Alana M. Murphy, MD
BASICS
DESCRIPTION
• Cystocele is prolapse of the bladder into the vagina
• Also referred to as anterior compartment prolapse
EPIDEMIOLOGY
Incidence
11% lifetime risk of surgery for pelvic organ prolapse (POP) or urinary incontinence (UI) (1)
Prevalence
• Difficult to determine due to several factors:
– Data mostly reported in the context of surgical treatment
– Cystocele may be asymptomatic
– Diagnosis requires a vaginal exam
• POP quantification (POP-Q) distribution in an observational study of women 18–82 yr old seeking routine gynecologic care (2):
– POP-Q stage 0: 6.4%
– POP-Q stage 1: 43.3%
– POP-Q stage 2: 47.7%
– POP-Q stage 3: 2.6%
RISK FACTORS
• Increasing age
• Parity
• Vaginal delivery (nerve, muscle, and connective tissue damage)
– Instrumented vaginal delivery may be associated with a higher risk of POP compared to spontaneous vaginal delivery
• Race (3)
– Hispanic women have highest prevalence of POP
• Increased intra-abdominal pressure (obesity, chronic cough, constipation)
• Pelvic surgery (hysterectomy, radical cystectomy)
• Congenital connective tissue disorders (Ehlers–Danlos syndrome)
Genetics
• Connective tissue disorders, bladder exstrophy
• POP prevalence rates differ according to race suggesting a genetic component (3)
PATHOPHYSIOLOGY
• Weakening of supporting and suspending structures: Cardinal ligaments, uterosacral ligaments, endopelvic fascia, pubocervical fascia, levator ani muscles
• Defect location:
– Central: Attenuation of the pubocervical fascia in the midline
– Lateral: Disruption of lateral attachments of the endopelvic fascia to the arcus tendineus fascia pelvis (ATFP)
– Combined defects
ASSOCIATED CONDITIONS
• Multicompartment POP
– Always suspect concomitant apical prolapse in the setting of stage ≥3 cystocele
• Storage symptoms/signs: Stress UI, urinary urgency, urgency urinary incontinence (UI)
• Voiding symptoms/signs: Weak urinary stream, urinary hesitancy, elevated postvoid residual (PVR) urine, bladder outlet obstruction, urinary retention
GENERAL PREVENTION
• Reduction of modifiable risk factors
• Additional studies examining the role of prophylactic vaginal support at the time of pelvic surgery (eg, hysterectomy) are needed
DIAGNOSIS
HISTORY
• Symptoms/signs: Pelvic pressure, vaginal pressure, sensation of a vaginal bulge, stress/urgency/ overflow UI, obstructive voiding symptoms, recurrent urinary tract infections (UTIs)
• Previous pelvic/vaginal surgical procedures
• Hormonal status
• Obstetric history
• Comorbidities
PHYSICAL EXAM
• Assessment of POP should be performed during a Valsalva maneuver
• Leading edge of POP should be used for staging purposes
• Examining a patient in a standing position may help determine the maximum extent of POP
• Assessment of the anterior compartment should be performed with support of the apical and posterior compartment to ensure the elimination of potentially distracting apical and posterior POP
• Baden-Walker grading system:
– Grade 0: No POP
– Grade 1: Leading edge descends halfway to the hymen
– Grade 2: Leading edge descends to the hymen
– Grade 3: Leading edge descends halfway past the hymen
– Grade 4: Procidentia or vault eversion
• POP-Q staging system:
– POP described using 9 reference measurements, including 2 measurements specific to the anterior vaginal wall
Aa: Distal anterior vaginal wall
Ba: Proximal anterior vaginal wall
– Stage 0: No POP
– Stage 1: Leading edge is >1 cm above the hymen
– Stage 2: Leading edge is between 1 cm above and 1 cm below the hymen (-1, 0, +1)
– Stage 3: Leading edge is >1 cm below the hymen but less than total vaginal length – 2 cm (TVL – 2 cm)
– Stage 4: Leading edge is below hymen by more than TVL – 2 cm
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• No lab testing is required for the diagnosis of a cystocele
• Urinalysis and urine culture as indicated
Imaging
• No imaging is required for the diagnosis or management of a cystocele
• A cystocele may inadvertently be detected on imaging studies, such as a cystogram
• Dynamic magnetic resonance imaging (MRI) with contrast:
– Examines pelvic structures in relation to one another during a Valsalva maneuver
– Aids in differentiation between a cystocele and an enterocele
– Aids in assessment of multicompartment POP
Diagnostic Procedures/Surgery
• Pelvic exam
– Employ standardized staging system (POP-Q or Baden-Walker)
• PVR assessment
• Urodynamics
– Only indicated to characterize associated storage and voiding symptoms/signs
Pathologic Findings
N/A
DIFFERENTIAL DIAGNOSIS
• Cystocele
• Enterocele
• Anterior vaginal wall masses: Urethral diverticulum, Skene gland cyst, epidermal inclusion cyst, leiomyoma, ectopic ureterocele, Bartholin duct cyst, Gartner duct cyst
TREATMENT
GENERAL MEASURES
• Observation
• Pelvic floor exercises (Kegel exercises) (4)[B]
• Vaginal pessary
• Surgical repair
MEDICATION
First Line
There are no data to support systemic or topical estrogen or other medications as a therapy for the treatment of cystocele.
Second Line
N/A
SURGERY/OTHER PROCEDURES
• Preoperative preparation:
– Optional hormone replacement with topical estrogen
• Perioperative factors:
– Single dose of preoperative antibiotics
– DVT prophylaxis with sequential compression devices
– Optional vaginal packing
– Optional temporary urethral catheterization
Consider in the setting of a multicompartment repair with or without an anti-incontinence procedure
• Transvaginal vs. transabdominal repair:
– Transvaginal repair:
Central defect repair: Plication of pubocervical fascia in the midline with horizontal mattress sutures
Lateral defect repair: Reattachment of the endopelvic fascia to the ATFP
Transvaginal mesh grafts provide a superior anatomic outcome but are associated with higher complication rates (5)[A]
– Transabdominal repair:
Only repair lateral defects
• Closure of the vagina (colpocleisis):
– Excellent option for geriatric women who no longer desire the ability to maintain sexual activity
• Perform a simultaneous repair of all POP defects and an anti-incontinence procedure for demonstrable stress UI
• Consider a prophylactic concomitant anti-incontinence procedure in patients with stage ≥3 cystocele and/or history of stress UI
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
• Observation:
– Appropriate if a patient is not symptomatic
• Pelvic floor exercises (Kegel exercises) (4)[B]
• Vaginal pessary:
– Good option for poor surgical candidates
– May be used as a temporary solution
– Risk of vaginal discharge, vaginal ulceration, vesicovaginal and rectovaginal fistula formation
Complementary & Alternative Therapies
N/A
ONGOING CARE
PROGNOSIS
• Recurrence rates as high as 30–70%
• Close to 30% of women will require reoperation for symptomatic POP (1)
COMPLICATIONS
• Bladder injury
• Ureteral injury/obstruction
• Bleeding
• Dyspareunia
• de novo stress UI
• Recurrent cystocele
FOLLOW-UP
Patient Monitoring
Evaluation for recurrent POP should largely be based on symptoms or clinical signs (elevated PVR, urinary retention, recurrent UTIs)
Patient Resources
• American Urogynecologic Society. http://www.voicesforpfd.org/p/cm/ld/fid=6
• International Urogynecological Association. www.iuga.org/resource/resmgr/Brochures/eng_pop.pdf
REFERENCES
1. Olsen AL, Smith VJ, Bergstrom JO, et al. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol. 1997;89:501–506.
2. Swift SE. The distribution of pelvic organ support in a population of female subjects seen for routine gynecologic healthcare. Am J Obstet Gynecol. 2000;183:277–285.
3. Nygaard I, Barber MD, Burgio KL, et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA. 2008;300:1311–1316.
4. Braekken IH, Majida M, Engh ME, et al. Can pelvic floor muscle training reverse pelvic organ prolapse and reduce prolapse symptoms? An assessor-blinded, randomized, controlled trial. Am J Obstet Gynecol. 2010;203:e1–e7.
5. Altman D, Väyrynen T, Engh ME, et al. Anterior colporrhaphy versus transvaginal mesh for pelvic-organ prolapse. N Engl J Med. 2011;364:1826–1836.
ADDITIONAL READING
• Chow D, Rodriguez LV. Epidemiology and prevalence of pelvic organ prolapse. Curr Opin Urol. 2013;23:293–298.
• Walters MD. Surgical correction of anterior vaginal wall prolapse. In: Walters MD, Karram MM, eds. Urogynecology and Reconstructive Pelvic Surgery, 3rd ed. Philadelphia, PA: Mosby Elsevier; 2007.
See Also (Topic, Algorithm, Media)
• Baden-Walker Staging
• Cystocele, Grading
• Cystocoele Enterocele Algorithm 
• Cystocele Image 
• Pelvic Organ Prolapse (Cystocele and Enterocoele)
• Pelvic Organ Prolapse Quantification System (POP-Q)
• Rectocele, Urologic Considerations
• Vaginal Mesh Erosion
• Vaginal Pessaries, Urologic Considerations
• Vaginal Prolapse
CODES
ICD9
• 618.01 Cystocele, midline
• 618.02 Cystocele, lateral
ICD10
• N81.10 Cystocele, unspecified
• N81.11 Cystocele, midline
• N81.12 Cystocele, lateral
CLINICAL/SURGICAL PEARLS
• Management of a cystocele should largely be based on patient preference and symptoms.
• Always suspect concomitant apical prolapse in the setting of stage ≥3 cystocele or a recurrent cystocele.
• Mesh grafts for cystocele repair provide a superior anatomic outcome but they are associated with higher complication rates.