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A cystocele is a protrusion (herniation) of the urinary bladder against the front (anterior) vaginal wall. A rectocele is a herniation of the rectum against the back (posterior) wall of the vagina.
A cystocele occurs when the tissues separating the bladder and vagina weaken, cause a bulge, and allow the bladder to droop into the vagina. Other portions of the vaginal vault may also fall down (prolapse), but they may or may not cause symptoms to develop.
A rectocele occurs when the muscles between the rectum and the vagina become weak from childbearing, old age, or surgery, allowing the rectum to herniate and cause a bulge of the posterior vagina. The condition may also reflect a weakness present in the wall since birth (congenital) and, in severe cases, will result in painful intercourse (dyspareunia) and difficulty defecating.
A mild cystocele (grade 1) is when the bladder droops only a short way into the vagina. A more severe type (grade 2) means that the bladder has drooped into the vagina far enough to reach the vaginal opening. The most advance cystocele (grade 3) is when the bladder bulges out through the vaginal opening.
Cystocele and rectocele, which often develop together, are typically seen in women who have had multiple vaginal births. Repeated straining from childbirth or heavy lifting or during bowel movements may also cause the bladder to prolapse. Although some degree of cystocele may be present after childbirth, it can worsen at menopause due to the lack of female hormones (estrogen), which causes the muscles around the vagina and bladder to weaken.
Incidence and Prevalence: Annually in the US, it is estimated that there are more than 300,000 surgeries for pelvic organ prolapse, which includes cystoceles and rectoceles, and that up to 11% of women 80 years of age or under have had surgery for one of these conditions (Handa). |
Source: Medical Disability Advisor
| History: A cystocele or rectocele may or may not be symptomatic. The individual may report a sensation of vaginal fullness or pressure, the feeling that something is falling out, a feeling that the bladder does not completely empty, urinary frequency, the need to push the bladder up in order to urinate, or the feeling of a mass bulging into the vagina. Symptoms can be aggravated by physical activity, prolonged standing, coughing, sneezing, or straining. If the urethra has been pushed out of position, the individual may leak urine when coughing, laughing, or lifting a heavy object (stress incontinence). A rectocele may cause constipation because of interference with muscle contractions in the rectum. The individual may also report having to manually push in (reduce) the rectocele before defecating. Physical exam: A doctor may be able to diagnose a grade 2 or grade 3 cystocele from a description of the symptoms and physical examination of the vagina. The fallen part of the bladder may be visible upon examination of the vagina; a smooth, bulging mass will be seen below the level of the cervix. Bearing down or straining moves the mass even farther into the vagina. Rectocele also reveals a bulging of the vagina and may also be visible upon visual examination. Tests: A test that involves taking x-rays of the bladder during urination (voiding cystourethrogram) shows the shape of the bladder and reveals problems that might block the normal flow of urine. Other x-rays and tests may be needed to rule out other problems in the urinary system, including a fluoroscopic examination (cinefluorography) while voiding to exclude other bladder abnormalities. Cystometry measures bladder capacity and control. A uroflowmeter analyses the urine flow. |
Source: Medical Disability Advisor
| Treatment options range from no treatment for a mild cystocele to surgery for a serious cystocele. A mild cystocele that may be bothersome can be treated with a device called a pessary. It is inserted into the vagina to support the vaginal walls, provide pelvic support, and hold the bladder in place. Pessaries come in a variety of shapes and sizes to allow for a comfortable fit. It can be a temporary management option, or in the case of older individuals who are not candidates for surgery, the treatment of choice. Pessaries must be removed regularly to avoid infection and prevent ulcers from developing.
Large cystoceles or rectoceles may require surgical repair to move the bladder back, suspending it into a more normal position (the Burch Colposuspension). Surgery permits better bladder control and allows for a more active lifestyle. Estrogen replacement therapy (ERT) may be recommended for postmenopausal women. This can help strengthen the muscles around the bladder and vagina, and can be used alone, with a pessary, or before and after surgery. The individual should be told of the advantages and risks of taking estrogen. Kegel muscle strengthening exercises will also be recommended. |
Source: Medical Disability Advisor
| The prognosis after surgery is excellent as long as the individual avoids conditions or activities that increase pressure in the pelvic and rectal area. Painful intercourse may occur if the repair is made too tight. If nonsurgical treatment with a pessary or other supportive device is chosen, the outcome is good but may provide only temporary improvement in some cases. |
Source: Medical Disability Advisor
| Pelvic floor exercises (Kegel exercises) may help strengthen the muscles of the vagina and those between the rectum and vagina. |
Source: Medical Disability Advisor
| A large cystocele can cause urine to leak when the individual sneezes, coughs, laughs, lifts, or does anything that puts pressure on the bladder (stress incontinence). It may also cause incomplete emptying of the bladder leading to recurrent urinary tract infections. The uterus can also drop from its normal position into the vagina (uterine prolapse), and is often associated with a cystocele because of the weakened vaginal tissue. Removal of the uterus (hysterectomy) may need to be done at the same time as the repair of a cystocele or rectocele. |
Source: Medical Disability Advisor
| Heavy lifting or straining can cause the cystocele or rectocele to worsen and should be avoided. Several days in the hospital and 4 to 6 weeks of recuperation should be expected for a full return to normal function after surgery. The individual can return to work after treatment but should continue to avoid heavy lifting, straining, and prolonged standing. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Was diagnosis of cystocele or rectocele confirmed?
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Were other bladder or uterine abnormalities considered in the differential diagnosis?
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Has individual experienced any complications associated with the cystocele or rectocele, such as stress incontinence, incomplete emptying of the bladder leading to recurrent urinary tract infections, or uterine prolapse due to weakened vaginal tissue?
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Does individual have coexisting conditions, such as obesity and constipation that affect the weight on the muscles, and could worsen the condition?
Regarding treatment:
- If treatment was by pessary, was it chosen as a temporary management option, or because individual was older and not a candidate for surgery? If for temporary management, what further treatment will be required?
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Was surgical repair successful in moving the bladder back into a more normal position? Was better bladder control achieved? Is further therapy anticipated?
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If postmenopausal, was estrogen replacement therapy (ERT) recommended to help strengthen muscles around the bladder and vagina? Was individual informed of the advantages and risks of taking estrogen?
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Has individual been compliant with recommended pelvic floor exercises (Kegel exercises) to help strengthen muscles of the vagina and those between the rectum and vagina?
Regarding prognosis:
- If treated nonsurgically with a pessary or other supportive device, does individual understand that although the outcome may be good, this may be only a temporary improvement?
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Following surgical correction, does individual understand that she must avoid conditions or activities that increase pressure in the pelvic and rectal area? Was individual instructed in proper ergonomics for lifting heavy objects?
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Source: Medical Disability Advisor
| Handa, V. L., et al. "Progression and Remission of Pelvic Organ Prolapse: A Longitudinal Study of Menopausal Women." American Journal of Obstetrics and Gynecology 190 1 (2004): 27-32. MD Consult. 1 Jan. 2004. Elsevier, Inc. 13 Jan. 2005 <http://home.mdconsult.com/das/journal/view/38921043-2/N/14318546?sid=282169324&source=MI>. |
Source: Medical Disability Advisor
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