Prolapsed Bladder

Line drawing indicating the relationship between the kidney, ureters, and bladder

The bladder is a hollow organ in the pelvis that stores urine. The pressure created when the bladder fills with urine is what causes the urge to urinate. During urination, the urine travels from the bladder through the urethra out of the body.

In women, the front wall of the vagina supports the bladder. This wall can weaken or loosen with age. Pregnancy and childbirth as well as pelvic surgery such as a hysterectomy can weaken this part of the vaginal wall, as well.

If it deteriorates enough, the bladder can prolapse, meaning it is no longer supported adequately and descends into the vagina. This may trigger problems such as urinary difficulties, discomfort, and stress incontinence (urine leakage caused by sneezing, coughing, exertion, etc.). Other organs can also prolapse into the vagina, including the uterus, the small intestine, and the rectum (rectocele).

Prolapsed bladders (also called cystoceles or fallen bladders) are separated into four grades based on how far the bladder droops into the vagina.

• Grade 1 (mild): Only a small portion of the bladder droops into the vagina.
• Grade 2 (moderate): The bladder droops enough to be able to reach the opening of the vagina.
• Grade 3 (severe): The bladder protrudes from the body through the vaginal opening.
• Grade 4 (complete): The entire bladder protrudes completely outside the vagina; usually associated with other forms of pelvic organ prolapse (uterine prolapse, rectocele, enterocele).

Prolapsed bladders are commonly associated with menopause. Prior to menopause, the ovaries produce the hormone called estrogen, which helps keep the vaginal tissues strong and healthy. After menopause, the tissues that support the vagina weaken.

Prolapsed bladder is common—approximately 40% of women over 50 years of age will have pelvic organ prolapse, and approximately 10% will require surgery for pelvic organ prolapse and urinary incontinence (leakage of urine).

The first symptom that women with a prolapsed bladder usually notice is a feeling of pressure in the vagina or bladder.

Other symptoms of a prolapsed bladder include the following:

• Discomfort or pain in the pelvis, lower abdomen, and when sitting
• Tissue protruding from the vagina (The tissue may be tender and may bleed.)
• Palpable bulge in the vagina
• Difficulty urinating
• A feeling that the bladder is not empty immediately after urinating (incomplete voiding)
• Stress incontinence (urine leakage during sneezing, coughing, exertion, etc.)
• More frequent bladder infections
• Painful intercourse (dyspareunia)
• Incontinence during intercourse
• Low back pain

Some women may not experience or notice symptoms from a mild (grade 1) prolapsed bladder.

Factors commonly associated with causing a prolapsed bladder are those that weaken the pelvic floor muscles and ligaments that support the bladder, urethra, uterus, and rectum, which can lead to detachment from the ligaments or pelvic bone where the muscles attach:

• Pregnancy and childbirth is the most common cause of a prolapsed bladder. The delivery process is stressful on the vaginal tissues and muscles, which support a woman's bladder.
• Aging can lead to the weakening of the muscles.
• Menopause: Estrogen, a hormone that helps maintain the strength and health of supporting tissues in the vagina, is not produced after menopause.
• Previous pelvic surgery: such as hysterectomy (removal of the uterus)
• Other risk factors that increase the pressure within the abdomen, leading to increased pressure on the pelvic floor muscles include chronic obstructive pulmonary disease (COPD), obesity, constipation, and heavy manual labor (for example, heavy lifting and straining).

Any woman who notices symptoms of a prolapsed bladder should contact her doctor.

A prolapsed bladder is commonly associated with prolapses of other organs within a woman's pelvis. Thus, timely medical care is recommended to evaluate for and to prevent problematic symptoms and complications caused by weakening tissue and muscle in the vagina. Prolapsed organs cannot heal themselves, and may worsen over time.

Several treatments are available to correct a prolapsed bladder.

Bladder prolapse is often treated by urologists and urogynecologists, but physical therapists also treat bladder prolapse.

Physical Exam

An exam of the female genitalia and pelvis is usually required in diagnosing a prolapsed bladder. Seeing the bladder bulging into the vagina on examination is diagnostic. In addition, you will be asked to strain/cough/bear down to determine the extent of the bladder prolapse, as well as determine if you have urinary leakage with increased pressure (stress urinary incontinence).

Voiding Cystourethrogram

For less obvious cases, the doctor may use a voiding cystourethrogram to help with the diagnosis. During the voiding cystourethrogram, a catheter is placed into the bladder through the urethra. The bladder is emptied and then a sterile contrast (dye) is passed through the catheter into the bladder until the bladder is full enough to void. A series of X-ray films then are taken during bladder filling and during urination. These X-ray films help the doctor determine the shape of the bladder and the cause of the urinary difficulty. The doctor may also test or take X-ray films of different parts of the abdomen to rule out other possible causes of discomfort or urinary difficulty.

Nerve Tests

After diagnosis, the doctor may test the nerves, muscles, and the intensity of the urine stream to help decide what type of treatment is appropriate.

Urodynamics

A test called urodynamics or video urodynamics may be performed at the doctor's discretion. Urodynamics measures pressure and volume relationships in the bladder and can also assess the function of the urethra and may be crucial in the decision-making of the urologist/urogynecologist.

Cystoscopy

Cystoscopy (looking into the bladder with a scope) may also be performed to identify treatment options. This test is usually an outpatient office procedure. Cystoscopy has few and usually minor risks and is tolerable for the vast majority of people.

Nonsurgical Treatment

Nonsurgical treatment consists of conservative management and the use of mechanical devices.

• Behavioral therapy and pelvic floor muscle exercise (PFME/Kegel) are conservative therapies for management of bladder prolapse. The goal of conservative treatment is the reduction of symptoms, prevention of worsening pelvic organ prolapse, increased support of the pelvic floor musculature, and avoiding or delaying surgery. Behavioral therapy includes reducing risk factors such as treating constipation, weight loss if obese, and discontinuing smoking if COPD/cough, etc. PFME are muscle exercises to strengthen the pelvic floor muscles. The contractions should be held for two to 10 seconds and should be performed regularly several times per day. A set of 10 sustained contractions for a duration of about 20 minutes should be performed 2-3 times per day. This form of therapy is suitable for mild to moderate pelvic organ prolapse.
• Mechanical devices: Pessaries are more commonly used in individuals who are too sick to have surgery or who refuse surgery. If the vagina is too wide or too short, the pessary may not fit well. Also one must be able to insert and remove the pessary to be able to use it. Studies have shown that if the pessary fits well, more than half of people will continue to use it for at least a year. Complications of a pessary include erosion of the pessary into the vagina, pain in the pelvis, vaginal discharge, stress urinary incontinence, troubles with urination, and bowel movements. The use of a pessary appears to be less costly compared to pelvic floor muscle exercises when a good fit for the pessary can be achieved.

Severe prolapsed bladders that cannot be managed with a pessary and/or behavioral therapy usually require surgery to correct them. There are several different types of surgery depending on the severity of the prolapse and whether or not other organs are affected.

• Prolapsed bladder surgery is usually performed through the vagina, and the goal is to secure the bladder in its correct position.
• The bladder is repaired with an incision in the vaginal wall.
• The prolapsed area is closed and the wall is strengthened. This may be done primarily using one's own tissues or through the use of grafts, which may be biologic (using other tissues) or synthetic (for example, mesh).
• If one has stress urinary incontinence, this is also corrected.
• Depending on the procedure, surgery can be performed while the woman is under general, regional, or local anesthesia. Most women are discharged home on the same day of surgery.
• Various materials have been used to strengthen pelvic weakness associated with prolapsed bladder. A surgeon should explain in detail the risks, benefits, and potential complications of these materials, and he or she should explain the procedure itself before proceeding with the surgery. Complications related to surgery may include bleeding, infection, pain, urinary incontinence, recurrent prolapse, trouble urinating, and injury to the bladder.
• The cost of surgical treatment will vary with the procedure performed, the length of hospitalization, and the presence/absence of other medical conditions.
• After surgery, most women can expect to return to a normal level of activity after 6 weeks.

After surgery, most women can expect to return to a normal level of activity after 6 weeks.

Estrogen replacement therapy may be used to help the body strengthen the muscles in and around the vagina.

• Estrogen replacement therapy may be contraindicated (such as in a people with certain types of cancer or at risk for certain types of cancers). The ovaries stop producing estrogen naturally after menopause, and the muscles of the vagina may weaken as a result.
• In mild cases of prolapsed bladder, estrogen may be prescribed in an attempt to reverse bladder prolapse symptoms, such as vaginal weakening and incontinence. For more severe degrees of prolapse, estrogen replacement therapy may be used along with other types of treatment.
• Estrogen can be administered orally as a pill or topically as a patch or cream. The cream has very little systemic absorption and has a potent effect locally where it is applied.
• Topical administration has less risk than the oral preparations.
• The application of estrogens to the anterior vagina and urethral area may be very helpful in alleviating urinary symptoms, such as urgency and frequency, even in the face of prolapsed bladder.

Physical therapy such as electrical stimulation and biofeedback may be used to help identify and strengthen the muscles in the pelvis, particularly in those individuals who fail to respond to pelvic floor muscle exercises on their own.

• Electrical stimulation: A doctor can apply a probe to targeted muscles within the vagina or on the pelvic floor. The probe is attached to a device that measures and delivers small electrical currents that contract the muscles. These contractions help strengthen the muscles. A less intrusive type of electrical stimulation is available that magnetically stimulates the pudendal nerve from outside the body. This activates the muscles of the pelvic floor and may help treat incontinence.
• Biofeedback: A sensor is used to monitor muscle activity in the vagina and on the pelvic floor. The doctor can recommend exercises that can strengthen these muscles. These exercises may help strengthen the muscles to reverse or relieve some symptoms related to a prolapsed bladder. The sensor can monitor the muscular contractions during the exercises, and the doctor may be able to determine if the targeted muscles would benefit from the exercises.

A woman undergoing treatment should schedule follow-up visits with her doctor to evaluate progress. Pessaries need to be removed and cleaned at regular intervals to prevent infection.

Preventative measures for prolapsed bladder include the following:

• Eat a high-fiber diet and daily intake of plenty of fluids
• Avoid straining during bowel movements, if possible
• Seek treatment for long-term constipation
• Avoid heavy lifting
• Lose weight if obesity is present

A prolapsed bladder is rarely a life-threatening condition. Most cases that are mild can be treated without surgery.

Severe prolapsed bladders can be completely corrected with surgery.

• Urology Care Foundation
• American Urogynecologic Society
• National Association for Continence
• American Urological Association
• National Kidney and Urologic Diseases Information Clearinghouse, Cystocele (Fallen Bladder)
• Projectlink Database, Cystocele Hub
• MedlinePlus, Urinary Incontinence
• American Urological Association, UrologyHealth.org