What are the treatment options for bladder prolapse?

Treatment Options for Bladder Prolapse

For bladder prolapse (cystocele), conservative management with pelvic floor muscle training and pessaries should be offered as first-line treatment before considering surgical options. 1

Initial Assessment and Conservative Management

• Pelvic floor muscle training (PFMT) with a qualified physical therapist is the most effective conservative approach for managing bladder prolapse, as it helps strengthen the supporting structures 2
• PFMT has demonstrated positive effects on prolapse symptoms and severity, with evidence showing anatomical and symptomatic improvement after six months of supervised training 3
• Pessaries are mechanical devices that provide support to the prolapsed organs and should be offered as a first-line conservative treatment option 1
• Regular follow-up care is essential when using pessaries to minimize complications 2
• Conservative treatments can be used in combination and should be associated with management of modifiable risk factors for prolapse 1
• Approximately 25% of women in the United States and 50% worldwide develop pelvic organ prolapse, making non-surgical options important for those who cannot or prefer not to undergo surgery 4

Surgical Management Options

• Surgery should only be considered if conservative options fail to meet patient expectations and if symptoms are disabling, related to the prolapse, and significant (stage 2 or more) 1
• Surgical approaches include:
  • Abdominal approaches (open, laparoscopic, or robotic) with mesh placement 1
  • Vaginal approaches using autologous tissue 1
• Laparoscopic sacrocolpopexy is recommended specifically for cases involving anterior (bladder) prolapse with apical involvement 1
• Minimally invasive sacrocolpopexy appears as effective as the traditional abdominal sacrocolpopexy, which is considered the gold standard 2
• Robotic-assisted and laparoscopic-assisted sacrocolpopexy are equally effective options 2
• Vaginal surgery with autologous tissue is recommended for elderly and fragile patients 1

Considerations for Treatment Selection

• The decision between surgical approaches should be based on:
  • Patient characteristics (age, comorbidities)
  • Associated pelvic floor disorders
  • Surgeon's expertise and skill level 2
• The decision to place mesh must be made in consultation with a multidisciplinary team 1
• Systematic reviews have shown that sacrocolpopexy has better long-term success for apical prolapse than vaginal techniques, though vaginal surgery remains an acceptable alternative 2
• Abdominal approaches may have increased long-term durability but involve longer operating times, increased pain, and higher costs compared to vaginal surgery 2

Post-Treatment Follow-Up

• After surgical treatment, patients should be reassessed by the surgeon even in the absence of symptoms or complications 1
• Long-term follow-up should be conducted by a primary care or specialist doctor 1
• Patients should be monitored for potential complications including pain, infection, bleeding, and incontinence 5

Common Pitfalls and Caveats

• There is often a weak correlation between anatomical correction and symptom improvement, as anatomical abnormalities may be caused by underlying functional disorders not corrected by surgery 5
• Guided pelvic floor muscle training is more beneficial than self-taught Kegel exercises, particularly for higher stage prolapse 2
• Transvaginal mesh has shown superior anatomic outcomes in some studies compared to native tissue repairs, but complication rates are higher and should be reserved for surgeons with adequate training 2
• Post-operative pain is a common complication after surgical repair that patients should be informed about 5