From the Guidelines
A cystocele, which is a type of prolapse that occurs when the bladder bulges into the vagina, is the condition referred to during weakness in the anterior compartment. This condition is characterized by the excessive descent of the bladder through the pelvic floor hiatus, typically involving protrusion of the anterior vaginal wall [ 1 ]. The management approach for a cystocele in the anterior compartment depends on symptom severity and patient preferences, ranging from conservative approaches to surgical intervention.
Conservative Management
For mild to moderate cases, the following conservative management options can be considered:
- Pelvic floor muscle exercises (Kegel exercises) performed 3 sets of 10 contractions daily for at least 12 weeks can strengthen supporting structures.
- Vaginal pessaries, particularly ring or Gellhorn types, provide mechanical support and are appropriate for women who wish to avoid surgery or have contraindications to it.
- Topical vaginal estrogen (such as estradiol cream 0.01%, 1-2g applied vaginally 2-3 times weekly) may improve tissue integrity, especially in postmenopausal women.
Surgical Intervention
For symptomatic women with advanced prolapse or those who have failed conservative management, surgical repair options include:
- Anterior colporrhaphy, which reinforces weakened vaginal tissues.
- Mesh procedures in select cases.
Lifestyle Modifications
Lifestyle modifications including weight loss for overweight patients, smoking cessation, and avoiding heavy lifting can prevent worsening of symptoms. Treatment decisions should consider the patient's age, sexual activity, desire for future pregnancies, and overall health status, as the goal is to relieve symptoms while maintaining normal bladder, bowel, and sexual function [ 1 ].
Diagnostic Evaluation
The initial evaluation of patients with pelvic organ prolapse (POP) symptoms is clinical and begins with a physical examination [ 1 ]. Imaging may be obtained when clinical evaluation is difficult or considered inadequate by the physician, or if patients present with persistent or recurrent prolapse symptoms after attempted surgical or nonsurgical treatments. Fluoroscopy Voiding Cystourethrography (VCUG) is a fluoroscopic technique that focuses on the bladder and urethra in the anterior compartment and can be used to evaluate cystocele and urethral hypermobility [ 1 ]. Transperineal US (TPUS) or translabial US can also be used for anatomic and functional evaluation of the pelvic floor, including evaluation of a protruding or bulging vaginal mass or clinically suspected POP [ 1 ].