Cystocele (bladder prolapse)

Pelvic organ prolapse (prolapse) is a very common pathology in women. In addition to discomfort, sexual dysfunction and gynecological disorders, the disease often leads to serious urological problems: imperative (urgent) urination, urinary leakage or incontinence (stress or mixed type), frequent relapses of infectious and inflammatory pathology of the urinary system (acute cystitis, pyelonephritis), disturbances in the outflow of urine (in some cases, up to acute or chronic urinary retention). Competent diagnosis and treatment of pelvic organ prolapse in many cases is the key to effectively eliminating the symptoms of a wide variety of bladder pathologies. Often, long-term and often recurrent cystitis in a patient who is unsuccessfully trying to overcome “resistant E. coli” is completely cured when the prolapse is corrected…

What is prolapse or prolapse of the pelvic organs (POP): bladder, uterus, vagina and rectum in women, how is it defined and classified?

It would seem that the very concept of prolapse of the uterus, vagina and rectum is quite obvious and its meaning follows from the name. However, many women, as well as general practitioners (family doctors), cannot determine whether they and their patients have POP. Sometimes even gynecologists and urologists who have not encountered POP in their practice cannot adequately assess the presence and severity of this pathology. In this regard, we will give some clarifications. PPO is usually called the displacement or prolapse of one or more pelvic organs (bladder, uterus, vagina and rectum) down towards the genital opening, up to their complete prolapse. According to the classification of the International Continence Society or ICS, this classification will be further referred to as the ICS classification, the degree of POP is assessed by the position of the following localizations and by the following measurements:

Anterior localizations.

Ah. A point that is 3 cm proximal (deeper) from the external opening of the urethra. In relation to the entrance to the vagina, this point can vary in position from –3 (normal) to + 3 (prolapse).

Va. The most distal (superficial) part of the anterior vaginal wall. In the absence of a cystocele (bladder prolapse) or any other “anterior” prolapse, this point is defined as – 3.

Top localizations.

C. The most distal (close to the outside) edge of the cervix or vaginal cuff (scar) after a hysterectomy (surgery to remove the uterus).

D. Localization of the posterior vaginal fornix (not determined if the patient has undergone hysterectomy or hysterectomy).

Posterior localizations.

Ap. A point in the middle of the posterior wall of the vagina, located 3 cm proximal (deep) from the entrance to the vagina. In relation to the genital fissure (entrance to the vagina), this localization can vary from – 3 to + 3.
Bp. The point on the posterior wall of the vagina that is farthest from the vaginal opening. In the absence of prolapse, it is defined as – 3.

Measurements

TVL. The greatest length of the vagina in its normal position.

gh. The distance between the midpoints of the vaginal opening and the external urethral opening.

pb. Measured from the posterior edge of the vaginal opening to the anterior edge of the anus.

Staging.

All measurements should be recorded as a series of numbers for positions Aa, Ba, C, Bp, Ap, TVL, gh and pb (e.g. –3, –3, –7, –9, –3, –3, 9, 2, 2 respectively, representing measurements for normal vagina and normal pelvic position). Using these measurements, PHE can be staged as follows:

• Stage 0. No prolapse. All locations are located at their highest points relative to the entrance to the vagina.

• Stage I. The most distal (protruding) point of prolapse is located 1 cm above the vaginal opening.

• Stage II. The most distal (protruding) point of prolapse is located 1 cm or less than 1 cm above or below the vaginal opening.

• Stage III. The most distal (protruding) point of prolapse is located more than 1 cm below the vaginal opening, but protrudes no more than 2 cm less than the TVL.

• Stage IV. Prolapse of pelvic organs along the entire length of the vagina (complete pelvic organ prolapse).

Accurate staging of POP and determination of the degree of pelvic organ prolapse in a woman can only be carried out by an experienced gynecologist or urogynecologist who has special education, qualifications and experience in this field.

How does POP manifest itself, what does prolapse of various pelvic organs look like, how does it bother a woman and what can it lead to? If you have frequent urination.

The most common symptoms of POP are:

• The presence of a visible or palpable mass protruding from the vagina.

• Feeling of pressure or heaviness in the perineum and pelvic floor.

• Possible pain or discomfort in the lumbar region and lower abdomen, complaints such as: “I feel as if something is falling out of me.”

• Constipation and the need to press on the back wall of the vagina in order to better empty the rectum is a symptom of rectal prolapse or rectocele.

• Urinary disorders: stress urinary incontinence or stress urinary incontinence (SUI), urinary frequency or frequent urge to urinate, weakened urinary stream or difficulty urinating.

• Sexual disorders: decreased sensitivity and tone of the vagina during sexual intercourse, vaginal dryness (dyspeyronia). Sexual partners often pay attention to the decrease in vaginal tone during intercourse.

These symptoms can occur individually or in combination. It is important to keep in mind that almost all symptoms are not absolutely specific to POP and their attribution specifically to pelvic organ prolapse is the prerogative of the doctor.

To make it easier for our readers to determine whether they have POP, we present what the different types of pelvic organ prolapse look like. Changes in the health status of women that were caused by the following PTOs are also described.

How common is POP in women?

According to the Women’s Health Initiative, pelvic organ prolapse occurs in 41% of American women over 50 years of age. In Russia, uterine prolapse and prolapse of the uterus and vaginal walls are observed in 15-30% of women, and over the age of 50 years, the frequency of prolapse increases to 40%. Among elderly and senile women, the frequency of genital prolapse reaches 50-60%.

Why does pelvic organ prolapse occur in women?

The causes of VET are very multifactorial and diverse:

traumatic and prolonged labor,

systemic dysplasia (insufficiency) of connective tissue,

estrogen deficiency (decrease in general and local levels of female sex hormones),

chronic diseases accompanied by increased intra-abdominal pressure (bronchitis, asthma, constipation, etc.),

disruption of microcirculation processes of blood and lymph in the pelvis,

obesity,

A sedentary lifestyle can also be a factor in the development of uterine prolapse (prolapse of the uterus), rectocele or cystocele.

All causes of POP can be divided into congenital and acquired. The first group of reasons includes:

• Congenital genetic abnormalities in the synthesis of elastin and collagen (the fibers that make up human fascia and ligaments);

• Genetically determined increased proteolytic (protein-destroying) activity of blood plasma, which also leads to weakening of the musculofascial apparatus of the pelvic floor.

Acquired factors include:

Multiple births and large fetuses;

Ruptures of perineal tissue during childbirth, especially those not adequately sutured;

Obesity, overweight;

Aging and age-related hormonal disorders;

Chronic cough;

Weight lifting.
Inadequate support of the pelvic organs by weakened muscles and fascia of the pelvic floor leads to their prolapse and the development of POP.

The pathogenesis (mechanism of development)uterine prolapse (uterine prolapse) and pelvic organs is not entirely clear at first glance. Why don’t the bladder, uterus, and rectum “sit” in their proper place – in the stomach and they “crawl out” through the vagina? According to modern views, prolapse of the bladder (cystocele), rectum (rectocele) and prolapse/prolapse of the uterus (uterocele) are, in fact, hernias of the fundus of the abdominal cavity.

What is the diagnosis of PTO?

The basis for diagnosing pelvic organ prolapse is a detailed conversation with a doctor, examination and physical examination. It is necessary to find out whether the woman has problems with urination and urine retention, frequent urination, how the intestines work and whether there is constipation, whether there are any complaints related to sexual activity (sexual desire, vaginal dryness, discomfort or pain during sexual intercourse, orgasm disorders, dissatisfaction of the sexual partner). The woman’s lifestyle is assessed, how socially and physically active she is, and how much the symptoms associated with POP and frequent SUI interfere with her. It turns out what the patient expects from treatment and how much she accepts surgical treatment. The examination is carried out in a gynecological chair. During the examination, the type and degree of POP occurring, the presence and severity of SUI are determined, and the standard measurements of the degree of pelvic organ prolapse described above are carried out. In some cases, additional research may be required. One simple test is the “pessary test.” Its meaning is that when a woman with prolapsed bladder and urethra is fitted with a pessary, which moves the prolapsed organs to a relatively normal position, the patient develops previously unnoticed stress urinary incontinence. This test also makes it possible to understand whether the pain in the lower abdomen and lower back that often occurs in such patients is related to pelvic organ prolapse. In some cases, for a more accurate diagnosis of urinary disorders, urodynamic studies may be required, in particular cystometry and pressure-flow studies, as well as measurement of the urethral profile and pelvic floor myography. The use of ultrasound (US) and nuclear magnetic resonance imaging (NMRI) allows us to better understand the anatomical features of the existing PTO.

What is the treatment for POP?

The main goals of treating pelvic organ prolapse in women are:

Restoring the normal anatomical position of the pelvic organs, eliminating their prolapse

Restoring adequate support for the pelvic organs using your own pelvic floor tissue or various plastic materials;

Elimination of such manifestations of POP as pain, sexual disorders, stress urinary incontinence, constipation, etc.

At the same time, it is extremely important to carry out treatment as gently as possible in order to avoid relapses and complications. Treatment of POP can be conservative or surgical. Conservative treatment methods primarily include exercises to strengthen the pelvic floor (Kegel exercises). They give a very noticeable effect for weak and moderately severe PTO. To be fair, the effectiveness of the exercises directly depends on the patient’s motivation, the correctness of his efforts, and increases significantly when exercising under the supervision of a qualified trainer.

Another type of conservative treatment for POP is the use of pessaries, devices made of rubber or plastic that are inserted into the vagina and support the prolapsed pelvic organs in a more normal position. Pessaries can be used as a temporary means for women awaiting surgery or for those who for some reason cannot or do not want to undergo surgery. The most effective treatment for POP is surgery. Operations to correct POP are divided into three groups:

I. Reconstruction of the anterior pelvis (anterior vaginal wall, urethra, bladder). Currently, along with classical anterior colporrhaphy, operations using synthetic meshes are used. As a rule, surgical approaches through the vagina are used.
II. Reconstruction of the midpelvis (uterus, as well as the cervix or vaginal cuff after previous hysterectomy operations). Various methods are used to fix the above formations to the sacrum or to various ligaments connecting to the sacrum. Both vaginal and abdominal (through the abdomen) approaches are used.

III. Reconstruction of the posterior pelvis (rectum, small intestine). The most commonly performed procedure is posterior colporrhaphy with or without levatoroplasty. For large defects of the rectovaginal fascia, synthetic meshes are used.

Unfortunately, there are no ideal treatments for POP. Conservative therapy is ineffective in most cases, and constant wearing of pessaries is fraught with chronic inflammation of the vagina and complications such as urinary tract infections. Although the operations give a very good effect (more than 80% of those operated on note a significant improvement), like all operations they can cause complications.

What complications occur after operations to correct POP and how often do they occur?

The incidence of general surgical complications such as bleeding, wound infection, poor wound healing is within 3–5%. Intense postoperative pain is typical for the first 5–7 days after surgery. However, the use of painkillers and reducing stress on the pelvic floor (patients are advised not to sit for the first 2 weeks after surgery) largely eliminates postoperative pain. The use of the most modern methods of surgical treatment and high-quality suture and plastic materials, and mainly the experience of the surgeon, significantly reduces the frequency of possible complications.

What is the prevention of VET?

The basis for the prevention of POP is a healthy lifestyle, proper nutrition, the fight against excess weight, and the avoidance of excessive physical activity and heavy lifting. Timely treatment of chronic constipation and prolonged cough should be carried out, as well as correction of age-related hormonal disorders. When preparing for childbirth, it is important to plan it carefully depending on the size of the fetus. Well, if extensive ruptures of the perineum after childbirth could not be avoided, the qualifications of the obstetrician-gynecologist who performs suturing of the perineal tissues play an extremely important role. In this regard, the maternity hospital and the doctor who will deliver the child should be chosen in advance.