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Bulge of the anterior vaginal wall

  Bulge of the anterior vaginal wall is very common, actually it is often a combination of bladder and urethra bulge with urinary dysfunction. Mild bulge generally has no symptoms; when prolapse is severe, clinical symptoms appear, and treatment is then required. Women often need to compress the vagina or use their hands to reposition the prolapsed tissue to completely empty the urine.

 

Table of Contents

1. What are the causes of cystocele?
2. What complications can be caused by cystocele?
3. What are the typical symptoms of cystocele?
4. How to prevent cystocele?
5. What laboratory tests are needed for cystocele?
6. Diet taboos for patients with cystocele
7. Routine methods of Western medicine for the treatment of cystocele

1. What are the causes of cystocele?

  1. Etiology

  The cause of cystocele is not completely clear, and the factors causing prolapse vary from individual to individual, which can be congenital or acquired factors. The maintenance of the normal structure of the vagina and surrounding pelvic organs is the result of the interaction of pelvic muscles and connective tissues. The upper part of the vagina is located above the anal muscle and is stabilized by the connective tissue connected above and behind. The middle part of the vagina is connected to the arcuate ligaments on both sides of the pelvic cavity. The loss of normal function of nerves, muscles, or connective tissues that play a normal supporting role, such as pelvic muscles, connective tissues, or both, can lead to the loss of vaginal support structures. Large infant delivery, multiple deliveries, or cesarean section, prolonged labor, can cause the pubovesical-cervical fascia to stretch, thin, and tear, causing part of the posterior bladder wall and bladder trigone to descend into the anterior vaginal wall, leading to bladder prolapse. Urethral prolapse often occurs with bladder prolapse and is caused by the shearing force (shearing effect) exerted by the fetal head on the urethra and its lower pubic symphysis during labor. If the pubocervical fascia, bladder cervix ligament, and levator ani muscles are excessively stretched or torn during labor, and the postpartum period does not recover as expected, the bladder base will lose its supporting force, gradually prolapse to the anterior vaginal wall, leading to vaginal prolapse.

  2. Pathogenesis

  Cystocele can be divided into two types: expansion type and displacement type. The expansion type is due to the overstretching and thinning of the anterior vaginal wall, which is often related to vaginal delivery and vaginal atrophy with age and menopause. The characteristic of this type is the disappearance of vaginal rugae on the anterior vaginal wall due to thinning or absence of the midline vaginal fascia. The displacement type is due to the pathological separation and elongation of the vaginal support tissue in front of the vaginal wall to the arcuate ligament of the pelvic wall. It can be unilateral or bilateral and is often associated with varying degrees of bladder prolapse and excessive movement of the urethra. The cystocele is shown in Figure 1, where the anterior vaginal wall and the bladder base on the inside are pathologically downwardly displaced.

2. What complications can be caused by cystocele?

  Cystocele often occurs concurrently with bladder prolapse, urethral obstruction, and poor urine excretion. Severe cases may experience difficulty in urination. Residual urine is prone to cause cystitis, leading to symptoms such as frequent urination, urgency, and dysuria. In severe cases, infection can ascend to the ureters and kidneys, causing ureteritis and pyelonephritis. If kidney infection is present, fever may occur (often greater than 39 degrees Celsius). A small number of women with prolapse may have hydronephrosis.

3. What are the typical symptoms of cystocele?

  Mild cystocele may have no symptoms, the feeling of incomplete urination is a manifestation of severe prolapse. The main symptom of women with cystocele is the prolapse of the vagina or related symptoms. They feel something protruding from the vagina. During labor, coughing, straining, or when abdominal pressure increases or the bladder is full of urine, the object increases in size and urine leaks out. After lying down or urinating, it shrinks or even disappears. Patients have a feeling of fullness in the vagina, a feeling of descent in the pelvic cavity, stress urinary incontinence or incomplete urination, pain in the lumbar sacral region that worsens after standing for a long time, and difficulty in sexual intercourse. Often, patients need to push the prolapsed vagina themselves to empty the urine.

  Clinical Staging:

  1. Degree I (mild): The anterior vaginal wall prolapse has reached the hymen edge but has not protruded outside the vaginal orifice.

  2. Degree II (moderate): Part of the anterior vaginal wall has prolapsed outside the vaginal orifice.

  3. Degree III (severe): The entire anterior vaginal wall has prolapsed outside the vaginal orifice.

  Signs include prolapse of a mass in the vagina, stress urinary incontinence, and 39% of women with cystocele experience stress urinary incontinence.

  In a condition of a full bladder, the patient is first placed in a lithotomy position to examine the external genitalia. If no corresponding signs are found or the extent of the maximum prolapse cannot be confirmed, a standing position examination is performed. If no obvious prolapsed tissue is found, gently separate the labia minora to expose the vestibule and hymen, assess the integrity of the perineum, and estimate the size of the prolapsed tissue. Compression of the posterior vaginal wall with the posterior blade of the speculum helps to expose the anterior vaginal wall. Then, ask the patient to strain or cough forcefully, observe the prolapse of pelvic organs, and it helps to differentiate between lateral defects and central defects. The former is manifested by the disappearance or separation of the vaginal sulcus; while the median prolapse is manifested by the presence of the vaginal sulcus, the descent of the anterior vaginal wall is accompanied by the descent of the bladder, and is accompanied or not accompanied by excessive movement of the urethra. If concurrent urethral prolapse occurs, when abdominal pressure increases, the urethra rotates downward and forward.

  Studies have shown that the feeling of incomplete urination in women with severe prolapse is attributed to urethral obstruction. When prolapse is reduced, urethral dysfunction is exposed, accompanied by stress urinary incontinence. For women with severe prolapse, it is very important to check urethral function after the prolapsed object is returned to its original position. If the patient urinates normally after the prolapsed object is returned, but still leaks urine during forced coughing or Valsalva maneuvers, it suggests dysfunctions of the urethral sphincter muscles.

4. How to prevent cystocele?

  1. Epidemiology

  Cystocele is very common, with mild prolapse commonly occurring in multiparous women. It can also occur occasionally in nulliparous women with poor developmental pelvic floor structures and in postmenopausal women with tissue atrophy. The incidence increases with age, but the actual incidence is still unclear.

  2. Prognosis

  Recurrence indicates that the relevant supporting tissue defects were not well identified and repaired during surgery, or may be related to the weakening, relaxation, or defect of tissues with the increase of age and menopause. Other factors include genetic factors, constipation, multiple pregnancies, heavy lifting, chronic pulmonary diseases, smoking, and lack of estrogen replacement therapy after menopause.

 

5. What laboratory tests are needed for cystocele?

  1. Urinalysis to exclude urinary tract infection in patients.

  2. Vaginal cytology scraping to estimate the maturity index and evaluate the patient's estrogen level.

  3. Urodynamic examination requires the use of a pessary inserted into the vagina before the urodynamic test to reduce prolapse. If there is stress urinary incontinence or emptying obstruction, this examination is required.

  4. Endoscopic examination to assess the function of complete bladder emptying, usually immediately after urination, and measure residual urine in a timely manner.

  5. Ultrasonic examination to measure residual urine.

6. Dietary taboos for patients with vaginal wall prolapse

  What to eat after surgery for vaginal wall prolapse

  1. Eat on time and in fixed amounts, and do not overeat or eat irregularly.

  2. Adhere to a low-fat diet, eat more lean meat, eggs, green vegetables, and fruits.

  3. Eat more grains and cereals such as corn and beans.

  4. Eat nutritious dried fruit foods such as peanuts, sesame seeds, and melons.

  5. Eat light diet, such as white porridge, green vegetables, and avoid eating gas-producing foods to prevent bloating, such as milk and beans.

  6. Consume high-protein, high-iron, and high-fiber foods such as cherries, grapes, fish soup, vegetables, etc., to prevent constipation and promote wound healing.

  7. If menstruation is heavy, eat more iron-rich foods to prevent iron deficiency anemia.

  What is bad for the body after surgery for vaginal wall prolapse

  1. Avoid spicy, alcoholic, frozen, and other foods.

  2. Do not take additional estrogen, especially after menopause.

7. Conventional methods of Western medicine for treating anterior vaginal wall prolapse

  1. Prevention:

  Prevent perineal injury, and postmenopausal women should actively exercise to increase the function of pelvic muscle groups.

  2. Precursors of disease occurrence:

  Mild cases have no obvious symptoms. Severe cases may feel a sensation of descent and lower back pain, with a mass protruding from the vagina, which is actually the prolapsed anterior vaginal wall. After long standing, intense activity, or increased abdominal pressure, the mass may enlarge, and the sensation of descent becomes more obvious. If there is only a prolapse of the anterior vaginal wall and bladder, the posterior angle of the bladder and urethra becomes acute, often causing difficulty in urination and urinary retention, and even secondary urinary tract infection. If the bladder prolapse is combined with urethral prolapse and complete prolapse of the anterior vaginal wall, the posterior angle of the bladder and urethra disappears, and urine may overflow during coughing, straining, or other activities that increase abdominal pressure, known as stress urinary incontinence.

 

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