain, discomfort or pain during sex may persist if they were present before the surgery or may occur as a new symptom.
- An urgent desire to pass urine may persist or occur as a new symptom.
- Surgery may not correct your urinary or bowel problems.
- Your vagina may be smaller, tighter or shorter after surgery. It is uncommon to be so small that you will not be able to have sex.
- If you have had prior surgery or radiation, there is a much lower success rate.
- You may become incontinent of urine. Fluoroscopic Urodynamic Studies before surgery may help predict the chance of you having stress incontinence following a cystocoele repair and thus the need to have a procedure to try to prevent this performed at the same time.
- You may be unable to empty your bladder adequately after surgery, requiring you to pass a catheter periodically to empty the bladder. If this occurs it is usually temporary and rarely permanent.
What are the other risks and complications?
It is often not possible to warn patients of every possible risk or potential complication with surgery especially if very rare. Yet it is important that you are aware of what risks are involved, especially the more common ones. This information is not meant to alarm you but allow you to make an informed consent to have surgery. It is very rare but unfortunately some patients can suffer complications and end up worse off as a result of their surgery.
There are general medical risks of abdominal, cardiovascular (heart), and pulmonary (lung) illnesses; 2-5%. These include Deep Vein Thrombosis (blood clots in deep leg veins), Pulmonary Embolus (these clots dislodging and going to the lungs), pneumonia, Myocardial Infarction (heart attack) and Cerebro-Vascular Accident (stroke).
There is a small risk of death; 5 in 10,000.
There is a small risk of bleeding requiring a blood transfusion; 3-5%.
Injury to the bladder, urethra or ureter is uncommon; 1-6%. If the bladder is perforated the catheter needs to remain in for 5-7 days.
Bowel, nerve or vascular injuries are rare.
There is a small risk of urine infection, wound infection, wound breakdown, haematoma (collection of blood) or seroma (collection of fluid) post-operatively; 5-10%.
Other rare complications include a significant pelvic haematoma (collection of blood), infection or abscess, a urinary fistula (leak). A fistula or communication between the vagina and the bladder or ureter can causes continuous leakage of urine from the vagina requiring further surgery to repair.
If a synthetic mesh is used in the repair this can erode into the bladder or vagina. Overall, the risk of complications requiring further surgery is 2-5%.
WHAT ARE THE ALTERNATIVE OPERATIONS?
Surgical repair can also be done through the abdomen with either a cut above the pubic bone or via laparoscopic (key hole) surgery. In some cases, synthetic materials may be used to help correct the problems.
HOW LONG DOES THE OPERATION TAKE?
About an hour but this may vary if combined with other procedures.
WHAT KIND OF ANAESTHETIC IS REQUIRED?
Usually a general or spinal anaesthetic. Your anaesthetist will discuss the options with you. You will need to fast beforehand.
WHAT DOES THE OPERATION INVOLVE?
Through a cut in the front wall of the vagina sutures are placed to put the bladder back into a more normal position.
WHAT IS THE NORMAL POST-OPERATIVE COURSE?
The usual hospital stay is usually 2 days. A pack placed in the vagina and a catheter in the bladder during the operation which are usually removed after 2 days. Most bladder symptoms resolve after 2 to 6 weeks.
It is usual following surgery to have some spotting, bleeding or discharge from the vagina. This usually stops by about 3 to 4 weeks. When this has stopped and the vaginal wound has healed you can have sexual intercourse, as comfortable (usually by 3 to 4 weeks).
It is usual to have some wound pain post-operatively but this mainly resolves by 4 weeks. Usually this is controlled with paracetamol. You can take up to 2 paracetamol every 4 hours to 6 hours (maximum 8 per day).
Some patients have some difficulty completely emptying their bladder initially. This is managed by learning to pass a small catheter via the urethra to empty the bladder, (Intermittent Self Catheterisation). You will be taught how to do this, If required. How often, and how long, this is required varies between patients. Most patients do not need to do this for more than 4 weeks. It is uncommon for this to be permanent which may then require further surgery.
You can usually return to your normal activities in about 4 to 6 weeks. You should avoid strenuous activity during this time and increase your activity level gradually. Avoid moderate lifting (over 5 kg) for 6 weeks and heavy lifting (over 10kg) for 12 weeks. Avoiding heavy lifting longterm will help prevent prolapse recurrence.
POST-OPERATIVE FOLLOW UP
You will be given a follow up appointment.
If you experience any of the following problems after discharge you should seek medical attention;
- Severe pain not controlled with pain killers
- Wound problems – infection or breakdown
- Inability to pass urine or pass a catheter if required
- Or any other significant trouble.
If at any stage your prolapse returns you should arrange a review visit.
You can control many of the activities that caused your cystocoele or made it worse. After surgery it is important to avoid smoking, maintain a healthy weight for your height, avoid constipation, and avoid activities that put strain on the lower pelvic muscles (such as heavy lifting or long periods of standing). You should continue with your pelvic floor exercises for life.
Version: V4, July 2017