Are you a woman experiencing discomfort or a bulging in the vaginal area, problems with urination and/or painful intercourse? Then perhaps your bladder has shifted out of its normal position. Read on to learn more about bladder and pelvic organ prolapse and what treatments are available.

Urologists Dr. Koushik Shaw and Dr. Lawrence Tsai (Dr. Law) team up with Dr. George Shashoua, a well respected Austin Uro-Gynecologist, to provide the ONLY Austin and Central Texas team to work under one roof to provide the best of two specialties to achieve optimum results. We are one of the few teams in Austin to offer comprehensive da Vinci Robotic repair of bladder prolapse, cystocele, rectocele, and robotic sacrocolpopexy (re-suspension of pelvic organs). Over the last seven years, We have had the opportunity to help many women with this condition. Bladder prolapse, or cystocele, can affect a woman in several ways. This can include discomfort with intercourse, general pelvic discomfort that worsens with exercise or as the day wears on, embarrassing social leakage, and weight gain due to exercise avoidance, to mention a few. Not to be underestimated, many Austin women return to say that repair of their bladder prolapse was the best thing they ever did for their quality of life.

Bladder Prolapse (Cystocele) Information

What is pelvic organ prolapse?

Under normal conditions in women, the bladder is held in position by a “hammock” of supportive pelvic floor under normal conditions in women, the pelvic organs (the bladder, uterus and rectum) are held in position by a “hammock” of supportive pelvic floor muscles and ligaments. When these muscles and tissues are stretched and/or weakened, one or more of the pelvic organs can sag through this supportive layer of muscles and ligaments and into the vagina, resulting in pelvic organ prolapse. With more advanced cases of prolapse, the bulge may be felt at the vaginal opening and can extend or “drop” to the outside of the vagina. Prolapse can be asymptomatic or can be very bothersome, associated with problems emptying the bladder, urinary tract infections or incontinence (unwanted loss of urine), pelvic pain, or incomplete defecation.

What causes pelvic organ prolapse?

Prolapse can develop for a variety of reasons, but the most significant contributing factor is stress on this supportive “hammock” during childbirth. Women who have multiple pregnancies or deliver vaginally are at higher risk. Other factors that can lead to prolapse include: age, genetics, chronic constipation, dramatic weight changes, menopause (when estrogen levels start to drop) and previous pelvic surgery.

What are the symptoms for pelvic organ prolapse?

Symptoms of pelvic organ prolapse depend on the organ that is prolapsing. One can have a prolapse of the bladder (cystocele), the rectum (rectocele), the uterus (uterine prolapse), or the small intestine (enterocele). Often, if prolapse is present, it is present for all the pelvic organs mentioned. Cystocele often causes:

  • Frequent urination
  • Urinary urgency or urinary leakage with urgency (trouble making it to the bathroom in time)
  • Stress incontinence – leakage with movement, typically when you exercise, cough, laugh, or sneeze
  • A sensation of incomplete bladder emptying or the need to push, strain or reposition to empty the bladder
  • Frequent urinary tract infections, often from poor bladder emptying
  • Discomfort or pain in the vagina, pelvis, lower abdomen, groin or lower back
  • Heaviness or pressure in the vaginal area
  • Painful intercourse (dyspareunia)
  • Tissue protruding from the vagina (feeling of a bulge or “ball” in the vagina)

Rectocele often causes:

  • Chronic constipation or a need to strain for bowel movements. A rectocele may also develop from chronic straining over time
  • Pelvic pressure or heaviness
  • The need to reduce the vaginal bulge to assist with bowel movements (vaginal splinting)
  • A feeling of incomplete defecation
  • Vaginal looseness with intercourse due to vaginal relaxation
  • If there is also a defect in the anal sphincter (from a tear in delivery or other injury), fecal incontinence may occur

Uterine prolapse often causes:

  • Pelvic pressure or heaviness
  • Painful intercourse
  • As the uterus drops, one may also experience lower back pain
  • A protrusion of the cervix or uterus outside of the vagina, with more advanced prolapse

Enterocele often causes:

  • Symptoms of an enterocele are often worse at the end of the day or after heavy lifting
  • Pelvic pressure or heaviness
  • Painful intercourse
  • Lower back or pelvic pain
  • Mild cases of prolapse may not cause any symptoms and can be monitored over time

How is prolapse diagnosed?

Prolapse is diagnosed by a pelvic examination, along with the patient’s person history of her symptoms. Imaging studies (such as a CAT scan or MRI) and other tests may be performed to rule out problems in other parts of the body and urinary system. Additionally, we may perform urodynamics or cystoscopy to further evaluate the bladder. Urodynamics is a test we perform in our clinic that measures pressures in the urethra and bladder, as well as bladder function to give us a better idea of what the problem is and how to best treat it. Cystoscopy is also performed in the office. For a cystoscopy, a small scope is passed through the urethra and into the bladder to assess the inner lining of the bladder. This is similar to having a catheter placed, with a camera on the end.

What are the treatment options for prolapse?

Pelvic floor physical therapy – For mild prolapse cases, behavior therapies such as Kegel exercises (which help strengthen pelvic floor muscles) or seeing a pelvic floor physical therapist may alleviate symptoms and help to stop or slow the progression of the prolapse. Vaginal estrogen can sometimes help with mild symptoms as well. While these treatments do not fix the physical prolapse, they can help if you are having mild-moderate symptoms.

Surgery – Surgery is usually the treatment of choice for more advanced or more symptomatic cases. Prolapse surgeries are done to restore the anatomy of the vagina to its pre-prolapse state. There are several types of surgical prolapse repairs; the type recommended is based on each individual’s symptoms and exam findings. In the case of small but symptomatic prolapse, a colporrhaphy or simple suture repair may be done to lift the bulging structures. This is also known as an anterior and posterior repair. With larger prolapses, the surgery of choice is often a vaginal mesh repair, uterosacral colpopexy or a sacrocolpopexy (done with the da Vinci robot or through an abdominal incision). These surgeries have seen significant advances in the last several years, with the utilization of mesh for extra and longer lasting support. The mesh used is similar to the mesh used to fix hernias. Vaginal mesh is thinner and lighter weight than hernia mesh and is designed specifically to be placed in this area. If stress urinary incontinence is also present, this is usually treated in the same setting by placement of a mid-urethral sling. Prolapse repairs whether done vaginally or abdominally typically include a one night stay in the hospital. Patients will often take 2 weeks of from work and are able to resume most daily activities after that time. All activities can be resumed after 6 weeks, including intercourse and more strenuous exercise. The recovery is the same if a sling is also performed. Pessary – A pessary is a donut shaped vaginal support device that is inserted into the vagina to lift the prolapsed organ(s). This is left in the vagina and removed and cleaned every 3 months. This is an alternative to surgery if your symptoms are severe and you are not a surgical candidate (for other medical reasons), or if you do not want to undergo surgery. For surgery or pessary candidates, we may refer you to see Dr. George Shashoua who is a urogynecologist, board certified in Female Pelvic Medicine and Reconstructive Surgery. Dr. Shashoua is located within our practice, which allows for an ease of continuity of care for our patients.

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