Cystocele

Definition

• Prolapse of the anterior vaginal wall in which the bladder protrudes into the vagina; if the urethra is also involved, it is called a cystourethrocele.
• A cystocele commonly develops when the pubocervical fascia is weakened.

Classification

Two Defects

• Pulsion cystocele: a central defect with attenuated pubocervical fascia.
• Traction cystocele: a lateral defect with avulsion of the fascia from the arcus tendineus fasciae pelvis.
• Characteristic of a pulsion cystocele in the image: the rugae of the vaginal wall are effaced over the bulge.
• Characteristic of a traction cystocele in the image: the rugae are preserved on the bulging wall.

• In the POP-Q system, points Aa and Ba describe the anterior vaginal wall.
• POP-Q stages range from 0 (no prolapse) through I (most distal point more than 1 cm above the hymen), II (between 1 cm above and 1 cm below) and III (more than 1 cm below but at least 2 cm short of total vaginal length) to IV (complete eversion).
• The older Baden-Walker system, based on the level of protrusion, is considered imprecise and only moderately reproducible and is no longer commonly used.

Occurrence & epidemiology

Epidemiology

• Pelvic organ prolapse is common, but its prevalence is difficult to determine; in a study of 8000 women, 8.3% reported symptomatic prolapse.
• Usually several sites are involved; cystocele, enterocele and rectocele are particularly likely to occur together.

Aetiopathogenesis

Aetiology and pathogenesis

• A common risk factor is the number of vaginal births, particularly with a prolonged second stage of labour, instrumental vaginal birth or a large-for-gestational-age newborn.
• Other factors are obesity, increasing age and chronically raised intra-abdominal pressure from constipation, heavy lifting or chronic respiratory disorders; sacral nerve disorders and connective tissue disorders are less common.

Clinical features

• Typical are pelvic or vaginal fullness, pressure and a sensation of organs falling out; the bulge appears particularly on straining or coughing, and mild prolapse may be asymptomatic.
• Insufficient urethral support may cause stress incontinence, whereas marked prolapse can kink the urethra, improve incontinence symptoms and even lead to urinary retention.
• Prolapse may negatively affect body image and be associated with dyspareunia and sexual dysfunction.

Diagnosis

How to Differentiate on the Examination Chair

• Helpful manoeuvre: lifting the lateral sulci with ring forceps — the traction cystocele disappears.
• Examination condition: the assessment is performed during straining and with a moderately full bladder.
• Honest assessment: the clinical classification is uncertain and has high inter-observer variability.

Typical imaging findings

• Clinical finding: On straining the anterior vaginal wall bulges as a soft, smooth hemisphere to the level of the introitus. No cervix is visible on this structure and the posterior wall stays in place.

• The diagnosis is clinical: the posterior vaginal wall is retracted with a speculum blade and the anterior wall is assessed at rest and on straining.
• Prolapse appears more severe when the examination is done upright or standing rather than supine.
• Occult stress incontinence is urine loss on cough testing with the prolapse reduced in women who do not report incontinence.

Keep learning in the app

Further reading (selection)

1. MSD Manual Professional: Anterior and Posterior Vaginal Wall Prolapse
2. MSD Manual Professional: Overview of Pelvic Organ Prolapse (POP)
3. International Urogynecology consultation chapter 2 committee 3: the clinical evaluation of pelvic organ prolapse including investigations into associated morbidity/pelvic floor dysfunction (Int Urogynecol J 2023, PubMed Central)
4. DocCheck Flexikon, Zystozele

Cross-references