What are the symptoms and clinical presentation of a prolapsed bladder (cystocele)?

Clinical Presentation of Pelvic Organ Prolapse (Cystocele)

A prolapsed bladder (cystocele) typically presents as a bulge or protrusion of tissue through the anterior vaginal wall that becomes more prominent during Valsalva maneuver, often accompanied by urinary symptoms including stress incontinence, incomplete emptying, or urinary urgency. 1

Visual and Physical Examination Findings

When examining a patient with suspected cystocele, the following clinical findings may be observed:

• Visual inspection findings:

  • Tissue bulging or protruding from the vaginal introitus, especially during bearing down 1
  • Anterior vaginal wall descent visible during Valsalva maneuver
  • In severe cases, tissue may protrude beyond the vaginal opening even at rest

• Physical examination findings (using split-speculum technique):

  • Descent of the anterior vaginal wall when the patient bears down
  • Quantifiable prolapse using the POP-Q (Pelvic Organ Prolapse Quantification) system 1
  • Possible concurrent prolapse in other compartments (apical, posterior) 1

Associated Symptoms

Patients with cystocele commonly report:

• Urinary symptoms:

  • Stress urinary incontinence (up to 60% of women with prolapse) 2
  • Sensation of incomplete bladder emptying
  • Urinary urgency or frequency
  • Urinary hesitancy or poor stream
  • Need to manually reduce the prolapse to void completely 3

• Other symptoms:

  • Sensation of vaginal pressure or fullness
  • Pelvic heaviness that worsens with prolonged standing or activity
  • Lower back or sacral pain 3
  • Dyspareunia (painful intercourse)
  • "Something falling out" of the vagina

Diagnostic Considerations

The diagnosis of cystocele is primarily clinical, but several important assessments should be performed:

• Essential evaluations:

  • Systematic physical examination in lithotomy position, assessing each compartment separately at rest and with Valsalva 1
  • Post-void residual measurement to rule out voiding dysfunction 1
  • Stress test to observe for involuntary urine loss during coughing/Valsalva 1
  • Urinalysis to exclude infection 1

• Advanced imaging (when indicated):

  • MR Defecography: provides comprehensive anatomic and functional evaluation of the entire pelvic floor with 85% agreement with physical examination for anterior compartment prolapse 4, 1
  • Transperineal Ultrasound: non-invasive alternative, most accurate for anterior compartment assessment 1

Important Clinical Considerations

• A large cystocele may cause urethral kinking, potentially masking stress urinary incontinence that becomes evident only after surgical repair (occult incontinence) 5
• Pelvic organ prolapse often affects multiple compartments simultaneously (up to 40% of women with urinary incontinence have some degree of prolapse) 2
• The severity of symptoms does not always correlate with the anatomical degree of prolapse 1
• Failing to assess all compartments can miss multi-compartment involvement 1

Common Pitfalls to Avoid

• Not performing stress testing with prolapse reduced: This can miss occult stress incontinence that may become evident after surgical correction 1, 5
• Focusing only on the visible prolapse: Multi-compartment involvement is common and requires comprehensive assessment 1
• Relying solely on patient-reported symptoms: The correlation between symptoms and anatomical findings is often poor, especially in advanced prolapse 1
• Ignoring concurrent conditions: Urinary incontinence and bowel dysfunction frequently coexist with prolapse and require assessment 1

The clinical presentation of cystocele should guide treatment decisions, with options ranging from conservative approaches (pelvic floor muscle training, vaginal pessaries) to surgical management based on symptom severity and impact on quality of life 1.