CYSTOCELE, URETHROCELE
A cystocele or urethrocele results from a loss of support for the anterior vagina, through rupture or attenuation of the pubovesicocervical fascia, manifested by descent or prolapse of the urethra (urethrocele) or bladder (cystocele). With the stretch or rupture of the principal muscular supports of the vagina and the breach of the pelvic fascia in the pubovesicocervical plane during parturition, the bladder may push forward and downward through the anterior vaginal wall to form the hernia known as cystocele. Although a minor defect of this type is the rule rather than the exception in parous women (10% to 15% of women, 30% to 40% after menopause), the size of such hernias depends on a variety of factors, among them the number and difficulty of previous deliveries, the general condition of the individual prior to delivery, and the quality of pre-and postpartum care. The cystocele may undergo further exacerbation between pregnancies, or in the postmenopausal period as a result of conditions that tend to increase the intraabdominal pressure such as obesity, chronic cough, heavy lifting, intrinsic tissue weakness, or atrophic changes caused by estrogen loss. Some authors include smoking as a risk factor. There is some experimental evidence that changes in gene activation after childbirth can affect elastin production and repair, increasing the risk of pelvic support defects.
Several classification systems are used for defining the extent of the
support defect encountered. Small cystoceles, involving only a slight deviation
from the normal, are referred to as first degree; those that advance nearly to
the introitus are second degree; those that come to the introitus or beyond are
third degree. Other classifications use a four-step designation with the
differentiation between the third and fourth degrees being the level of the
hymenal ring. The POP-Q assessment system is a much more detailed method of
quantification that is used extensively for research but has failed to gain wide
clinical usage.
A cystocele does not necessarily cause symptoms. If the hernia is large
enough to produce incomplete voiding, the stasis leads to recurrent attacks of
cystitis with dysuria, frequency, nocturia, and stress incontinence. The
individual may complain of suprapubic pressure, a dragging sensation in the
pelvis, or the presence of a vaginal mass. Pain and dyspareunia are rare
symptoms.
Stress urinary incontinence is a common presenting complaint for these
patients. Cystocele and urethrocele can be demonstrated by pressing against the
perineum of a patient in the lithotomy position and having her strain.
Occasionally, it is necessary to have the patient stand to determine the degree
of herniation and incontinence present. An evaluation of urinary function is
advisable, especially if surgical therapy is being considered. In the past, the
functional significance of a cystourethrocele was gauged by elevating the
bladder neck (using fingers or an instrument) and asking the patient to strain (referred to as a Bonney or Marshall- Marchetti test).
This test has fallen out of favor as nonspecific and unreliable. Anterior
support failures are best demonstrated by having the patient strain or cough
while observing the vaginal opening through the separated labia. When a
urethrocele or cystocele is present, a downward movement and forward rotation of
the vaginal wall toward the introitus is demonstrated. A Sims speculum or the
lower half of a Graves, Peterson, or other vaginal
speculum may be used to retract the posterior vaginal wall, facilitating the
identification of the support defect.
Treatment generally consists of weight reduction, treatment of chronic cough (if present), and any infections. Topical or systemic estrogen therapy is often prescribed, but the evidence is controversial. Specific measures include pessary therapy, pelvic muscle exercises, and surgical repair.
