Bladder Prolapse

What is bladder prolapse?

Bladder prolapse, also called a cystocele, is when the bladder drops from its normal position and bulges into the front wall of the vagina. It happens when the muscles and supporting tissues of the pelvic floor, which normally hold the bladder in place, become weakened or stretched.

What are the symptoms of bladder prolapse?

A mild bladder prolapse often causes no symptoms at all, and may only be picked up during an examination for something else, such as cervical screening. When symptoms do occur, they can include:

• a feeling of heaviness, pressure or dragging in the vagina or pelvis, often worse by the end of the day or after standing, lifting or coughing, and better when lying down
• a bulge or lump you can feel or see at or from the vaginal opening
• difficulty fully emptying your bladder, a slow or stop-start flow, or needing to strain to pass urine
• needing to pee more often, or leaking urine when you cough, sneeze or exercise
• frequent urinary tract infections
• discomfort or pain during sex
• difficulty inserting tampons or a menstrual cup
• lower back pain.

Some women find they need to change position on the toilet, or gently press the bulge back, to empty their bladder fully.

What causes bladder prolapse and who is at risk?

Bladder prolapse happens when the pelvic floor muscles and ligaments supporting the bladder weaken or become damaged. The most common cause is pregnancy and vaginal childbirth, particularly after a long or difficult labour, an assisted delivery (forceps or ventouse), or delivering a large baby or multiple babies; the more vaginal births you've had, the higher your risk.

Other things that increase your risk include:

• menopause, when falling oestrogen levels reduce the strength and elasticity of supporting tissue, and ageing generally
• long-term constipation and straining on the toilet
• a persistent cough, for example from smoking or bronchitis
• carrying excess weight (a BMI over 30)
• repeated heavy lifting
• previous pelvic surgery, including a hysterectomy
• a family history of prolapse, or an inherited connective tissue condition such as joint hypermobility syndrome, Marfan syndrome or Ehlers-Danlos syndromes.

Bladder prolapse is common, affecting around half of women to some degree, though not everyone has symptoms. It's also possible to have more than one type of pelvic organ prolapse at the same time, for example alongside a prolapse of the womb, vaginal vault or bowel.

Are there different grades of bladder prolapse?

Bladder prolapse is usually described in 3 grades of severity (some clinicians use a wider 1 to 4 scale for pelvic organ prolapse generally):

• grade 1 (mild): the bladder drops only a short way into the vagina
• grade 2 (moderate): the bladder drops to the vaginal opening, or just outside it
• grade 3 (severe): the bladder bulges noticeably beyond the vaginal opening.

The grade doesn't always match how much a prolapse bothers you day to day; some women with a higher grade have few symptoms, while others with a milder grade find it more disruptive.

How is bladder prolapse diagnosed?

A doctor will ask about your symptoms and medical history, then carry out a pelvic examination, which includes an internal examination of the vagina. You may be examined lying on your side with your knees drawn up, or standing, and may be asked to cough or strain so the doctor can see how the prolapse behaves under pressure. A smooth, tube-shaped instrument called a speculum may be used to see the vaginal walls clearly. You can ask for a chaperone, and for a female doctor if you'd prefer one.

If you have bladder symptoms, you may be referred for further tests, which can include:

• a urine test, to check for infection
• urodynamic testing, which measures how well your bladder holds and releases urine
• cystoscopy, where a thin, lighted tube is passed into the bladder via the urethra to look for any abnormalities
• an ultrasound scan of the pelvis.

How is bladder prolapse treated?

If your prolapse isn't causing symptoms or bothering you, you may not need treatment; you can always revisit this if things change. Treatment otherwise depends on how severe the prolapse is and how much it affects your life.

Self-care and lifestyle

• maintain a healthy weight for you
• eat more fibre and drink plenty of water to avoid constipation, and avoid straining on the toilet
• avoid heavy lifting. If you must lift something, bend your knees, keep the load close to your body, and breathe out as you lift rather than holding your breath
• choose low-impact exercise such as walking, swimming or cycling over high-impact activity like running or jumping, at least until your pelvic floor is stronger
• stop smoking, partly to reduce the chronic cough that can worsen prolapse.

Pelvic floor physiotherapy

Supervised pelvic floor muscle training, ideally with a specialist pelvic health physiotherapist, is usually the first treatment offered and has good evidence behind it.

Technique matters: some women need their pelvic floor muscles strengthened, while others have overactive, tight muscles that need relaxing instead, so assessment before starting an exercise programme is worthwhile. Physiotherapy also covers practical pressure-management skills, such as how to lift, move and exercise without straining the pelvic floor, along with bladder and bowel habit advice.

Daily pelvic floor exercises usually need 8 to 12 weeks of consistent practice before you notice measurable strength gains, though changes to pressure management and daily habits can sometimes ease symptoms sooner. Physiotherapy won't necessarily make a more severe prolapse disappear completely, but it can often reduce symptoms enough that they no longer interfere with daily life.

Certain abdominal exercises, including crunches, sit-ups and some Pilates moves, can increase downward pressure on the pelvic organs and may be worth avoiding or modifying; a physiotherapist can suggest alternatives such as modified planks and controlled pelvic tilts.

Hormonal and device-based treatment

• Vaginal oestrogen, as a cream, tablet or ring, can improve the strength and quality of vaginal tissue, particularly after menopause, and may help if you have recurrent urinary tract infections
• A vaginal pessary, a plastic or silicone device (a ring pessary is the most common type) fitted by a doctor or specialist nurse to support the bladder and vaginal walls. You may need to try a few types or sizes to find a comfortable fit, and it will need regular removal, cleaning and replacement. A pessary doesn't affect fertility and can be used long-term or as a trial before deciding on surgery.

Surgery

Surgery may be considered for a severe prolapse, or if other treatments haven't sufficiently helped. The most common procedure is an anterior repair (colporrhaphy), where a surgeon moves the bladder back into position and tightens the supportive tissue between the bladder and vagina, usually working through the vagina. It's often done as a day case or with a short hospital stay, and recovery to feeling fully better can take anywhere from a few weeks to a few months, depending on the procedure and the individual.

If you may want to become pregnant again in future, it's generally recommended to wait until you've completed your family before having prolapse surgery, since a further vaginal birth can cause the prolapse to return. Surgery isn't always a permanent fix, and a prolapse can recur, sometimes needing further surgery.

When should you see a doctor?

See a GP if you notice a lump in or around your vagina, or any other symptoms of bladder prolapse, particularly if lifestyle changes and pelvic floor exercises aren't helping, or if a chronic cough or constipation is making things worse.

Seek medical assessment more urgently if you have unexplained vaginal bleeding (especially after menopause), sudden or severe symptoms, significant pain, or a bulge that has appeared quickly, since these need to be checked before starting other treatment. Go to the emergency department if you're completely unable to pass urine, as this can lead to infection or kidney damage if not treated promptly.