Dear Doctor: I’m a 75-year-old woman and have been diagnosed with a dropped bladder due to a hysterectomy in my mid-40s. I have discomfort, particularly when I walk a long distance or do heavy lifting; some leakage problems; and frequently have UTIs. What can be done?
Dear Reader: A prolapsed bladder, also known as a fallen bladder, or cystocele, is common after a hysterectomy. It’s due to the drop in estrogen levels that occurs after the uterus and ovaries are removed. Estrogen, the primary female sex hormone, plays an important role in keeping the pelvic tissues toned and strong. Additional causes of the condition can include physical stresses, such as childbirth, frequent straining due to constipation or a chronic cough, heavy lifting and obesity. The decrease in estrogen that accompanies menopause can also contribute to bladder prolapse.
The condition is broken down into four separate stages, from mild to severe, depending on the degree to which the bladder has dropped. Women with a mild case -- Stage 1 -- may not experience any symptoms. When the condition is more advanced, symptoms include the discomfort, stress incontinence and frequent urinary tract infections that you mentioned, as well as lower back pain, difficulty with urination or bowel movements, pain during intercourse and a bulge of tissue from the vagina. In the most advanced cases -- Stage 4 -- the entire bladder protrudes.
Treatment depends on how far the bladder has dropped, as well as variables such as age, medical history, general health and personal preferences. In moderate cases, nonsurgical treatments can help. These include estrogen replacement therapy, which can be administered in a patch, as a pill or in a cream, and is used to strengthen the tissues that support the bladder. Kegel exercises, which are deliberate contractions of the muscles that you use to control urination, strengthen the pelvic floor. Electrical stimulation is used to trigger muscle contractions and build strength and tone, and some women have success with biofeedback.
Another nonsurgical option is a pessary. That’s a rubbery, donutlike device that is inserted into the vagina, much like a diaphragm. The pessary provides physical support. It can ease discomfort and has been shown to help with urinary control. It generally takes just one office visit with a urologist to be measured and fitted with the appropriate device. After that, pessaries require monthly cleaning. Depending on the device, this can be done at home, or it may need to be done in the urologist’s office. Many women do well with a pessary, while others experience discomfort or irritation. Infections are possible, but when a pessary is fitted and cleaned properly, the risk is small.
For severe cases of bladder prolapse, or when the less-invasive methods of managing the condition are not successful, reconstructive surgery may be needed. The goal is to return the bladder to its proper position. Before opting for surgical repair, be sure to learn all about the procedure you will have, as well as the potential risks, benefits and other options available.
(Send your questions to firstname.lastname@example.org, or write: Ask the Doctors, c/o UCLA Health Sciences Media Relations, 10880 Wilshire Blvd., Suite 1450, Los Angeles, CA, 90024. Owing to the volume of mail, personal replies cannot be provided.)