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Prolapsed Bladder

What is Prolapsed Bladder?

In women, the front wall of the vagina supports the bladder. This front wall can weaken due to age, and stress from vaginal childbirth. When this happens, the bladder can descend down into the vagina and this is called a prolapsed bladder or fallen bladder.

The severity of the prolapse is graded according to how far down it descends into the vagina.

  • Grade 1: There is mild descent of the bladder into the vagina

  • Grade 2: The bladder descends to within 1cm of the level of the vaginal opening

  • Grade 3: The bladder descends by > 1cm below the level of the vaginal opening

  • Grade 4: There is complete protrusion of the bladder out of the vagina

Is the bladder the only organ that can prolapse into the vagina?

No. The vagina consists of a front (anterior) wall, a back (posterior) wall, a roof and an opening at the bottom. A weakness in any of these components can result in prolapse of the related nearby organs into the vagina.

  • Front wall: The bladder sits here and a prolapse here is also called a cystocele.

  • Back wall: The small bowel and rectum are located here and herniations of these organs are called an enterocele or a rectocele respectively.

  • Roof: The uterus (womb) can herniate and this is called a uterine prolapse.

How common is it?

About 30%-40% of women will have some kind of vaginal prolapse in their lifetime. Some may not cause any symptom. It is more common with age and in women after menopause, childbirth or a hysterectomy (surgical removal of the womb). Many women do not seek medical attention and choose to live with it for fear of embarrassment.

What are the symptoms?

Women may describe a dragging sensation or pressure in the vagina. Some can feel a lump protruding out of the vagina. Some describe painful intercourse. Voiding symptoms such as stress urinary incontinence, or difficulty emptying the bladder may be described. If there is a prolapse of the back wall (enterocele or rectocele), bowel symptoms like constipation or difficulty emptying the bowel may be described.

How is it diagnosed?

A physical examination is essential in making a diagnosis. This is always done with care and consideration, in the presence of a female chaperone. You may be asked to bear down to show the prolapse.

A urodynamics study (bladder pressure test) is used to test for any bladder storage or voiding problems. Incontinence can sometimes be masked by a prolapse and you may be asked to cough and bear down to look for leakage with and without the prolapse being pushed back. This will help the surgeon decide whether an incontinence surgery has to be done at the same time as the prolapse surgery.

A cystoscopy (look inside the bladder with a tubelike camera) is sometimes done, especially if the patient also complains of the frequent need to urinate, blood in the urine or bladder pain.

What are the treatments?

Treatment is only indicated if the patient is symptomatic.

Conservative treatments

  • A vaginal pessary may be preferred instead of surgery in some women, especially if the prolapse is mild with minimal symptoms. This is a device that is placed into the vagina to help support the prolapsed organ. It needs to be changed regularly every few months. This may also be appropriate in those who are not sexually active or those who are too frail to have surgery.

  • Lifestyle modifications like losing weight, avoiding heavy impact activities or straining can help prevent the prolapse from worsening.

  • Pelvic floor exercises can help strengthen the muscles of the pelvic floor and can be part of the treatment for mild to moderate prolapse.

  • Oestrogen therapy helps strengthen the muscles and tissues in the vagina and also prevent infection especially if a pessary is used. There are some risks of being on oestrogen therapy and you have to discuss this with your doctor.

Surgical treatments

  • Prolapse repair surgery is usually done under general anaesthesia or spinal anaesthesia.

  • A vaginal incision is made where the defect is and the prolapsed area is repaired and strengthened with stitches. Sometimes, this repair is reinforced with the use of mesh.

  • Some stitches may be placed at the top of the vagina to fix it to strong tissues in the pelvis or the sacrum (bone at the base of the spine).

  • In some cases, a concurrent sling procedure is done to treat stress urinary incontinence.

  • The possible complications are: wound infection, bladder or ureteric (tubes that drain the kidneys to the bladder) injury, buttock pain, mesh erosion, painful intercourse, recurrence of prolapse.

  • A catheter will be inserted to drain the bladder and a pack inserted into the vagina at the end of the case. These stay in for 1 to 2 days.

  • Antibiotics will be given to prevent an infection and if mesh is used, a longer course (1 week) is prescribed.

  • The expected length of stay in the hospital is 2 to 4 days.

  • After the surgery, patients are advised not to do heavy lifting or strenuous activities for 6 weeks.