Cystocele Repair

Cystocele repair is a surgical intervention aimed at restoring the normal position and support of the bladder. A cystocele is also described as a prolapsed, dropped, herniated, and fallen bladder. The procedure involves strengthening the supportive tissues and structures in the anterior vaginal wall to reposition the bladder and alleviate the symptoms associated with cystocele. 

Types of Cystoceles

It can be considered based on grading their severity according to the level of descent and the location of the anatomy.

Severity grading includes:

• Grade 1 (Mild): Slight sagging of the bladder within the vagina.
• Grade 2 (Moderate): Bladder at the opening into the vagina.
• Grade 3 (Severe): Bladder protrudes through its opening.

Anatomically classified:

• Apical defect: Upper vagina.
• Medial defect: Middle vagina.
• Lateral defect: Sides of vagina.
  

Severity and location vary from case to case. 

Symptoms of Cystoceles

A variety of symptoms are associated with cystoceles, also referred to as prolapsed bladders. For some women, especially in mild cases, none of the symptoms surface. But as it advances, some of the following symptoms may exhibit: 

• Pelvic Pressure or Fullness: A heaviness or pressure felt in the pelvis area. 
• Vaginal Bulge: A bulge seen in the vagina or a feeling of something coming out. 
• Urinary Problems: The patient may complain of frequent urination, hesitancy while starting the stream, weak flow, incomplete emptying sensation, urinary leakage, and more infections. 
• Discomfort: Painful intercourse, lower back pain, pelvic pressure with straining, coughing, lifting. 
• Difficulty inserting period products: Includes tampons and period cups.
• Other Symptoms: Symptoms get worse with standing and improve when lying down.

Cause of Cystoceles

Generally, cystocele occurs when tissues become loose or weak, permitting a bladder to sag into the vagina. Some of these reasons are: 

• Childbirth: Vaginal delivery and multiple childbirths weaken pelvic floor muscles, and prolonged labor increases risk. 
• Old Age: In this case, old women are deprived of pelvic muscle strength after menopause by hormonal changes that usually occur due to an estrogen deficiency. 
• Increased Abdominal Pressure: Conditions such as chronic cough, constipation, heavy lifting, and obesity increase abdominal pressure, leading to strain on the pelvic floor. 
• Genetics: Some women may inherit different weak connective tissues that increase the risk of cystocele. 
• Pelvic Surgery: Previous pelvic surgeries like hysterectomy sometimes weaken the pelvic floor.
• Connective Tissue Disorders: Certain connective tissue disorders heighten the risks.

Complication of Cystoceles

Cystoceles can range from treatable complications to many complications due to progress or lack of treatment. The following is a list of possible complications: 

• Urinary Issues: Incomplete emptying of the bladder often makes a person susceptible to recurrent infections and UTIs, urinary incontinence, or the conditions of retention.
• Discomfort and agony: Chronic pelvic pain makes it difficult to perform daily activities; sexual difficulties arise from dyspareunia.
• Quality of life: Urinary incontinence and pelvic pain can cause anxiety and depression; symptoms can restrict physical activity.
• Progression of prolapse: Prolapse of other organs such as the rectum or uterus due to a weakened pelvic floor. 
• Kidney Damage (Rare): Severe urinary retention may allow urine to flow back into the kidney, causing kidney injury. This is a rare but serious complication. 

Risk factors of Cystoceles

Many risk factors apply to women and manage their cystoceles or prolapsed bladder. Here are the chief risk factors: 

Various factors that raise the risk for weakened pelvic floors are: Vaginal birth, multiple births, difficulties while delivering, age, especially after the menopausal state, obesity, chronic intra-abdominal pressure (as in conditions like chronic coughing, constipation, heavy lifting), genetic conditions, previous surgery in the pelvic region connected to connective tissue disorders.

Prevention 

Preventing cystoceles involves strengthening the pelvic floor and reducing strain on the supporting tissue. A summary of the measures to be taken in prevention includes the following preventive approaches:

• Kegel exercises regularly could be beneficial, improving support to the bladder by contracting and relaxing the control muscles for urine flow through these particular exercises.
• Healthy weight or losing weight relieves the strain on the pelvic floor.
• Eat a high-fiber diet; consume adequate fluids, and exercise can prevent constipation and make defecating easier.
• Use appropriate lifting methods while lifting heavy items to lessen strain on the pelvic floor.
• Seek treatment for the underlying cause of a chronic cough. 
• Post-menopausal estrogen replacement therapy might help keep pelvic floor muscles strong but talk to your doctor about side effects and risks.
• Post-natal care, careful pushing, along with pelvic floor exercises can help reduce the risk of childbirth.

Benefits of Cystocele Repair

The quality of life in women is improved by cystocele repair, thereby relieving discomforting symptoms associated with a prolapsed bladder. 

• Pelvic Pressure and Discomfort Relief: Repair relieves pressure from heaviness and fullness in the pelvic area.
• Improved Urinary Performance: Incontinence and frequency, urgency, and risk of UTIs are reduced.
• Decreased Vaginal Bulging: This reduces the discomfort caused by bladder protrusion. 
• Improved Sexual Function: Facilitates intercourse and increases satisfaction. 
• Increased Comfort and Mobility: Decreased symptoms enable women to resume activities while also contributing to easier exercise.
• Improved Quality of Life: Represents the physical and emotional well-being of a woman. 
• Reduction of Complications: Minimizes kidney problems and organ prolapse.

The specific surgical approach for cystocele repair may vary depending on the severity of the prolapse, the patient's overall health, and the surgeon's expertise. Here is an overview of the commonly performed procedures:

Diagnosis

Diagnosis of cystocele involves a medical history, physical examination, and sometimes other tests:

1. Medical History: The doctor asks about symptoms such as pelvic pressure, urinary difficulties, and pain during sexual intercourse and subsequent information about childbirth, surgeries, and any chronic diseases. 

2. Physical Examination: The pelvic examination confirms the presence of bulges, tests the strength of the pelvic floor and may require the patient to strain or cough.

3. Additional Tests: 

• Urodynamic testing – Shows how the bladder functions.
• Cystourethrogram – An X-ray that gives the shape of the bladder during voiding.
• Postvoid residual urine – Indicates how well the bladder empties.
• MRI – If required gives more detailed images of the pelvis organs.

Treatment:

Anesthesia was used for comfort during the procedure, and the incision as needed was made by the surgeon for accurate repositioning of the bladder. The supporting tissues were repaired with sutures and probably augmented using a mesh graft for additional support. Finally, the sutures were used to close the incision.

1. Anterior Colporrhaphy:

a. Anesthesia: The patient is placed under general or regional anesthesia for optimal comfort during the procedure.
b. Incision: A surgical incision is made in the anterior vaginal wall to access the weakened tissues and structures.
c. Repair of the Vaginal Wall: The supportive tissues and fascia in the anterior vaginal wall are reinforced and tightened to restore the bladder's normal position.
d. Closure: The incision is carefully closed using sutures to secure the repaired tissues.

2. Mesh Augmentation:

a. Anesthesia: General anesthesia is administered to ensure the patient's comfort throughout the procedure.
b. Mesh Placement: A synthetic mesh is inserted through an incision in the anterior vaginal wall to provide additional support and reinforcement to the weakened tissues. The mesh acts as a scaffold, promoting tissue growth and stability.
c. Securement and Closure: The mesh is securely positioned, and the incision is closed using sutures or surgical adhesive.

3. Minimally Invasive Techniques:

Minimally invasive approaches, such as laparoscopic or robotic-assisted procedures, may be utilized for cystocele repair. These techniques involve using small incisions and specialized instruments to access and repair the prolapsed tissues. The specific steps of the procedure vary depending on the approach chosen.

Post-Operative Care:

Postoperative care after cystocele repair is important for a smooth recovery and to reduce complications. Here's a more elaborate insight into what that care consists of:

• Pain Management: Expect pain. The doctor will give you some medications, then you will be given oral pain meds for home. 
• Taking Care of the Wound: Monitor the surgical site for signs of infection. Monitor and remove any catheter placed. 
• Vaginal Drainage: Normal vaginal discharge or bleeding may be managed during the early postoperative period with packing, which would be removed as directed. 
• Bowel Management: Take stool softeners to avoid straining and therefore pressure on the surgical repair. 
• Activity Restrictions: No heavy lifting or strenuous exercise. Mobilization should be gradual to reduce arm clots.
• Urinary Care: Keep an eye on your urine output; learn catheter care if you go home with one. 
• Hygiene: Wash the perineal region gently to reduce the chances of infection.