Ask the Doctors

Dear Doctor: I am a woman in my early 70s who has been diagnosed with a bladder prolapse. I have no symptoms and was told I don't need surgery until symptoms appear. I have since learned that this condition is quite prevalent among women, but seldom discussed or written about. Should I seek surgery, which could lead to serious complications, even though my case is mild?

Dear Reader: You're correct that your condition -- and thus your worry -- is shared by many women. Before we explore the options, let's begin with an explainer: Bladder prolapse, or a cystocele, is one type of pelvic organ prolapse, which is a protrusion of pelvic organs into the vaginal region. In a cystocele, the front portion of the vaginal wall becomes weak, allowing the bladder to bulge down into the vaginal region.

The prevalence of pelvic organ prolapse is unclear. In 2003, about 200,000 women had surgery for symptomatic prolapse, with the majority of these surgeries due to a cystocele. However, many people go about their lives not even knowing they have a prolapse. A 2008 study described the symptoms of pelvic organ prolapse to 1,961 women over the age of 20 and asked whether they had those symptoms; 2.9 percent answered that they did.

The likelihood of a cystocele or other type of pelvic organ prolapse increases with age. A 2002 study assessed the presence of prolapse in 27,342 women, ages 50 to 79, based on vaginal exams. As you're aware, cystoceles were much more common than people realized. In women with a uterus, the prevalence of a cystocele was 34.3 percent; in those whose uterus had been removed, the prevalence was 32.9 percent.

One major risk factor for a cystocele is having had children. The more children a woman has, the greater the risk of a cystocele. Compared to the risk of women without children, the risk of pelvic organ prolapse is four-fold greater with the first child, eight-fold greater with the second, nine-fold greater with the third and 10-fold greater with the fourth. The theory is that pregnancy and delivery injure the muscles and nerves in the pelvic region, allowing for herniations in the vaginal area. The risk of pelvic organ prolapse also increases with prolonged labor, having a high-birthweight infant and having a first pregnancy before the age of 25.

Another risk factor for cystocele is increasing age. The majority of patients who seek treatment for symptomatic pelvic organ prolapse are in their 60s and 70s. Obesity also increases the risk of cystocele, with obese women having a 47 percent increased risk of prolapse.

Many patients with cystoceles feel the bulge of the bladder into the vaginal region, as if something has dropped into the vaginal area. In addition, women can have increased frequency, urgency and urinary incontinence with cystoceles. All of these symptoms may decrease the desire for sexual intercourse.

Women with urinary symptoms or pelvic discomfort can consider a pessary, a device inserted into the vagina to support the bladder, or surgery to lift the bladder and tighten the pelvic floor ligaments and muscles. But because you're not having any symptoms of cystocele, I wouldn't recommend surgical or medical treatment, which always poses some risk -- even if small.

For now, try pelvic floor muscle training exercises to prevent the cystocele from getting worse. Vaginal estrogen or the osteoporosis medication raloxifene might help as well. Although they haven't been studied extensively for this use, they have the potential to strengthen the vaginal tissues.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o Media Relations, UCLA Health, 924 Westwood Blvd., Suite 350, Los Angeles, CA, 90095. Owing to the volume of mail, personal replies cannot be provided.)

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