Cystocele: Symptoms, Types, Causes and Treatment

Cystocele, also known as anterior vaginal wall prolapse, is a common pelvic floor disorder where the bladder descends into the vagina due to weakening of the supportive tissues. This can cause a range of symptoms and significantly impact quality of life. In this article, we’ll provide a comprehensive, evidence-based guide to cystocele—exploring its symptoms, the different types, underlying causes, and the most effective treatment options available.

Symptoms of Cystocele

Cystocele symptoms often vary in severity and can affect daily life in multiple ways. Some women may experience noticeable discomfort, while others may have mild or even no symptoms. Recognizing these symptoms is crucial for timely diagnosis and management.

Symptom	Description	Frequency/Severity	Source(s)
Vaginal Bulge	Sensation or visible bulge in vagina	Common, esp. in higher grades	4 13
Urinary Incontinence	Leakage with coughing, laughing, or exertion (stress), or sudden urge (urge)	Very common; stress incontinence in 65%	2 4
Voiding Difficulty	Trouble starting or completing urination, incomplete emptying	More frequent with large cystoceles	1 2 3
Urgency	Sudden, strong need to urinate	Up to 60%	2 4
Nocturia	Waking at night to urinate	Associated with reduced bladder capacity	4
Pelvic Pressure	Heaviness, pressure, or discomfort	Variable	13
Recurrent UTIs	Bladder infections due to incomplete emptying	Less common	13

Table 1: Key Symptoms

Vaginal Bulge and Sensation of Pressure

The hallmark symptom of cystocele is the sensation of a bulge or fullness in the vagina, especially when standing, lifting heavy objects, or during physical activity. Women may notice or even see tissue protruding from the vaginal opening, particularly with higher-grade cystocele. This bulging is strongly associated with the severity of the prolapse 4 13.

Urinary Symptoms

• Stress Urinary Incontinence (SUI): This is the involuntary leakage of urine during activities that increase abdominal pressure, such as coughing, sneezing, or exercising. Studies report that up to 65% of women with cystocele have stress incontinence 2 4.
• Urge Incontinence: Characterized by a sudden, intense urge to urinate followed by leakage. About 60% of women with cystocele experience urgency or urge incontinence 2 4.
• Voiding Difficulty: Includes difficulty starting urination, a weak stream, or a feeling of incomplete emptying. These issues are more common in women with larger cystoceles due to the mechanical obstruction of the bladder outlet 1 2 3.
• Nocturia: The need to get up several times at night to urinate is linked to reduced bladder capacity and sometimes detrusor overactivity 4.
• Recurrent Urinary Tract Infections (UTIs): Incomplete bladder emptying due to cystocele can predispose to infections, though this is less common 13.

Pelvic Discomfort and Other Effects

Women might also report pelvic heaviness, pressure, or discomfort, particularly towards the end of the day or after prolonged standing. In severe cases, cystocele can lead to complications such as cystitis, bladder stones, or, in neglected instances, kidney problems due to urinary retention 13.

Types of Cystocele

Not all cystoceles are alike. Understanding the different types helps tailor diagnosis and treatment, as the underlying anatomical defect determines the most effective repair technique.

Type	Anatomic Defect/Location	Clinical Features	Source(s)
Central/Medial	Midline pubocervical fascia defect	Classic bulge, often mid-vagina	5 9 12
Lateral/Paravaginal	Detachment from lateral pelvic wall (arcus tendineus fascia pelvis)	Bulge more lateral, may be less pronounced	5 9 11 12
Apical	Failure at the vaginal apex/cervical ring	Cystocele often with uterine/vault prolapse	5 10
Cystourethrocele	Involvement of bladder neck and urethra	Highly correlated with stress incontinence	8

Table 2: Types of Cystocele

Central (Medial) Cystocele

This type results from a central weakening or defect in the pubocervical fascia, leading to a midline bulge of the bladder into the vagina. It’s the “classic” presentation and is often most visible when a woman strains down (Valsalva maneuver) 5 9.

Lateral (Paravaginal) Cystocele

Here, the supporting tissues at the sides of the vagina (endopelvic fascia) detach from their normal attachment points along the pelvic walls (arcus tendineus fascia pelvis). This can cause the bladder to descend laterally rather than centrally. Sometimes, the bulge is less obvious but can still cause significant urinary symptoms 5 11 12.

Apical Cystocele

When support at the very top (apex) of the vagina fails—often at the cervix or uterine-vaginal junction—the bladder and upper vagina can descend together, frequently accompanied by uterine or vaginal vault prolapse. Apical defects are especially important to recognize, as they may require different surgical approaches for effective correction 5 10.

Cystourethrocele

This term is used when both the bladder and urethra are involved in the prolapse. Cystourethrocele is strongly associated with stress urinary incontinence and is more likely in women with bladder neck hypermobility 8. Bladder neck funneling on ultrasound is a common finding in this group.

Causes of Cystocele

Cystocele develops when the normal support structures of the bladder and vaginal wall are weakened or injured. Understanding the causes is essential for both prevention and targeted treatment.

Cause	Mechanism/Pathology	Risk Factors or Triggers	Source(s)
Childbirth Trauma	Stretching/tearing of fascia/muscles	Vaginal delivery, forceps	5 10 13
Connective Tissue Defects	Weakness or degeneration of fascia	Aging, genetic predisposition	5 15
Increased Abdominal Pressure	Chronic straining, heavy lifting	Chronic cough, constipation, obesity	10 13
Levator Ani Injury	Muscle damage, loss of pelvic floor tone	Traumatic delivery, aging	6 10
Surgical or Iatrogenic	Disruption during pelvic surgery	Hysterectomy, prior repairs	12 13

Table 3: Causes of Cystocele

Childbirth and Pelvic Trauma

The most common cause of cystocele is trauma to the pelvic floor during childbirth. The process of labor, especially with large babies, forceps delivery, or prolonged pushing, can overstretch or tear the supportive fascia and muscles (particularly the pubocervical fascia and levator ani muscle) 5 13.

Connective Tissue Weakness

Aging, menopause, and genetic factors can lead to weakening or degeneration of the collagen and connective tissues that support the bladder and vaginal wall. Certain connective tissue disorders may also predispose women to cystocele 5 15.

Increased Abdominal Pressure

Conditions that chronically increase intra-abdominal pressure—such as obesity, chronic coughing (from smoking or lung disease), constipation, or heavy lifting—can stretch and damage the pelvic supports, increasing the risk of cystocele 10 13.

Levator Ani and Muscular Injury

Direct injury or atrophy of the pelvic floor muscles, particularly the levator ani, reduces the structural support for the bladder and vagina. This may occur with traumatic deliveries, aging, or even as a result of previous pelvic surgeries 6 10.

Surgical and Iatrogenic Factors

Previous pelvic surgeries, especially hysterectomy or prior prolapse repairs, can disrupt normal support structures or change the orientation of the pelvic organs, increasing the risk of cystocele development or recurrence 12 13.

Treatment of Cystocele

Management of cystocele is individualized, depending on symptom severity, degree of prolapse, patient preferences, and overall health. Treatment ranges from conservative measures to advanced surgical procedures.

Treatment	Approach/Technique	Key Points/Outcomes	Source(s)
Conservative	Pessary, pelvic floor exercises	Symptom control, non-invasive	1 13
Anterior Colporrhaphy	Repair of pubocervical fascia	Standard surgery, recurrence 3–15%	12 18
Paravaginal Repair	Reattachment of lateral supports	For lateral defects, high success	11 12
Mesh-Augmented Repair	Synthetic or biologic mesh	For recurrent/severe cases, risk of complications	14 15 16
Laparoscopic Sacropexy	Mesh attachment to sacrum	Lower risk of sexual side effects, durable	16
Sling Procedures	Pubovaginal, midurethral slings	For cystocele + SUI, supports bladder neck	17 18

Table 4: Treatment Options

Conservative Management

• Pessary: A silicone or plastic device is fitted into the vagina to support the bladder and vaginal wall. This is effective for many women, especially those who are not surgical candidates or wish to avoid surgery. Pessaries can help relieve symptoms and may be used long-term with proper care 1 13.
• Pelvic Floor Muscle Training (PFMT): Also known as Kegel exercises, these strengthen the pelvic muscles and may reduce symptoms, particularly in mild cases or as adjuncts to other treatments.

Surgical Treatments

Anterior Colporrhaphy

The traditional surgical repair involves plicating (folding and suturing) the weakened pubocervical fascia to reinforce the vaginal wall. It is effective for central (midline) defects and remains widely performed, although recurrence rates can range from 3% to 15% 12 18.

Paravaginal Repair

This procedure specifically addresses lateral defects by reattaching the endopelvic fascia to the pelvic sidewall (arcus tendineus fascia pelvis). It is highly effective for lateral cystoceles, with success rates above 90% in selected patients 11 12.

Mesh-Augmented Repairs

For severe or recurrent cystoceles, synthetic or biologic mesh may be used to strengthen the repair. Mesh is especially useful when native tissue is poor (e.g., in connective tissue disorders) or in cases of multiple recurrences 14 15. However, mesh procedures carry risks, including mesh erosion, pain, and infection. Recent studies show that laparoscopic mesh sacropexy is safer and preserves sexual function better than transvaginal mesh placement 16.

Laparoscopic Sacropexy

This minimally invasive approach attaches the vaginal apex (and sometimes the bladder base) to the sacrum using mesh. It offers durable support and fewer complications, particularly for sexually active women or those with apical prolapse 16.

Sling Procedures

When stress urinary incontinence coexists with cystocele, sling procedures (such as pubovaginal or midurethral slings) may be performed alongside cystocele repair. These provide additional support to the bladder neck and urethra, improving both prolapse and incontinence outcomes 17 18.

Outcome and Prognosis

Most women experience significant improvement in symptoms and quality of life after appropriate treatment. Operative repair resolves stress incontinence in over 90% of cases and urge incontinence in most patients 2. However, cystocele may recur, especially if underlying risk factors persist or the appropriate anatomical defect is not fully corrected 15. Mesh use can reduce recurrence but must be balanced against potential complications 14 16.

Conclusion

Cystocele is a prevalent condition with a spectrum of symptoms, types, and causes. Successful management depends on accurate diagnosis and individualized treatment.

Key Points:

• Cystocele symptoms include vaginal bulge, urinary incontinence, voiding difficulties, and pelvic pressure 1 2 4.
• Types of cystocele (central, lateral, apical, cystourethrocele) are defined by the location and nature of the supportive defect 5 8 9 12.
• Causes include childbirth trauma, connective tissue weakness, increased abdominal pressure, and muscle injury 5 6 10 13.
• Treatment options range from pessaries and pelvic floor exercises to advanced surgical repairs, with choice guided by cystocele type, severity, and patient needs 1 12 14 16 17.
• Surgical outcomes are generally excellent, especially when the underlying defect is properly identified and corrected 2 11 12 17.

If you suspect you have symptoms of cystocele, speak with a healthcare provider for accurate diagnosis and to discuss the best management strategy for you.