Cystocele and urinary incontinence: causes and treatment

The bladder sits just above the front wall of the vagina. A layer of connective tissue (fascia) and the pelvic floor muscles hold it up like a hammock. When this support weakens, the bladder sags into the vagina. This is called a cystocele or, in everyday language, a “fallen bladder.”

Along with a cystocele, the support of the urethra (the urinary channel) often weakens too. When you cough or laugh, the pressure inside the abdomen rises, and a poorly supported urethra cannot close tightly at that moment, so urine leaks. In some women the opposite happens: the sagging bladder kinks the urethra, urine is hard to pass and the bladder does not empty completely.

To choose the right treatment, it is important to know when the leakage happens:

Here, “stress” does not mean psychological stress but a sudden rise in pressure inside the abdomen.

Let us be clear about one important difference: the TOT procedure treats only stress urinary incontinence. With urge incontinence, the problem is not in the urethra but in the bladder itself, so a tape does not help. This type is treated by cutting down on coffee and tea, a sensible fluid routine, gradually lengthening the time between trips to the toilet, pelvic floor exercises and, if needed, medication prescribed by a urologist. Many women have both types at once. In that case, we determine which one predominates and plan treatment accordingly.

• leaking urine when you cough, laugh, sneeze, climb stairs or exercise;
• a feeling of bulging or fullness in the vagina, or that “something is coming down,” with heaviness that increases over the day and when standing;
• a soft bulge at the vaginal opening that you can feel with your hand and push back in;
• a feeling that the bladder has not emptied completely, a weak stream, and sometimes needing to push the bulge back by hand to pass urine;
• frequent urination and recurrent urinary tract infections;
• discomfort during sex.

Burning, pain and frequent urination can also be signs of a urinary tract infection. That is why a urine test is always done before treatment.

• vaginal childbirth, especially multiple and difficult deliveries, or a large baby;
• pregnancy: the growing uterus pressing on the pelvic floor for months;
• menopause: as estrogen levels fall, tissues become thinner and lose their elasticity;
• conditions that constantly raise the pressure inside the abdomen: chronic cough, asthma and bronchitis, constipation, heavy lifting, excess weight;
• smoking: it causes a chronic cough and weakens tissues;
• congenital weakness of connective tissue and previous pelvic surgery.

Urinary incontinence can happen at any age: in a young woman after childbirth as well as during menopause. We explain what is normal in the first months after childbirth in our article 5 intimate problems after childbirth.

• Grade I: the bladder sags slightly into the vagina. It often causes no symptoms and is found by chance during an examination.
• Grade II: the sagging reaches the vaginal opening, causing a feeling of bulging and heaviness.
• Grade III: the bladder comes out beyond the vaginal opening when you strain, or even at rest.

The treatment decision is based on symptoms, not on the grade: a mild cystocele that causes no symptoms usually does not need surgery.

Sometimes the uterus drops along with the bladder (uterine prolapse), or the wall of the rectum sags (rectocele). If there is uterine prolapse, we assess the situation together with a gynecologist and build the treatment plan jointly.

Do not wait — seek urgent care if:

• you cannot pass urine at all and have a painful feeling of fullness in your lower abdomen;
• you have frequent, burning urination together with a fever or lower back pain;
• you see blood in your urine;
• the part protruding from the vagina will not go back in, hurts or bleeds.

The appointment starts with a conversation: when does the leakage happen, how many times a day do you urinate, do you get up at night to urinate, how many births have you had, and do you have constipation or a cough? If you keep a bladder diary for at least 3 days before the appointment — noting what you drink, when you go to the toilet and when leaks happen — the diagnosis becomes much easier.

Then a private examination follows:

• physical examination: usually lying down, sometimes standing; the grade of the cystocele and of any other prolapse is determined;
• cough test: with a full bladder, you are asked to cough, and we check whether urine leaks;
• urine test: to rule out an infection, because an infection can also cause leakage;
• measuring residual urine: an ultrasound checks how much urine is left in the bladder after you urinate.

If your symptoms are mixed, if you have had surgery before or if the diagnosis is unclear, we recommend additional urological tests (for example, urodynamic testing) and a consultation with a urologist.

Non-surgical (conservative) treatment

Non-surgical treatment is the first step, and for many women it significantly reduces symptoms:

• Kegel exercises: the main non-surgical treatment for stress urinary incontinence. At least 3 months of regular exercise is recommended, and improvement is often felt in months 3–5. We explain the correct technique step by step on the aesthetic proctology page.
• weight loss: excess weight is a constant load on the pelvic floor, and losing weight can reduce leakage;
• treating a cough and constipation, and quitting smoking;
• fluid routine: not drastically cutting back on fluids but spreading them evenly through the day; cutting down on coffee, tea and fizzy drinks;
• pessary: a soft ring placed in the vagina that supports the bladder and the urethra. It is a good option for women who do not want surgery, are still planning to have children or are not suitable candidates for surgery. We show you at the appointment how to insert, remove and clean it.

The TOT procedure

If stress urinary incontinence continues despite exercises and limits your life, surgery is the main treatment. For this, we use the TOT (transobturator tape) procedure. It is one of the sling procedures, in which a supporting tape is placed under the urethra.

• A small incision of about 1 cm is made in the front wall of the vagina, below the urethra. There is no incision on the abdomen.
• A thin, soft synthetic tape is placed under the middle part of the urethra. Its ends are brought out through two tiny punctures on the inner thighs.
• The tape does not squeeze the urethra: it supports it at the moment you cough or strain and prevents urine from leaking.
• The procedure usually takes 15–20 minutes and is done under spinal anesthesia (an injection in the lower back that numbs the lower half of the body) or sedation (a light, medication-induced sleep).
• The stitches dissolve on their own and do not need to be removed. You are usually discharged the same day or the next day.

Important: the tape does not lift the bladder or the uterus; it only supports the urethra. If the bladder has sagged, this is corrected with a separate operation, anterior colporrhaphy.

Every operation has its risks. In the first weeks after TOT, you may have pain in the groin and inner thighs and temporary difficulty passing urine. Rarely, the tape may become visible in the vagina (exposure), frequent urination may develop, or the leakage may not go away completely or may come back years later. We discuss these risks openly with you before surgery.

Anterior colporrhaphy

If a cystocele causes symptoms, the bladder is put back in place with anterior colporrhaphy. An incision is made in the front wall of the vagina, the weakened supporting layer that holds the bladder is reinforced by stitching the patient's own tissues, and excess vaginal lining is removed. You usually stay in the hospital for 1 day.

If a cystocele and stress urinary incontinence occur together, anterior colporrhaphy and TOT are often done in the same session. When indicated, rectocele repair or vaginoplasty can be added as well. This is called combined (“bouquet”) surgery. In severe cases, when several organs have sagged together, the surgical plan is prepared individually.

The table shows what to expect on average; your exact timeline is given after the examination.

In the first days, swelling may make the urge to urinate feel weaker. That is why it is recommended to urinate regularly, about every 2–3 hours.

1. Strengthen your pelvic floor muscles: during pregnancy, after childbirth and during menopause.
2. Prevent constipation: high-fiber food, enough water, no straining on the toilet. The cause of long-lasting constipation must always be investigated.
3. Watch your weight: excess weight is a constant load on the pelvic floor.
4. Treat a cough and quit smoking: every hard cough puts pressure on the pelvic floor.
5. Lift correctly: bend your knees, tighten your pelvic floor before lifting and don't hold your breath.