Your Guide to Bladder Prolapse

Pelvic structures such as the bladder, the vagina, the rectum or the uterus are all supported by a network of muscles and tissues that act like a hammock of support. This support system is often referred to as the pelvic floor. Due to a variety of factors, these muscles and tissues can become weak and stretch over time. This can lead to the pelvic structures “falling” and bulging into the vagina which is often called pelvic prolapse.

When the support of the bladder becomes weak, it can be the bladder which bulges into the vagina. This can be called bladder prolapse or a cystocele. Bladder prolapse does not always need to be treated and does not cause bothersome symptoms in all women. Once you know that you have bladder prolapse, focusing on how this may or may not affect your quality of life can be a useful guide as you consider your options.

One of the most important jobs of the the pelvic floor muscles and tissues is to provide stability for many of the abdominal and pelvic organs. Plenty of things that we do all of the time - laughing, coughing, sneezing, lifting, exercising - can create a lot of pressure within the abdomen and pelvis. The pelvic floor muscles help to regulate these pressures and provide structure and support for your bladder, rectum, vagina and other organs. The pelvic floor is often included in your core muscles that help to stabilize your movements.

In addition to providing support and structure, the pelvic floor also assists in several functional ways. The pelvic floor muscles help to control bladder and bowel function by acting as sphincter muscles that contribute to continence of urine and stool. Weakness of the pelvic floor can lead to unwanted loss of urine or stool that is termed incontinence. In addition, failures of the pelvic floor can also make it more difficult to eliminate urine or stool.

Another important functional role of the pelvic floor is in sexual health. In both men and women, a properly functioning pelvic floor is vital for sexual function. Disorders of the pelvic floor can lead to pain associated with sexual activiity for both women and men. Many people find it difficult to discuss this aspect of pelvic floor dysfunction but it can be among the most common and the most distressing.

There may be many factors that contribute to weakness of the pelvic floor and thus to bladder prolapse. One of the most common of these is pregnancy and childbirth. Having multiple pregnancies or difficult delveries both seem to be associated with higher rates of bladder prolapse. It is thought that the increased stress placed on the pelvic floor as well as the trauma that can occur with delivery likely contributes to weakness of the muscles and stretching or even tearing of the connecting tissues. Once some parts of the pelvic floor are damaged or weakened, other muscles may try to compensate. This can cause imbalance and lead to further dysfunction. Weakness, stretching, tearing or other dysfunction of the pelvic floor can eventually lead to bladder prolapse.

However, pregnancy and delivery are not the only contributors to bladder prolapse. Any factor that increases stress, pressure or trauma to the pelvic floor can lead to weakening and prolapse. Some commonly identified risk factors for bladder prolapse include:

• Advancing age

• Pelvic surgeries

• Menopause

• Heavy or repetitive lifting

• Obesity

• Frequent straining to pass urine or stool

• Chronic constipation

• Diseases that lead to chronic cough (COPD, chronic bronchitis)

Based on the problems that can be seen with a weak pelvic floor, you might think that there could never be a problem with a pelvic floor that is “too strong”. In some ways, this is true. A truly “strong” pelvic floor is capable of supporting the pelvic organs and resisting increases in pressure on those organs. However, a pelvic floor that is always active, often in response to an injury of other muscles, can be a significant problem as well. Overactive pelvic floor muscles are called hypertonic and can result from injuries to surrounding tissue or muscles, overwork of the core muscles in general, disorders of the bladder or bowel, or even stress and anxiety. A hypertonic pelvic floor results in muscles that are too tense and are active even when they are not necessary to resist pressure in the pelvic or abdomen. If these muslces are overused, it can be difficult to relax them or to even know when they are tense.

There are a variety of different problems that can result from a hypertonic pelvic floor. This includes with chronic pain and soreness, pain or difficulty with sexual activiity and problems passing urine or stool. It is often necessary to work with a specialized healthcare provider called a pelvic floor physical therapist in order to treat pelvic floor hypertonicity. Occasionally, use of medications, injections or other therapies may also be needed.

It is important to remember that all bladder prolapse does not result in bothersome, or even noticeable symptoms. Also, just because you have some symptoms of bladder prolapse does not mean that it must be treated. However, knowing the most common symptoms of bladder prolapse will help you to identify any issues that are bothersome to you and help you to make a decision as to which options are best for you.

The most common symptom of any type of pelvic prlolapse is seeing or feeling a bulge into the vagina. the bulge may remain inside of the vagina or may protrude out from the opening of the vagina. Other common symptoms include:

• Pressure or pain in the pelvis or vagina

• Painful or difficult sexual activity

• Frequent or urgent urination

• Urinary leakage (incontinence)

• Difficulty completely emptying the bladder or having to push on a vaginal bulge to empty

Treatments for Bladder Prolapse

A common reason why patients do not bring up bothersome Bladder Prolapse is because they are fearful of needing surgery to address it. While surgery is the right choice for many women with different types of pelvic prolapse, there are other options available to try if you are concerned about the possibility of surgery. More conservative therapies, often called behavioral therapies, involve non-invasive treatments that do not require a trip to the operating room.

It bears repeating, especially when considering treatment options for Bladder Prolapse, that all prolapse does not need to be treated. If you are not bothered by your prolapse symptoms and they are not causing issues such as preventing you from emptying your bladder, it is completely reasonable not to have any treatment at all. However, this choice should be yours and should be made knowing that you have several options including surgery and behavioral therapies.

Not all therapies for Bladder Prolapse require a surgery. More conservative therapies, often called behavioral therapies, may be an option for some women with some types of prolapse.

One of the most common behavioral treatments for prolapse is using pelvic floor exercises to strengthen the pelvic muscles of the pelvic floor. Pelvic floor exercise is often known as Kegel exercises and can begin by simply discussing with your health provider whether these are likely to be effective for you. The success of pelvic floor exercise can depend on the extent of the bladder prolapse as well as the symptoms of the prolapse. In addition, in patients with overactive or hypertonic pelvic floor muscles, Kegel exercise may cause further problems. However, it is worth discussing with your provider whether pelvic floor exercise may be right for you.

Meeting with a specialized healthcare provider called a Pelvic Floor Physical Therapist may provide additional benefits to a regimen of pelvic exercises. Pelvic Floor Therapists specialize in rehabilitation of the pelvic floor that focuses on more than just strengthening the muscles. They can provide guidance for exercises, tips on things you may want to avoid, guidance habits that can improve pelvic floor stength and function as well as help to educate you on the anatomy and proper function of your pelvic floor. Many people who have been frustrated by attempts at pelvic floor exercises on their own find meeting with a Pelvic Floor Therapist to be very useful.

Another non-surgical treatment for bladder prolapse is use of a pessary. A vaginal pessary is a soft, flexible device (often in the shape of a ring or a doughnut) that is inserted into the vagina to prevent the bladder from bulging into the vaginal space. Pessaries can be left in place for several months, but do need to be changed periodically. It is often useful if you are able to remove, clean and replace the pessary yourself. Not all types of prolapse can be treated with a pessary. It can sometimes take several attempts to find a pessary that is comfortable but remains in place.

The surgical options for pelvic prolapse in general and Bladder Prolapse specifically can vary greatly depending on how much prolapse is present, the symptoms that are bothering you, whether or not you have had a previous pelvic surgery such as a hysterectomy and whether any other structures besides the bladder are also prolapsed. It is important to discuss your type of prolapse and surgical options with your provider. However, in general, surgical treatments for Bladder Prolapse can be grouped.

Vaginal Surgery

In vaginal surgeries for bladder prolapse, an incision is made within the vagina. The goal is to restore the support for the falling bladder. This often requires using suture to repair tears in the supporting tissue of the bladder (called fascia). These tears may be in the middle, underneath where the bladder normally sits, or the tears may be off to one or both sides of the bladder. In bladder prolapse, it is is often the case that the supporting structures of the most interior part of the vagina (the cervix or the apex) have fallen as well as the bladder. If this is the case, repair of the bladder prolapse will also require attaching this upper portion of the vagina to a strong supporting structure in the pelvis as well. Other types of prolapse, such as prolapse of the rectum into the vagina (rectocele) can also be repaired at the time of a vaginal surgery. In addition, patients with Stress Urinary Incontinence (SUI) who want an incontinence surgery can have this done at the same time as a vaginal repair (though through a nearby but separate incision).

Although considered an “open” surgery, vaginal repair of prolapse does not involve cutting through muscle tissue which may help to speed recovery. Patients may or may not need to spend an overnight in the hospital depending on a variety of factors. You will be advised to avoid strenuous activity, including heavy lifting, for several weeks after surgery.

Abdominal Surgery

Surgery for Bladder Prolapse may involve abdominal surgery, particularly when there are other structures which have prolapsed such as the uterus or the upper or innermost part of the vagina (cervix or apex). With significant prolapse of these other areas, simply repairing Bladder Prolapse through a vaginal incision may not be enough. Also, if the prolapse of the upper vagina is extensive enough, this can require attaching this part of the vagina to a very strong structure (called a sacrocolpopexy). Repair of complicated prolapse like this may require both an approach through the vagina as well as the abdomen.

More often, today, abdominal repairs of prolapse occur as laparoscopic or robot-assisted laparoscopic surgery. This means that the surgery is performed through several small incisions rather rather than one large incision. Advantages of these types of prolapse repairs over one large abdominal incision include less pain and faster recovery after surgery. The pelvis is very deep and seeing into it for surgery can be very difficult through a single, large incision. There may also be an advantage that laprascopic surgeries have in terms of making visualization of the surgery easier.

Prolapse reapair when the uterus is present and is falling along with the bladder and other structures can be complicated. In this situation, it is best to discuss in depth with your provider, keeping in mind that options exist that both remove and preserve the uterus. However, their are advantages and disadvantages to each approach that should be discussed in depth.

Prolapse Mesh

For patients, one of the most confusing and frightening aspects of prolapse repair surrounds the use of what is usually called synthetic mesh to treat vaginal prolapse. Part of the difficulty for patients is that synthetic mesh is used in pelvic health (and other areas of surgery) in a variety of different ways. The safety and usefulness of each of these uses are as different as the uses. Synthetic mesh is still most frequently used in pelvic health to treat Stress Incontinence (SUI) with mid-urethral slings. Many consider this to be the gold-standard treatment for SUI. Synthetic mesh is also used to treat pelvic prolapse in an abdominal procedure (often laparoscopic or robot-assisted laparoscopic) called a sacrocolpopexy. Again, this is a common and generally safe use of mesh and would also be considered a standard therapy for certain types of prolapse by most experts.

The confusion is caused by a 2011 FDA-issued public health notification of events associated with transvaginal mesh products. This was followed by a 2019 order by the FDA to remove all such transvaginal mesh products from the market. This has led to confusion among many patients about the continued use of synthetic mesh for mid-urethral slings as well as for sacrocolpopexy.

The position of experts in this area, particularly regarding the use of synthetic mesh for incontinence slings is well-summarized in the “SUFU Position Statement Update on the Use of Synthetic Midurethral SlingsSUFU Position Statement Update on the Use of Synthetic Midurethral Slings”. The types of synthetic mesh that remain on the market are safe and effective for surgical implant. Synthetic mesh used as a sling material is the most extensively studied type of medical device in history. Again, when used for mid-urethral slings, synthetic mesh remains the standard of care in the surgical treatment of stress incontinence.