What is a cystocele?

What is a Cystocele?

A cystocele is a bladder hernia through the anterior wall of the vagina, representing a form of pelvic organ prolapse (POP) in the anterior compartment of the pelvic floor. 1, 2

Anatomical Definition and Classification

A cystocele occurs when the supportive tissues between the bladder and vagina weaken, allowing the bladder to bulge into the vaginal canal. This condition is part of pelvic organ prolapse, which may involve various compartments of the pelvic floor:

• Anterior compartment: Cystocele (bladder prolapse) and/or urethrocele
• Apical compartment: Uterine/cervical and/or vaginal prolapse
• Posterior compartment: Rectocele

Cystoceles are typically graded on a scale of 0-3 based on severity:

• Grade 0: No prolapse
• Grade 1: Mild prolapse
• Grade 2: Moderate prolapse
• Grade 3: Severe prolapse (bladder extends significantly into the vaginal canal) 3

Pathophysiology

The development of a cystocele involves:

• Weakening of the pelvic floor support tissues
• Changes in collagen composition and extracellular matrix
• Altered function of vaginal fibroblasts, particularly in postmenopausal women 4

Research shows that cells from postmenopausal women with POP deposit matrices with:

• Higher percentage of collagen fibers
• Less anisotropic orientation
• Increased stiffness compared to controls 4

Clinical Presentation

Common symptoms include:

• Vaginal bulge sensation (strongly associated with higher grades of cystocele) 3
• Urinary symptoms:
  • Stress urinary incontinence (leakage when coughing/sneezing)
  • Urge incontinence
  • Incomplete bladder emptying
  • Recurrent urinary tract infections
• Pelvic pressure or discomfort
• Sexual dysfunction

It's important to note that the correlation between cystocele severity and urinary symptoms is not always straightforward. Studies show no consistent relationship between the existence and degree of cystocele and functional lower urinary tract symptoms 3.

Diagnosis

Diagnosis primarily involves:

1. Physical examination: To determine the grade of cystocele and presence of other pelvic floor disorders 5

2. Imaging studies (when clinical evaluation is difficult or inadequate):

   • Fluoroscopy Cystocolpoproctography (CCP): Shows excellent sensitivity (96%) for detecting cystoceles compared to physical examination 1
   • MR Defecography: Provides comprehensive anatomic and functional evaluation of the entire pelvic floor 1
   • Transperineal ultrasound: For anatomic and functional evaluation 5
   • Voiding Cystourethrography (VCUG): Defines cystocele as extension of the opacified urinary bladder below the level of the pubic symphysis 1

Management Considerations

Treatment options should be based on:

1. Symptom severity: Asymptomatic or mildly symptomatic cystoceles may not require intervention
2. Impact on quality of life: Treatment is indicated when symptoms significantly affect daily activities
3. Patient age and overall health: Surgical approaches vary based on age and comorbidities
4. Presence of associated pelvic floor disorders: Often requires comprehensive assessment of all compartments

Potential Complications

Without appropriate management, cystoceles may lead to:

• Progressive worsening of urinary symptoms
• Recurrent urinary tract infections
• Sexual dysfunction
• Psychological distress and reduced quality of life

It's important to recognize that surgical repair, while effective, can have complications including mesh erosion (9.1%), local pain (5.5%), and dyspareunia (16.7%) 6.

Key Points for Clinicians

• Cystocele is common in elderly women but can occur at any age
• There is often discordance between anatomical findings and functional symptoms
• Comprehensive evaluation should include assessment for other pelvic floor disorders
• Imaging studies provide valuable information when clinical examination is inadequate
• Treatment decisions should prioritize symptom relief and quality of life improvement