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Cystocele Repair

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Treatment Options:
Surgical Treatment  

Title:
Cystocele Repair

Description:

Introduction

Weakness in the top of the vagina can lead to a cystocele. Cystoceles are essentially hernias in the top (anterior) part of the vagina that allow the bladder to protrude into the vaginal opening. The protrusion of the bladder into the vagina can be minor and unrecongnized by the patient or completely protrude from the vaginal opening (introitus).  There are two scales to grade the severity of bladder prolapse.  The Baden-Walker scale grades cystoceles from Grade I to Grade IV. Grade I prolapse is a minor protrusion into the vagina usually only identified with valsalva maneuvers (bearing down on the bladder). Grade IV prolapse is rare and describes a bladder protrusion that is outside of the vagina at rest. The other grading system is the POP-Q scale. This system is much more descriptive and requries measurement of the protrusion. POP-Q grading is often used preferentially in studies on prolapse surgery. Some clinicians are careful to assign the cystocele to either the central or lateral type of defect. Lateral defects occur with a separation of the vaginal wall strength tissue that is under the bladder from the pelvic sidewall.  This most often seen following childbirth.  Central cystocele defects usually are weaknesses in the vaginal support tissue allowing the bladder to sag into the vagina in the midline.

Symptoms

Symptoms related to a cystocele vary.  Some pateints experience no symptoms related to the prolapse.  The most common symptom is the ability of the patient to feel the prolapse.  Sometimes this will lead to pelvic pressure and pain.  Occasionally the patient can experience pain during intercourse.  Urinary symptoms may occur with a cystocele.  Difficulty with emptying is seen in patients with more prominent cystoceles.  This could lead to recurrent urinary tract infections.  Urinary frequency, urinary urgency and urge incontinence are often attributed to bladder prolapse though many patients experience these symptoms without a cystocele.  Stress incontinence often is occurs with a cystocele but there is debate whether the cystocele causes the leakage. Some surgeons will attempt to correct the leakage with a cystocele repair.

Etiology

Prior vaginal delivery appears to contribute significantly to the development of bladder prolapse. Traumatic deliveries, longer labor and foceps delivery may contribute to eventual development of a cystocele.  There is excellent evidence that genetics may play a part in the development of vaginal prolapse. Rarely a patient may develop a tear in the vaginal wall with other forms of trauma such a car wreck.

Treatment

There are several options for treatment of cystoceles.  One option is watchful waiting.  Not all patients with a cystocele require surgery.  It is hard to recommend surgery for a patient if the degree of prolapse is small and no symptoms are present. The patient can safely wait for development of symptoms over time. If the patient is not interested in surgery but is symptomatic a pessary could be used to correct the cystocele. A pessary is a plastic device which is inserted into the vagina to push the bladder into position. The pessary rests against the pelvic sidewall to provide the support for the prolapsing vaginal wall. Given the variation in vaginal width and depth, pessaries have to be fitted by a healthcare professional. Correct fitting can be difficult in some patients leading to vaginal erosion or expulsion of the pessary. The most common treatment for cystoceles is surgical correction.

Surgical correction of a cystocele can be very simple or quite complex. Surgery can be performed through the vagina or abdomen but is most often performed transvaginally. Usually the patients vaginal and pelvic tissues are used to provide the new support for the vaginal wall but there has been tremendous interest in using other materials to provide extra support for poor vaginal tissues when correcting a major cystocele.

The most common surgery to correct a cystocele is plication of the anterior vaginal wall tissues. The premise for the procedure is that there is a discreet central defect under the bladder. Sutures are used to approximate the edges of the defect. Often there is excess vaginal wall that has developed from the chronic protrusion. This excess tissue is removed during this procedure. Some surgeons argue that there are very few central defect cystoceles and this procedure should only be used rarely. This procedure requires little time in surgery and this is often a day surgery case.

Occasionally the anterior vaginal wall can be supported by sutures placed in the edges of tissue that has separated from the pelvic sidewall.  Some surgeons will then support the vaginal wall with the abdominal wall by passing the sutures through the strength tissue of the abdomen. The sutures in can also be used to reapproximate the bladder support tissue to the pelvic sidewall.  This is often referred to as a paravaginal defect repair and can be performed through the vagina or through the abdomen. This type of repair is primarily designed to correct a lateral defect.  This is a day surgery procedure in most cases unless an abdominal approach is used.

Mesh or biologic material can be used to augment the cystocele repair. Generally augmentation of the cystocele repair is used when the prolapse is more significant (Grade III or Grade IV) or if the prolapse is recurrent. The mesh most often used is a soft widely pored polypropylene similar to that used in midurethral slings and in abdominal hernia repairs. Biologic materials include human dermis, human fascia lata, porcine (pig) dermis, and sheep intestinal wall collagen. Often this material is shaped to so as to be wide enough to span from pelvic sidewall to pelvic sidewall and from the bladder neck to the apex (deepest point) of the vagina. Sutures are used to connect the augment material to these areas.  Some of the augments come in kit that make the placement of the mesh or biologic material easier.  Usually the augment has arms that are placed through natural openings in the groin (obturator foramen) providing extra support by attaching to tissues in these areas. Given these repairs are more complex, more operative time is required and often the patient will require at least an overnight stay in the hospital.

Possible Complications

Usually cystocele repairs are free of any complications. However there are a few potential issues that can occur with the repair.  As the repair is performed near the bladder and urethra, injury to either could occur.  Grade IV cystoceles can be so prominent that the ureters could be in the surgical field and potentially become injured. Though unlikely there could be injury to nerves deep in the pelvis. If permanent suture is used there can be erosion of the suture into the vaginal wall requiring removal. If mesh is used, there can be extrusion and exposure of the mesh in the vaginal wall requiring excision. Pain in the pelvis and pain with intercourse are possible. If aggressive repair is performed the vagina can be foreshortened or the opening of the vagina can be narrowed. Rarely, patients can develop issues with urinary frequency and urgency and urge incontinence after a cystocele repair.  If the cystocele is prominent and no surgery is performed to prevent leakage with stress (stress incontinence), the patient may develop stress incontinence though not present prior to surgery.  Urinary retention can occur in rare cases and is usually temporary.

Although not a complication, one of the greatest concerns is regarding recurrent prolapse. Despite appropriate and skillful surgical correction of a cystocele the recurrance rates at five years approach 40% in some series.  Additionally, the patient can develop prolapse in other areas of the vagina.  Enteroceles (protrusion of small intestine into the vagina), rectoceles (protrusion of the rectum into the vagina) and vault prolapse (eversion of the apex of the vagina out of the vaginal opening) can develop after cystocele repairs.  These defects are often misdiagnosed as a recurrent cystocele.

Post-Operative Course

Patients are asked to refrain from heavy lifting and straining after a cystocele repair for approximately 4 weeks.  Generally walking in the neighborhood, mall or at work is reasonable if the pace is kept slow.  Lifting up to 15 pounds is acceptable.  Intercourse should be avoided for 6 weeks. Patients are generally sent home with an antibiotic and pain medications. Post-operative visits are set for 2 weeks and 3 months following surgery.  More frequent visits may be required if problems are encountered.

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Dr. Isom-Batz Lectures on the Aged Bladder

Dr. Isom-Batz presented an invited lecture to the Texas Health Resources Presbyterian Dallas Internal Medicine Grand Rounds on bladder dysfunction in elderly patients.  The lecture, which was attended by Internal Medicine residents, faculty and staff, was well received.  If you have questions regarding the evaluation and management of bladder dysfunction please schedule an appointment to see Dr. Isom-Batz.