Pelvic organ prolapse is common but rarely discussed.  Women who have a prolapse often have bladder issues too.  A cystocele, or a prolapse of the vagina and bladder, impacts the bladder more than other types of prolapse.  So what kind of bladder symptoms do women with a cystocele have?

How a prolapse impacts the bladder

Let’s start with a little background.  For the bladder to empty, the bladder muscle (also called the detrusor muscle), has to be able to squeeze hard enough to push the urine out of the bladder and through the urethra (the tube that leads to the outside).  When you have a bladder prolapse, the bladder sits lower.  It can be severe enough that the bladder sits outside the vagina.  This means that the bladder has to squeeze really hard to empty.  It has to squeeze hard enough to push the urine up and then out of the body.  And the prolapse can also push on the urethra and partially block it.  This too can also make it harder to empty. (find more information about prolapse here).

Bladder symptoms with a prolapse

Women with prolapse often feel like they are having trouble emptying.  Their stream may be slow.  It may stop and start.  It may just take a bit for the stream to get started.  Usually they empty just fine but the process feels much longer and harder.

Women with prolapse are also more likely to have urgency incontinence symptoms.  They may feel the need to empty all the time.  They may need to rush to the bathroom with that “gotta go” feeling.  They may leak before they get there.

Since the prolapse makes it harder to empty, women with prolapse are less likely to have symptoms of stress incontinence.  The prolapse just makes it harder for the leaking to happen.  This means that women who do have prolapse and stress incontinence may notice that the stress incontinence improves as the prolapse get bigger (and makes it even harder to empty).

Bladder symptoms after prolapse treatment

So what happens to bladder symptoms when the prolapse is treated?  When a prolapse is treated (with either a pessary or surgery), it is usually easier to empty.  About 60% of the time, urgency incontinence will completely resolve.  This happens without any other treatment.  But new symptoms of stress urinary incontinence are more likely to happen and they can happen up to 25% of the time.  When it is easier to empty, it just makes it easier to leak.

Everyone who treats prolapse knows that leaking can happen after the treatment.  We also know that if we fix the prolapse but give you leaking, you aren’t going to be happy.  That is why we test and look for leaking before prolapse surgery.  There are a few different ways that this can be done.  You can wear a pessary to see if you leak.  You can have a special bladder testing called urodynamics.  You can place a bladder sling at the time of the prolapse surgery to minimize the chance of leaking.  You can wait until after the prolapse repair and treat the leaking if needed.  The most important thing is  honest communcation.  Be sure to discuss bladder symptoms before any prolapse treatment and agree on a treatment approach.

Khayyami et al. Int Urogynecol J 2021; 32(8):2119-23.

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