Bladder Drop and Incontinence

Many women have problems with what doctors refer to as prolapse. One specific area of prolapse is with the bladder. Most prolapse is considered some form of a hernia. Similar to hernias of the groin or "belly button," pelvic hernias and prolapse are caused by a break in the tough tissue or fascia that acts as a supportive layer. When the fascia is broken or separated, other organs or areas can bulge through.

One of the most common areas of prolapse is the bladder. The bladder sits right in front of the anterior vagina. If the support of the bladder is disrupted, such as in childbirth or just over time, the bladder can bulge into the vagina or even out through the vaginal opening.

Some forms of urinary incontinence can be caused by or complicated by bladder drop. Frequently, patients who leak urine with coughing, sneezing, or with exercise, have a defect in the bladder support that contributes to the leaking.

Dr. Cullen Richardson studied the defects involved with bladder support problems and found three different support areas that can break and cause a bladder hernia. The first and most common site is where the bladder fascia attaches to the pelvic bones. This is referred to as a lateral defect or paravaginal defect cystocele. As the lateral support is broken, the bladder is allowed to drop down out of position. This is similar to spring support on a trampoline that attaches to the frame.

The other two types of hernia defects are transverse and midline defects. These two are less common and are likened to a tear in the trampoline fabric itself.

Common treatments for bladder prolapse include exercises to strengthen the pelvic muscles, pessary treatment, and surgery. Bladder prolapse is not a dangerous condition and many women live without any treatment. Pessaries are similar to contraceptive diaphragms which are placed in the vagina and act as a supporting "shelf" to hold the bladder in place and keep it from protruding out the vaginal opening.

Common surgeries for bladder prolapse include an "anterior repair." This is a god procedure for transverse and midline defects. Essentially the vaginal mucosa is opened exposing the supporting bladder fascia. This fascia is then sewn with stitches closing the defect.

Lateral or paravaginal defects are repaired either vaginally, laparoscopically or abdominally. Each surgeon has his/her preferred method of operating. The goal of the surgery is to re-attach the fascia to the lateral pelvic bones. I perform these surgeries laparoscopically. This allows a similar procedure to the abdominal method, but uses only small one centimeter incisions. Laparoscopy magnifies the view and the defects are identified. Permanent sutures are then placed to hold the support back into its normal position.

Incontinence surgery can be performed at the same time. There are minimally invasive procedures used to treat stress incontinence. These will be addressed in an upcoming post.

Laparoscopy for Pelvic Prolapse

The latest addition to this blog is regarding pelvic prolapse. More common terms heard at your doctor’s office are: cystocele, rectocele, and uterine or uterovaginal prolapse. This occurs when the thick tissue, or fascia, which supports the female structures, becomes weakened over time. This is most likely due to injury sustained with labor during childbirth or with previous pelvic surgery such as hysterectomy. Anything that interrupts by tearing or disrupting nerve input to the supporting muscles can contribute to the problem of prolapse.

The most common symptoms of prolapse are pelvic pressure, a bulge either felt or seen at the vaginal opening. Many patients have problems with bowel movements even requiring “splinting” or use of a finger in the vagina to help express stool. With cystocele, patients can have either urinary retention (the inability to void), and or leaking urine with coughing, sneezing, etc. This is known as stress incontinence.

I would like to mention that a cystocele can be of three different natures. The support of the bladder runs underneath the bladder, runs to the side and attaches to the connective tissue of the side of the pelvis. This attaching tissue may have breaks at the lateral attachment, in the midline, or at the top of the bladder where the bladder sits on the anterior part of the lower uterus. The most common defect seen is the lateral attachment defect in greater than 90% of patients. These breaks in the fascia are considered to be hernias as they allow abdominal and pelvic contents to bulge through the fascia.

The most recent surgery performed was in a woman in her 60’s. She had problems with bowel movements, stress incontinence, and pelvic pressure. On her examination, she had a rectocele (bulging of the rectum into the vagina), cystocele (bulging of the bladder into the vagina), stress incontinence and prolapse of the uterus. She desired to preserve her uterus. This is appropriate as the uterus itself is not involved in support of the pelvic organs.

This patient underwent a laparoscopic surgery which, through laparoscopic suturing, re-established support of the upper vagina and uterus to the uterosacral ligaments. This is a relatively simple surgery for uterine prolapse that has an 80% success rate. The benefit of this is uterine preservation.

The second portion of the surgery was to correct cystocele. As this patient had a lateral defect, her repair consisted of re-attaching the supporting tissue to the side at the area it originally detached. If there is a large separation, a modification can be made that may increase the likelihood of a successful repair. This surgery, paravaginal repair, can be done vaginally, abdominally, or laparoscopically. Laparoscopic surgery allows much easier visualization of the area of concern with precise placement of sutures to correct the torn supporting tissue.

After this, a mesh “sling” was place underneath the urethra to correct the stress incontinence. This was done with a small one centimeter incision in the vagina with two small incisions on the lower abdominal wall. There are many ways to treat stress incontinence. The two “gold standard” treatments are Burch Urethropexy and suburethral slings.

The final part of the procedure was a traditional posterior repair correcting the defect in the supporting tissue between the rectum and vagina.

The surgery went well without any complications. The patient had a normal recovery and went home on the third day after surgery. She was urinating on her own and was holding urine with coughing. She had a quick return to normal diet and her pain was controlled with pain pills. Infact, this patient had adequate pain control with only Tylenol on day number three after surgery.

Laparoscopic correction of pelvic organ prolapse allows wonderful visualization of the specific defects causing prolapse. It also allows preservation of the uterus if desired. The traditional advantages of laparoscopy apply in these cases. These benefits include smaller incisions, quicker recovery, and shorter hospital stay.