Cystocele

The symptoms of a cystocele may include: • a vaginal bulge • the feeling that something is falling out of the vagina • the sensation of pelvic heaviness or fullness • difficulty starting a urine stream • a feeling of incomplete urination • frequent or urgent urination • fecal incontinence • frequent urinary tract infections • back and pelvic pain • fatigue • painful sexual intercourse • bleeding A bladder that has dropped from its normal position and into the vagina can cause some forms of incontinence and incomplete emptying of the bladder. Complications Complications may include urinary retention, recurring urinary tract infections and incontinence. The anterior vaginal wall may protrude though the vaginal introitus (opening). This can interfere with sexual activity. Recurrent urinary tract infections are common for those who have urinary retention. In addition, though cystocele can be treated, some treatments may not alleviate troubling symptoms, and further treatment may need to be performed. Cystoceles may affect the quality of life; women who have cystoceles tend to avoid leaving their homes and avoid social situations. The resulting incontinence puts women at risk of being placed in a nursing home or long-term care facility. == Cause ==

A cystocele occurs when the muscles, fascia, tendons and connective tissues between a woman's bladder and vagina weaken, or detach. The type of cystocele that can develop can be due to one, two or three vaginal wall attachment failures: the midline defect, the paravaginal defect, and the transverse defect. The midline defect is a cystocele caused by the overstretching of the vaginal wall; the paravaginal defect is the separation of the vaginal connective tissue at the arcus tendineus fascia pelvis; the transverse defect is when the pubocervical fascia becomes detached from the top (apex) of the vagina. Muscle injuries have been identified in women with cystocele. These injuries are more likely to occur in women who have given birth than those who have not. These muscular injuries result in less support to the anterior vaginal wall. Some women with connective tissue disorders are predisposed to developing anterior vaginal wall collapse. Up to one third of women with Marfan syndrome have a history of vaginal wall collapse. Ehlers-Danlos syndrome in women is associated with a rate of 3 out of 4. • exercising incorrectly • ethnicity (risk is greater for Hispanic and whites) • hypoestrogenism • pelvic floor trauma • connective tissue disorders • spina bifida • childbirth; correlates to the number of births • forceps delivery • age • chronically high intra-abdominal pressures • chronic obstructive pulmonary disease • constipation • obesity Connective tissue disorders predispose women to developing cystocele and other pelvic organ prolapses. The tissues tensile strength of the vaginal wall decreases when the structure of the collagen fibers change and become weaker. == Diagnosis ==

There are two types of cystocele. The first is distension. This is thought to be due to the overstretching of the vaginal wall and is most often associated with aging, menopause and vaginal delivery. It can be observed when the rugae are less visible or absent. The second type is displacement. Displacement is the detachment or abnormal elongation of supportive tissue. If a woman has difficulty emptying her bladder, the clinician may measure the amount of urine left in the woman's bladder after she urinates called the postvoid residual. This is measured by ultrasound. A voiding cystourethrogram involves taking X-rays of the bladder during urination. This X-ray shows the shape of the bladder and lets the doctor see any problems that might block the normal flow of urine. Grading Several scales exist to grade the severity of a cystocele. The pelvic organ prolapse quantification (POP-Q) assessment, developed in 1996, quantifies the descent of the cystocele into the vagina. Classifications Cystoceles can be further described as being apical, medial, or lateral. Apical cystocele is located upper third of the vagina. The structures involved are the endopelvic fascia and ligaments. The cardinal ligaments and the uterosacral ligaments suspend the upper vaginal-dome. The cystocele in this region of the vagina is thought to be due to a cardinal ligament defect. Medial cystocele forms in the mid-vagina and is related to a defect in the suspension provided by a sagittal suspension system defect in the uterosacral ligaments and pubocervical fascia. The pubocervical fascia may thin or tear and create the cystocele. An aid in diagnosis is the creation of a 'shiny' spot on the epithelium of the vagina. This defect can be assessed by MRI. Lateral cystocele forms when the pelviperineal muscle and its ligamentous–fascial develop a defect. The ligamentous– fascial creates a 'hammock-like' suspension and support for the lateral sides of the vagina. Defects in this lateral support system result in a lack of bladder support. Cystocele that develops laterally is associated with an anatomic imbalance between anterior vaginal wall and the arcus tendineus fasciae pelvis – the essential ligament structure. == Prevention ==

Cystocele may be mild enough not to result in symptoms that are troubling to a woman. In this case, steps to prevent it from worsening include: • smoking cessation • losing weight • pelvic floor strengthening • treatment of a chronic cough • maintaining healthy bowel habits • eating high fiber foods • avoiding constipation and straining ==Treatment==

Treatment options range from no treatment for a mild cystocele to surgery for a more extensive cystocele. Treatment can consist of a combination of non-surgical and surgical management. Treatment choice is also related to age, desire to have children, severity of impairment, desire to continue sexual intercourse, and other diseases that a woman may have. There are sometimes complications with the use of a pessary. Another review on the surgical management of cystocele describes a more successful treatment that more strongly attaches the ligaments and fascia to the vagina to lift and stabilize it. Post-surgical complications can develop. The complications following surgical treatment of cystocele are: • side effects or reactions to anesthesia • bleeding • infection • painful intercourse • Urinary incontinence • constipation • bladder injuries • urethral injuries • urinary tract infection. Recurrent surgery on the pelvic organs may not be due to a failure of the surgery to correct the cystocele. Subsequent surgeries can be directly or indirectly related to the primary surgery. == Epidemiology ==

A large study found a rate of 29% over a woman's lifetime. Other studies indicate a recurrence rate as low as 3%. == History ==

Notable is the mention of cystoceles in many older cultures and locations. Hippocrates thought that recent childbirth, wet feet, 'sexual excesses', exertion, and fatigue may have contributed to prolapse. Polybus, Hippocrates's son-in-law, wrote: "a prolapsed uterus was treated by using local astringent lotions, a natural sponge packed into the vagina, or placement of half a pomegranate in the vagina." In 350 A.D., another practitioner named Soranus described his treatments, which stated that the pomegranate should be dipped into vinegar before insertion. Success could be enhanced if the woman were on bed rest and had reduced food and fluid intake. If the treatment was still not successful, the woman's legs were tied together for three days. In 1521, Berengario da Carpi performed the first surgical treatment for prolapse. This was to tie a rope around the prolapse, tighten it for two days until it was no longer viable, and cut it off. Wine, aloe, and honey were then applied to the stump. In the 1700s, a Swiss gynecologist, Peyer, published a description of a cystocele. He was able to describe and document both cystoceles and uterine prolapse. In 1730, Halder associated cystocele with childbirth. During this same time, efforts began to standardize the terminology that is still familiar today. In the 1800s, the surgical advancements of anesthesia, suturing, suturing materials, and acceptance of Joseph Lister's theories of antisepsis improved outcomes for women with cystocele. The first surgical techniques were practiced on female cadavers. In 1823, Geradin proposed that an incision and resection may provide treatment. In 1830, the first dissection of the vagina was performed by Dieffenbach on a living woman. In 1834, Mendé proposed that dissecting and repairing the edges of the tissues could be done. In 1859, Huguier proposed that the amputation of the cervix was going to solve the problem of elongation. In 1866, a method of correcting a cystocele was proposed that resembled current procedures. Sim subsequently developed another procedure that did not require the full-thickness dissection of the vaginal wall. In 1888, another method of treating anterior vaginal wall Manchester combined an anterior vaginal wall repair with an amputation of the cervix and a perineorrhaphy. In 1909, White noted the high rate of recurrence of cystocele repair. At this time it was proposed that reattaching the vagina to support structures was more successful and resulted in less recurrence. This same proposal was proposed again in 1976, but further studies indicated that the recurrence rate was not better. In 1888, treatments were tried that entered the abdomen to make reattachments. Some did not agree with this and suggested an approach through the inguinal canal. In 1898, further abdominal approaches were proposed. No further advances have been noted until 1961 when reattachment of the anterior vaginal wall to Cooper's ligament began to be used. Unfortunately, posterior vaginal wall prolapse occurred in some patients even though the anterior repair was successful. In 1955, using mesh to support pelvic structures became common. In 1970, tissue from pigs began to be used to strengthen the anterior vaginal wall in surgery. Beginning in 1976, improvement in suturing began along with the surgical removal of the vagina being used to treat prolapse of the bladder. In 1991, assumptions about the detailed anatomy of the pelvic support structures began to be questioned regarding the existence of some pelvic structures and the non-existence of others. More recently, stem cells and robot-assisted laparoscopic surgery have been used to treat cystoceles. == Cystocele in animals ==

In cows, cystocele is a complicated case of vaginal prolapse, occurring before calving. Urinary bladder must be emptied by punction before replacment of genital organs. Forboutaedje vexheye kimince vudaedje.jpg|recent case, emptying with one needle Forboutaedje vexheye mitan vudeye.jpg|same, after partial emptying Forboutaedje vexheye coraedje xhlé troes aweyes.jpg|one-day-old case, being emptied with 3 needles Forboutaedje vexheye vatche.webm|video with two previous cases == See also ==