Could a cystocele (bladder prolapse) with a pessary in place be the cause of moderate (grade 2) hydronephrosis in an elderly patient?

Yes, bladder prolapse (cystocele) with a pessary in place can absolutely cause moderate hydronephrosis in an elderly patient.

Both the prolapse itself and the pessary are recognized causes of urinary tract obstruction leading to hydronephrosis, and the pessary should be removed immediately to assess if it is contributing to the obstruction 1, 2.

Mechanism of Obstruction

The hydronephrosis can occur through two distinct mechanisms:

• Direct ureteral kinking/compression: Severe cystocele causes the prolapsed bladder to squeeze or kink the ureters, particularly the distal portions, leading to upstream obstruction 3, 4
• Pessary-related obstruction: The pessary itself can cause direct compression of the ureters or bladder neck, or if oversized/misplaced, can worsen the anatomical distortion 1

The prevalence of hydronephrosis with pelvic organ prolapse ranges from 3.5% to 30.6%, with higher rates in more severe prolapse stages 5. A 2023 study found hydronephrosis prevalence of 65.3% among patients with uterine prolapse 4.

Immediate Management Algorithm

Step 1: Assess for urosepsis and renal function

• Check serum creatinine, CBC, urinalysis
• If fever, elevated WBC, or signs of infection are present → immediate antibiotic therapy and consider urgent nephrostomy drainage 1

Step 2: Remove the pessary

• In the absence of urosepsis, conservative management begins with pessary removal and urinary catheter placement 1
• This allows assessment of whether the pessary is contributing to obstruction

Step 3: Imaging to confirm hydronephrosis resolution

• If renal function is normal: CT scan to assess mechanism and degree of obstruction 1
• If renal insufficiency present: abdominal ultrasound is sufficient 1
• Repeat imaging at 3 months post-intervention to document resolution 3, 6

Critical Pitfalls to Avoid

Do not assume the pessary is innocent: Even properly fitted pessaries can cause hydroureteronephrosis, especially if follow-up visits have been delayed 7. The COVID-19 era saw increased pessary complications due to postponed check-ups 7.

Do not rely on serum creatinine alone: Creatinine does not consistently predict hydronephrosis in POP patients 5. Upper tract imaging is essential in advanced prolapse regardless of creatinine levels.

Do not delay intervention: Unrecognized obstruction can progress to chronic renal failure and end-stage renal disease 2. Every elderly female with bilateral hydronephrosis of unknown cause requires gynecologic examination 2.

Definitive Treatment Considerations

After pessary removal and stabilization:

• If hydronephrosis persists: The prolapse itself is the primary cause, requiring surgical correction 8, 3
• Resolution rates after surgery: 56% to 83% complete resolution of hydronephrosis following surgical prolapse repair 5, with one study showing 84.6% resolution 4
• If pessary must be continued: Requires meticulous follow-up every 3-6 months with proper fitting and local estrogen therapy to prevent erosions 7

The key distinction is that while both the prolapse and pessary can cause obstruction, the pessary is immediately modifiable and should be removed first to clarify the etiology 1.