Cystocele (Bladder Prolapse)

Overview

A cystocele, also called bladder prolapse or anterior vaginal wall prolapse, occurs when the supportive tissue between the bladder and vaginal wall weakens, allowing the bladder to drop and bulge into the vagina. This condition is a type of pelvic organ prolapse and can range from mild cases that cause no symptoms to severe prolapse where the bladder protrudes outside the vaginal opening.

Under normal anatomy, the bladder sits in front of the vagina, supported by pelvic floor muscles, ligaments, and fascia that form a hammock of support. When these tissues weaken or tear, the bladder herniates into the vaginal space, causing the vaginal wall to bulge inward. Up to 50% of women who have given birth vaginally have some degree of prolapse, though only 10-20% experience bothersome symptoms. The condition often goes unreported due to embarrassment, despite being both common and treatable.

Doctors grade cystocele severity using the POP-Q staging system. Stage 1 represents mild prolapse where the bladder drops less than 1 cm into the vagina and usually causes no symptoms. Stage 2 involves moderate prolapse reaching approximately the level of the vaginal opening. Stage 3 indicates significant prolapse with the bladder protruding past the vaginal opening. Stage 4 represents complete prolapse with maximum descent and the bladder fully outside the vaginal opening.

Symptoms

Many women with mild cystocele experience no symptoms, and the condition may be discovered incidentally during a routine pelvic examination. When symptoms do occur, they typically worsen with standing, walking, or lifting and improve when lying down.

The most characteristic symptom is a sensation of vaginal bulge or pressure, often described as feeling like something is falling out. Women may notice a visible or palpable bulge at the vaginal opening or feel as though they are sitting on a ball. Pelvic heaviness and aching pressure are common complaints.

Urinary symptoms frequently accompany cystocele. Many women experience difficulty completely emptying the bladder and may need to change position or manually support the vaginal wall to urinate. Stress urinary incontinence—leaking urine with coughing, sneezing, or exercise—often coexists with prolapse. Other urinary symptoms include frequent urination, urgency, slow urinary stream, and recurrent urinary tract infections.

Sexual symptoms may include discomfort during intercourse, a feeling of looseness, or reduced satisfaction. Because cystocele often occurs alongside rectocele (prolapse of the rectum into the vagina), some women also experience difficulty with bowel movements.

Causes

Vaginal childbirth is the primary cause of cystocele. Delivery stretches and can damage the pelvic floor muscles and connective tissues that support the bladder. Risk increases with multiple deliveries, large babies, prolonged pushing, and forceps or vacuum-assisted delivery. While cesarean delivery reduces the risk, it does not eliminate it entirely.

Menopause and estrogen loss significantly contribute to cystocele development. Estrogen maintains the strength and elasticity of pelvic tissues, and the decline that occurs after menopause accelerates tissue deterioration. This explains why prolapse symptoms often worsen or first appear in the postmenopausal years. Atrophic vaginitis frequently accompanies prolapse in postmenopausal women and can worsen symptoms.

Chronic straining places repeated pressure on the pelvic floor and weakens supporting structures over time. Constipation requiring frequent straining is a major risk factor, as is chronic coughing from conditions like COPD, asthma, or smoking. Occupational or recreational heavy lifting also contributes through repeated Valsalva maneuvers.

Other risk factors include obesity, which increases pressure on the pelvic floor; genetic predisposition and family history of prolapse; connective tissue disorders such as Ehlers-Danlos syndrome; prior pelvic surgery including hysterectomy; and the natural tissue weakening that occurs with aging.

Diagnosis

Diagnosis begins with a thorough medical history covering symptoms, childbirth history, and the impact on quality of life. The doctor will ask about bladder and bowel function, sexual symptoms, and what activities worsen or improve the prolapse.

Pelvic examination is the cornerstone of diagnosis. The doctor examines the patient both lying down and standing, asking her to strain or cough to demonstrate the prolapse at its maximum extent. The examination assesses the grade of prolapse, which structures are involved (anterior, posterior, or apical), and the quality of the vaginal tissues.

The POP-Q examination provides standardized measurements of prolapse by measuring specific anatomical points relative to the hymen. This creates reproducible staging that can track changes over time.

Additional testing may include measuring post-void residual urine volume to check for urinary retention, urodynamic studies if incontinence or retention is present, and occasionally MRI for complex cases requiring detailed anatomical assessment.

Treatment

Treatment depends on the severity of symptoms and the patient’s preferences and overall health. Many women with mild to moderate cystocele manage successfully with conservative measures.

Pelvic Floor Exercises. Kegel exercises strengthen the pelvic floor muscles and can improve support for the bladder. These exercises must be performed correctly and consistently to be effective, and many women benefit from guidance by a pelvic floor physiotherapist. Pelvic floor dysfunction often contributes to prolapse symptoms, and targeted physical therapy can address muscle weakness and coordination problems.

Lifestyle Modifications. Treating and preventing constipation reduces straining that worsens prolapse. Avoiding heavy lifting, losing weight if overweight, quitting smoking, and managing chronic cough all help reduce pressure on the pelvic floor.

Vaginal Estrogen. For postmenopausal women, topical estrogen in the form of cream, tablet, or ring improves tissue quality and elasticity. It also helps women tolerate pessary use and can reduce urinary symptoms associated with atrophic vaginitis.

Pessary. A pessary is a silicone or plastic device inserted into the vagina to support the prolapsed bladder. Available in various shapes including ring, Gellhorn, and donut configurations, pessaries are fitted by a healthcare provider. They offer an effective nonsurgical option, particularly for women who cannot undergo surgery or prefer to avoid it. Pessaries require regular removal and cleaning, may need refitting over time, and can occasionally cause discharge or vaginal ulceration.

Surgical Treatment. Surgery may be considered when conservative measures fail, symptoms significantly affect quality of life, and the patient is a suitable surgical candidate. Anterior colporrhaphy, the traditional native tissue repair, uses a vaginal approach to fold and strengthen the weakened tissue supporting the bladder. This procedure has good success rates and avoids mesh-related complications.

Transvaginal mesh for prolapse repair has been largely discontinued due to high complication rates including erosion and pain, leading to FDA actions and manufacturer withdrawals. Sacrocolpopexy, performed through an abdominal approach (open, laparoscopic, or robotic), uses mesh to attach the vaginal apex to the sacrum and remains an option for selected cases, particularly for vault prolapse. Obliterative surgery, which closes the vaginal canal, offers very effective prolapse relief for women who do not wish to preserve vaginal function.

Because cystocele repair alone may unmask hidden stress incontinence, the surgeon may recommend a concurrent incontinence procedure based on preoperative assessment.

When to See a Doctor

Seek medical evaluation if you notice a vaginal bulge, feel pressure or heaviness in the pelvis, or experience difficulty emptying your bladder. While cystocele is not a medical emergency, symptoms typically worsen over time without treatment.

Seek prompt care if you are unable to urinate, experience severe pelvic discomfort, notice vaginal ulceration or bleeding, or find that a prolapsed bulge cannot be pushed back into position.

After surgical repair, follow your surgeon’s instructions regarding activity restrictions, which typically include avoiding heavy lifting for 6-12 weeks and pelvic rest for 6-8 weeks. Recurrence rates range from 10-30%, so continuing pelvic floor exercises and lifestyle modifications remains important for long-term success.

Many women with cystocele manage well with conservative care, and surgery is effective when needed. If you are experiencing symptoms, do not hesitate to discuss them with your healthcare provider—effective treatments are available, and you do not need to suffer in silence.