I've been diagnosed with a mild case of prolapse of the bladder. Will it get worse over time (I'm 53 years old), and what treatment options are there?

As we get older, it is not uncommon for the bladder-which sits right on top of the uterus and vagina---to sag, or prolapse, into the vagina, forming what is called a cystocele. It occurs when the muscles of the pelvic floor, which help support these organs, relax or weaken. Let me assure you that a cystocele will not turn into cancer and is more annoying than harmful.

(Uterine prolapse, which is a weakening of the supporting structures of the uterus, often exists with bladder prolapse but can exist separately. You might not be able to know exactly if what's "slipping" is your bladder or uterus, but your doctor will.)

Recognizing Your Symptoms
Patients with cystocele often experience pelvic pressure and lower back pain and may leak urine when they cough or sneeze (stress incontinence).

Some women will actually retain urine in the bladder, which can become a reservoir for bacteria, leading to urinary tract infections. If the cystocele is more advanced, the pressure of the bladder protruding into the vagina will sometimes cause a bulge or mass to stick out from the vagina.

Many women are reluctant to tell their doctor about their symptoms because they're embarrassed or believe that bladder prolapse is just a natural part of aging and something they have to live with. But since a cystocele can get worse over time, detecting it early and treating it make good sense.

Treatment Options
Here are some strategies to strengthen pelvic floor muscles and relieve symptoms.

Do Kegels. You may be able to keep your prolapse from worsening and relieve symptoms of lower back pain and pelvic pressure by doing Kegel exercises (tightening the vaginal and pelvic muscles as if to stop urinating). To get the most out of them, it's important to contract the correct muscles. Your gynecologist can show you how. Or ask your doctor if she has NEOCONTROL, a special chair that produces pulsing magnetic fields that "exercise" the pelvic floor muscles for you.

Try a tampon. If you are leaking urine when you cough, sneeze, or exercise, wear a tampon (even if you're finished having periods) to provide some support for the bladder and block the escape of urine. Follow the package insert guidelines for how long you can safely wear a tampon without increasing your risk of toxic shock syndrome--usually 4 to 8 hours.

Lose the belly. Excess abdominal fat may put more pressure on your bladder, which will cause the cystocele to sag -more. If you're overweight, lose the extra pounds sensibly through a lowfat diet and regular exercise such as brisk walking.

Ask about a pessary. Your gynecologist can fit you for a pessary, a device that is placed in the vagina (similar to a contraceptive diaphragm) to support the bladder.

Consider estrogen replacement therapy (ERT). If you are postmenopausal, ERT may provide relief. The depletion of estrogen that accompanies menopause may exacerbate the problems associated with pelvic floor weakness.

Surgery can correct the problem for the long-term. The procedure can be done vaginally, avoiding abdominal surgery and a long recovery, and is usually successful. Some slipping may recur 10 years after surgery in about 25% of women.

Causes of Bladder Prolapse
Several factors can lead to a weakening of pelvic floor muscles and the development of a cystocele. Here are some possible causes:
CHILDBIRTH. During vaginal childbirth, pelvic muscles and connective tissues can be damaged through stretching or trauma.

MENOPAUSAL ESTROGEN DEFICIENCY. The loss of estrogen can cause the muscles and connective tissues supporting the bladder to weaken, allowing the cystocele to form.

CONSTIPATION. The repetitive bearing down and pushing associated with chronic constipation can weaken the pelvic floor.

HYSTERECTOMY. If ligaments cut when the uterus was removed are not reattached to the top of the vagina, there is less support for the bladder.

PHOTO (COLOR): Mary Jane Minkin, MD

PHOTO (COLOR): Don't let symptoms of bladder prolapse keep you sidelined.


by Mary Jane Minkin, MD, with Toby Hanlon, EdD

Dr. Minkin is a board-certified obstetrician/gynecologist in New Haven, CT, clinical professor at Yale University School of Medicine, and coauthor of What Every Woman Needs to Know about Menopause (Yale University Press, 1996).

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