What is a cystocele and how is it managed?

Cystocele: Overview and Management

A cystocele is a bladder hernia through the anterior vaginal wall, commonly occurring in elderly women, requiring management based on symptom severity and anatomical defects. 1

Definition and Pathophysiology

• A cystocele occurs when the bladder protrudes into the vagina due to weakening of the fibromuscular supports between the bladder and vagina 1, 2
• It represents a form of pelvic organ prolapse (POP) in the anterior compartment, where the bladder descends below its normal anatomical position 2
• Recent research suggests that apical defects (level I support) contribute significantly to cystocele formation in 72.2% of cases, with 30.8% caused exclusively by apical defects 3

Clinical Presentation

• Patients may present with a sensation of vaginal bulging or protrusion 4
• Associated symptoms can include:
  • Urinary stress incontinence (in approximately 38.3% of cases) 5
  • Urinary urgency or frequency 2
  • Voiding difficulties due to urethral kinking in large cystoceles 2
  • Incomplete bladder emptying 2
• Cystoceles are frequently associated with other forms of prolapse:
  • Hysterocele or vaginal vault prolapse (87.2% of cases) 5
  • Rectocele (70.2% of cases) 5
  • Enterocele (19.1% of cases) 5

Diagnosis and Evaluation

• Clinical examination is the cornerstone of diagnosis, with imaging reserved for cases where clinical evaluation is difficult or inadequate 4
• Imaging may be indicated when:
  • Clinical evaluation is difficult or considered inadequate 4
  • Patients have persistent or recurrent symptoms after treatment 4
  • There is a need to differentiate between different types of prolapse 4
  • Assessment of associated structural defects or functional abnormalities is required 4

Imaging Options

• Voiding Cystourethrography (VCUG):

  • Focuses on the anterior compartment (cystocele and urethral hypermobility) 4
  • Defines cystocele as extension of the opacified urinary bladder below the pubic symphysis 4
  • Can measure urethral angle relative to vertical axis 4
  • Limited to anterior compartment structures 4

• MR Defecography:

  • Provides comprehensive anatomic and functional evaluation of the entire pelvic floor 4
  • Can detect levator muscle defects with high interobserver reliability 4
  • Shows good agreement with physical examination for anterior compartment prolapse (85%) 4

• Transperineal Ultrasound (TPUS):

  • Non-invasive technique for anatomic and functional evaluation 4
  • Can detect levator muscle avulsion, a predictor of prolapse recurrence 4
  • Shows significant correlation with physical examination, particularly in the anterior compartment 4

Management Approaches

Conservative Management

• For mild cases or when surgery is contraindicated:
  • Pelvic floor muscle exercises 2
  • Vaginal pessaries 2
  • Lifestyle modifications (weight loss, avoiding heavy lifting) 2

Surgical Management

• Surgical intervention is indicated when symptoms affect quality of life or when conservative measures fail 1

• Surgical techniques include:

  • Anterior Colporrhaphy:

    • Traditional approach for cystocele repair 6
    • Involves plication of the pubocervical fascia 6

  • Vaginal Patch Plastron:

    • Uses a vaginal strip (6-8cm in length and 4cm in width) to support the bladder 5
    • Suspension of this strip to the tendinous arch of the pelvic fascia 5
    • Corrects both median and lateral cystoceles 6
    • Short-term results show 93% success rate in treating cystoceles 5

  • Paravaginal Repair:

    • Addresses lateral defects by reattaching the lateral vaginal wall to the arcus tendineus fascia pelvis 6

• When cystocele is associated with apical defects, addressing both components is essential for successful treatment 3

Considerations and Caveats

• There is often no direct clinico-anatomical correlation, but functional disturbance remains a major factor in determining the need for surgery 1
• Surgical technique should be chosen based on:
  • Patient's age and classification 1
  • Presence of concomitant prolapse in other compartments 2
  • Whether the cystocele is caused by apical defects, which if not addressed may lead to treatment failure 3
• Patients should be counseled about the possibility of failure or recurrence 1
• Confidence between patient and surgeon remains crucial for good management outcomes 1