Cystocele repair

Definition

A cystocele is the protrusion or prolapse of the bladder into the vagina. A number of surgical interventions are available to treat cystoceles.

Purpose

A prolapse occurs when an organ falls out of its normal anatomical position. The pelvic organs normally have tissue (muscle, ligaments, etc.) holding them in place. Certain factors, however, may cause those tissues to weaken, leading to prolapse of the organs. A cystocele may be the result of a central or lateral (side) defect. A central defect occurs when the bladder protrudes into the center of the anterior (front) wall of the vagina due to a defect in the pubocervical fascia (fibrous tissue that separates the bladder and vagina). The pubocervical fascia is also attached on each side to tough connective tissue called the arcus tendineus; if a defect occurs close to this attachment, it is called a lateral or paravaginal defect. A central and lateral defect may be present simultaneously. The location of the defect determines what surgical procedure is performed.

Factors that are linked to cystocele development include age, repeated childbirth, hormone deficiency, menopause, constipation, ongoing physical activity, heavy lifting, and prior hysterectomy . Symptoms of bladder prolapse include stress incontinence (inadvertent leakage of urine with physical activity), urinary frequency, difficult urination, a vaginal bulge, vaginal pressure or pain, painful sexual intercourse, and lower back pain. Urinary incontinence is the most common symptom of a cystocele.

Surgery is generally not performed unless the symptoms of the prolapse have begun to interfere with daily life. A staging system is used to grade the severity of a cystocele. A stage I, II, or III prolapse descends to progressively lower areas of the vagina. A stage IV prolapse descends to or protrudes through the vaginal opening. Surgery is generally reserved for stage III and IV cystoceles.

Demographics

Approximately 22.7 out of every 10,000 women will undergo pelvic prolapse surgery. The rate is highest among women between 60 and 69 years of age (42 per 10,000); the mean age of patients is 54.6. White women undergo pelvic prolapse surgery at a rate of 19.6 per 10,000 and a mean age of 54.3, while 6.4 per 10,000 African American women have surgery at a mean age of 49.3.

A 2002 study indicated cystocele repair accounts for 8% of all prolapse repair surgeries; in 1997, approximately 18,500 cystocele repairs were performed. Cystocele repair was combined with rectal prolapse repair in 10% of prolapse surgeries, with hysterectomy (surgical removal of the uterus) in 6%, and with both procedures in 16%.

Description

The goals of cystocele repair are to relieve a patient's symptoms, to improve or maintain urinary and sexual function, to return pelvic structures to their original position, and to prevent the formation of new defects. The anatomical structures involved in a cystocele may be approached vaginally, abdominally, or laparoscopically.

Vaginal repair

Anterior colporrhaphy is the most common procedure to repair a central defect. The patient is first given general or regional anesthesia. A speculum is inserted into the vagina to hold it open during the procedure. An incision is made into the vaginal skin and the defect in the underlying fascia is identified. The vaginal skin is separated from the fascia and the defect is folded over

In this cystocele repair by anterior colporrhaphy, a speculum is used to hold open the vagina, and the cystocele is visualized (A). The wall of the vagina is cut open to reveal an opening in the supporting structures, or fascia (B). The defect is closed (C), and the vaginal skin is repaired (D). (

Illustration by GGS Inc.

)

Lateral defects may be repaired vaginally or abdominally. During a vaginal paravaginal repair, the approach and initial incision are similar to anterior colporrhaphy. The defect to the fascia is located and reattached to the arcus tendineus using sutures. The incision may then be stitched closed.

Abdominal and laparoscopic repair

A cystocele caused by a lateral defect may be treated through an abdominal incision made transversely (from side to side) just above the pubic hairline. The space between the pubic bone and bladder is identified and opened and the pubocervical fascia reattached to the arcus tendineus using methods similar to the vaginal paravaginal repair. In some cases, a retropubic colposuspension is performed during the same surgery. Also called a Burch procedure, colposuspension treats urinary incontinence by suspending the bladder neck to nearby ligaments with sutures. Other surgical treatments for incontinence may be combined with paravaginal repair.

A lateral defect may also be repaired by laparoscopy , a surgical procedure in which a laparoscope (a thin, lighted tube) and various instruments are inserted into the abdomen through small incisions. A patient's recovery time following laparoscopic surgery is shorter and less painful than following a traditional laparotomy (a larger surgical incision into the abdominal cavity).

Diagnosis/Preparation

Physical examination is most often used to diagnose a cystocele. A speculum is inserted into the vagina and the patient is asked to strain or sit in an upright position; this increase in intra-abdominal pressure maximizes the degree of prolapse and aids in diagnosis. The physician then inspects the walls of the vagina for prolapse or bulging.

In some cases, a physical examination cannot sufficiently diagnose pelvic prolapse. For example, cystography may be used to determine the extent of a cystocele; the bladder is filled by urinary catheter with contrast medium and then x rayed. Ultrasound or magnetic resonance imaging may also be used to visualize the pelvic structures.

Women who have gone through menopause may be given six weeks of estrogen therapy prior to surgery; this is thought to improve circulation to the vaginal walls and thus improve recovery time. Antibiotics may be administered to decrease the risk of postsurgical infection. An intravenous (IV) line is placed and a Foley catheter is inserted into the bladder directly preceding surgery.

Aftercare

A Foley catheter may remain for one to two days after surgery. The patient is given a liquid diet until normal bowel function returns. The patient also is instructed to avoid activities for several weeks that cause strain on the surgical site; these include lifting, coughing, long periods of standing, sneezing, straining with bowel movements, and sexual intercourse.

Risks

Risks of cystocele repair include potential complications associated with anesthesia, infection, bleeding, injury to other pelvic structures, dyspareunia (painful intercourse), recurrent prolapse, and failure to correct the defect.

Normal results

A woman usually is able to resume normal activities, including sexual intercourse, in about four weeks after the procedure. After successful cystocele repair, symptoms recede, although a separate procedure may be needed to treat stress incontinence.

Morbidity and mortality rates

The risk of cystocele recurrence following surgical repair depends on the procedure used to treat it. Anterior colporrhaphy is associated with a 0–20% rate of recurrence; this rate is higher when colporrhaphy is combined with other surgical procedures. Abdominal paravaginal repair results in a 5% chance of recurrence, while vaginal paravaginal repair has the highest recurrence rate (7–22%).

Alternatives

Surgery is generally reserved for more severe cystoceles. Milder cases may be treated by a number of medical interventions. The physician may recommend that the patient do Kegel exercises, a series of contractions and relaxations of the muscles in the perineal area. These exercises are thought to strengthen the pelvic floor and may help prevent urinary incontinence.

A pessary, a device that is inserted into the vagina to help support the pelvic organs, may be recommeded. Pessaries come in different shapes and sizes and must be fitted to the patient by a physician. Hormone replacement therapy may also be prescribed if the woman has gone through menopause; hormones may improve the quality of the supporting tissues in the pelvis.

Resources

BOOKS

Ryan, Kenneth J., et al. Kistner's Gynecology and Women's Health. 7th ed. St. Louis, MO: Mosby, Inc., 1999.

Walsh, Patrick C., et al. Campbell's Urology. 8th ed. Philadelphia: Elsevier Science, 2002.

PERIODICALS

Brown, Jeanette S., L. Elaine Waetjen, Leslee L. Subak, David H. Thom, Stephen Van Den Eeden, and Eric Vittinghoff. "Pelvic Organ Prolapse Surgery in the United States, 1997." American Journal of Obstetrics and Gynecology 186 (April 2002): 712–6.

Cespedes, R. Duane, Cindy A. Cross, and Edward J. McGuire. "Pelvic Prolapse: Diagnosing and Treating Cystoceles, Rectoceles, and Enteroceles." Medscape Women's Health eJournal 3 (1998).

Viera, Anthony, and Margaret Larkins-Pettigrew. "Practice Use of the Pessary." American Family Physician 61 (May 1, 2000): 2719–2726.

ORGANIZATIONS

American Board of Obstetrics and Gynecology. 2915 Vine Street, Dallas, TX 75204. (214) 871-1619. http://www.abog.org .

American Urological Association. 1120 North Charles Street, Baltimore, MD 21201. (410) 727-1100. http://www.auanet.org .

OTHER

"Cystocele (Fallen Bladder)." National Kidney and Urologic Diseases Information Clearinghouse. March 2002 [cited April 11, 2003]. http://www.niddk.nih.gov/health/urolog/summary/cystocel .

Miklos, John. "Vaginal Prolapse Relaxation." OBGYN.net . 2002 [cited April 11, 2003]. <http://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/mik os-vagprolapse> .

Stephanie Dionne Sherk

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Cystocele repair is usually performed in a hospital operating room by a gynecologist, urologist, or urogynecologist. A gynecologist is a medical doctor who specializes in the areas of women's general and reproductive health, pregnancy, and labor and childbirth. A urologist is a medical doctor who specializes in the diagnosis and treatment of diseases of the urinary tract and genital organs. A urogynecologist studies aspects of both fields.

QUESTIONS TO ASK THE DOCTOR

• What defect is causing the cystocele?
• What surgical procedure is recommended for treatment?
• Will other procedures be performed to treat urinary incontinence (e.g. Burch procedure)?
• What nonsurgical alternatives are available?
• How soon after surgery may normal activities be resumed?