Cystocele

Specialty: Gynecology and breast.

• Previous vaginal wall prolapse
• descent of the bladder
• vaginal bladder hernia

Why it occurs

• Defect of the pubocervical fascia due to tears during vaginal delivery
• Chronic constipation and abdominal hyperpressure
• Menopausal hypoestrogenism
• Aging and constitutional laxity of the connective tissue
• Previous pelvic surgeries (such as previous hysterectomy that alters apical support)

Initial workup

Detailed pelvic examination with a single leaflet speculum to evaluate the isolated anterior vaginal wall under Valsalva maneuver. Quantification using the POP-Q system. Ultrasound or catheterization measurement of postvoid residual urine volume (a urine residue greater than 100 mL indicates ineffective bladder emptying). Urodynamic study if surgical correction is planned to rule out occult urinary incontinence.

Standard management

• Conjugated estrogens or topical vaginal estriol in cream to improve the elasticity and trophism of the anterior vaginal mucosa. The definitive treatment of severe symptomatic cystoceles (grades III and IV) is surgical (anterior colporrhaphy or repair of the pubocervical fascia) or the placement of a vaginal pessary in patients who are not candidates for surgery (note: training of the pelvic floor muscles through guided Kegel exercises is effective in slowing down progression in early stages).