Cystocele (bladder prolapse): symptoms, causes, treatment and exercises

The NHS says pelvic organ prolapse may not cause symptoms, but if it does they can include a feeling of heaviness, discomfort or pressure in the lower tummy or vagina, feeling or seeing a bulge or lump inside or coming out of the vagina, pain, discomfort or numbness during sex, problems pooing such as constipation, and problems peeing such as feeling the bladder is not emptying fully, needing to go more often or leaking a small amount of pee when you cough, sneeze or exercise.

Northern Care Alliance and Leeds Teaching Hospitals leaflets describe a large cystocele as often causing or being associated with urinary leakage, urgency, frequency, difficulty passing urine and a feeling of incomplete emptying. Some people have to push the bulge back into the vagina or lean forward to empty the bladder completely, and incomplete emptying may make you prone to urine infections. Some people find the bulge causes a dragging or aching sensation or is uncomfortable during sex.

The NHS says pelvic organ prolapse is sometimes only found during tests done for another reason, such as cervical screening.

The NHS says treatment depends on which organs have prolapsed and how severely, and your doctor will also consider your age, overall health and whether you plan to have children. If you do not have symptoms, or the prolapse is not bothering you, you may not need medical treatment. You and your doctor decide together what is best.

If the prolapse is more severe or your symptoms are affecting daily life, the NHS lists hormone treatment (a vaginal cream, tablets or a hormone-releasing ring), vaginal support pessaries, physiotherapy and pelvic floor muscle training, usually with a specialist women's health physiotherapist, and surgery if the prolapse is severe.

The NHS suggests several things you can do yourself: maintain a healthy weight, eat more fibre, drink plenty of water and do gentle exercise like walking to avoid constipation, avoid activities that put a lot of strain on the pelvic floor such as heavy lifting, running and trampolining, and do regular pelvic floor exercises. Stopping smoking means you are less likely to have a persistent cough that puts pressure on the pelvic floor.

NHS trust leaflets explain that the pelvic floor muscle runs from the coccyx at the back to the pubic bone at the front and supports the uterus, vagina, bladder and rectum, that exercises may not get rid of the prolapse but make you more comfortable, and that they are best taught by an expert, usually a continence nurse adviser or women's health physiotherapist. They carry no risk, and help overall comfort even if surgery is needed later.

The NHS describes vaginal support pessaries as plastic or silicone devices inserted into the vagina to help support the pelvic organs. The Leeds Teaching Hospitals NHS Trust and Northern Care Alliance leaflets describe a ring pessary, a soft plastic ring that pushes the prolapse back up. It usually gets rid of the dragging sensation and can improve urinary and bowel symptoms, needs changing every 6 to 9 months, or earlier if there is any bleeding or discharge, and can be very popular.

Other pessaries may be used if a ring is not suitable, such as a shelf or Gellhorn pessary for those who are not sexually active, which is stronger and needs changing every 4 to 6 months. Some couples feel that a pessary gets in the way during intercourse, but many are not bothered.

The NHS says that if the prolapse is severe, surgery to lift and support the pelvic organs may be an option. The trust leaflets describe the anterior repair (anterior colporrhaphy), an operation performed through the vagina to repair the weakened front wall. They say that a test of bladder function (urodynamics) is sometimes needed beforehand, particularly if the prolapse is large or there are urinary symptoms.

The leaflets list risks including bleeding, infection, deep vein thrombosis, damage to local organs such as the bladder, pain, changes in bladder symptoms or sensation during intercourse, and recurrence: they say if you have one prolapse the risk of having another sometime during your life is 30%, and that the operation may fail to relieve symptoms or can be repeated. The NHS says surgery using vaginal mesh to treat prolapse is no longer done on the NHS unless there is no alternative, and anyone who has had mesh and thinks it is causing problems should speak to a GP or surgeon.

The pelvic floor muscles form a sling across the opening of the pelvis and, with surrounding tissue, hold the bladder, uterus and rectum in place. The NHS says pelvic organ prolapse can happen when the pelvic floor muscles weaken, that it is more common as you get older, particularly after the menopause, and that causes include pregnancy and childbirth, being overweight, long-term constipation and straining, persistent coughing and pelvic surgery such as hysterectomy.

Some health conditions also make a prolapse more likely: joint hypermobility syndrome, Marfan syndrome and Ehlers-Danlos syndromes, the NHS says. The trust leaflets add that damage at the time of childbirth is usually the root cause but is most noticeable after the menopause, and that chronic strain from heavy lifting and constipation is related.

The NHS says a GP will ask about your symptoms and examine you, feeling for lumps in the pelvic area and inside the vagina, and may gently insert a speculum to see if there is a prolapse. You can ask for a chaperone or a female doctor. If you have bladder problems the GP may refer you to hospital for further tests.

If you are diagnosed with a prolapse, the NHS says it may be given a number from 1 to 4 depending on how severe it is, with 4 being a severe prolapse.

The NHS lists pregnancy and childbirth among the causes of pelvic organ prolapse, and the trust leaflets say it usually occurs because of damage at the time of childbirth but is most noticeable after the menopause. The NHS says your doctor will consider whether you are planning to have children in the future when advising on treatment. If you are pregnant or planning a pregnancy, tell your midwife or doctor about prolapse symptoms and ask about pelvic floor exercises.

The NHS says to see a GP if you have a lump in or around your vagina or any other symptoms of pelvic organ prolapse. The trust leaflets say incomplete bladder emptying makes urine infections more likely, so mention bladder symptoms to your GP. A prolapse that permanently protrudes can dry out and ulcerate, so it should not be left.

On the NHS, a GP can examine you and refer you to a women's health physiotherapist, continence service or urogynaecology clinic for pessary fitting, exercises or surgery. Bladder and Bowel UK is the national charity named by the NHS for information and support.

Some people choose private gynaecology or urogynaecology opinions or surgery. The options are the same, so check the surgeon's experience with prolapse procedures and what alternatives to surgery have been tried.