PANCE Blueprint Genitourinary (5%)

Bladder Prolapse (Cystocele)

Patient will present as → a 45-year-old female complaining of pressure in the pelvis and vagina along with discomfort when straining. She also feels that her bladder hasn't fully emptied after urinating.

A bladder prolapse (cystocele) occurs when the supportive connective tissues separating the bladder and vagina weaken

  • This results in a bulge (prolapse) of the posterior bladder into the anterior vaginal wall (a bladder hernia) + urinary symptoms
  • This can occur after childbirth or after lifting heavy objects for a period of time.
    • A chronic cough can repeatedly strain these connective tissues, leading to a cystocele
    • Obese women are more likely to develop a cystocele.
  • Perceived or discovered BULGE IN THE VAGINA
  • May present with difficulty starting urine stream, feeling of incomplete emptying of bladder, and frequency or urgency of urination
    • May also have leakage of urine (stress incontinence)

Cystocele demonstrating descent of the anterior vaginal wall with a bulge of the bladder into the vagina

Tests for a cystocele include a pelvic exam and urodynamic studies

  • A tissue bulge into the vagina indicates pelvic organ prolapse
  • A urinalysis should be performed on all patients

Those with few or no obvious symptoms typically don't require treatment.

For those with symptoms:

  • Kegel exercises, pelvic floor retraining, behavioral therapies, and weight loss
  • pessaryA pessary can be inserted to provide extra support to these connective tissues and prevent the bladder from prolapsing into the vagina.

If symptoms are very bothersome and not relieved with more conservative measures, surgery may be necessary to strengthen the support underneath the bladder

Question 1
A 48-year old married Caucasian presents to you with a 6-month history of 'feeling a lump down below' and backache. The lump is bigger when she has been on her feet all day. She also complains of poor urinary stream and a feeling of incomplete emptying of her bladder. She admits to no urinary incontinence or bowel symptoms. She had a total abdominal hysterectomy (TAH) 4 years ago for menorrhagia. She has two children who were delivered vaginally. The most likely diagnosis is
Presents with bowels symptoms as well as 'Feeling a lump down below'.
Uterine prolapse
She has had TAH, but vault prolapse would present with a 'feeling a lump down below' and not urinary symptoms.
Cervical polyp
May present with vaginal discharge and bleeding, but not urinary symptoms.
Question 1 Explanation: 
'Feeling a lump down below' with urinary symptoms suggests anterior vaginal wall prolapse (cystocele).
Question 2
Which surgical technique is most appropriate for correcting cystocele?
Posterior repair
Is usually done to repair rectocele.
Manchester repair
Is usually done to repair uterine prolapse.
Anterior repair
Is usually done to repair vault prolapse.
Question 2 Explanation: 
Anterior repair is the most appropriate surgical repair technique for cystocele.
There are 2 questions to complete.
Shaded items are complete.

References: Merck Manual · UpToDate

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