There are several options for treatment of cystoceles.
One option is watchful waiting. Not all patients with a cystocele require surgery. It is hard to recommend surgery for a patient if the degree of prolapse is small and no symptoms are present. The patient can safely wait for development of symptoms over time. If the patient is not interested in surgery but is symptomatic a pessary could be used to correct the cystocele. A pessary is a plastic device which is inserted into the vagina to push the bladder into position. The pessary rests against the pelvic sidewall to provide the support for the prolapsing vaginal wall. Given the variation in vaginal width and depth, pessaries have to be fitted by a healthcare professional. Correct fitting can be difficult in some patients leading to vaginal erosion or expulsion of the pessary. The most common treatment for cystoceles is surgical correction.
Surgical correction of a cystocele can be very simple or quite complex.
Surgery can be performed through the vagina or abdomen but is most often performed trans vaginally. Usually the patients vaginal and pelvic tissues are used to provide the new support for the vaginal wall but there has been tremendous interest in using other materials to provide extra support for poor vaginal tissues when correcting a major cystocele.
The most common surgery to correct a cystocele is plication of the anterior vaginal wall tissues. The premise for the procedure is that there is a discreet central defect under the bladder. Sutures are used to approximate the edges of the defect. Often there is excess vaginal wall that has developed from the chronic protrusion. This excess tissue is removed during this procedure. Some surgeons argue that there are very few central defect cystoceles and this procedure should only be used rarely. This procedure requires little time in surgery and this is often a day surgery case.
Occasionally the anterior vaginal wall can be supported by sutures placed in the edges of tissue that has separated from the pelvic sidewall. Some surgeons will then support the vaginal wall with the abdominal wall by passing the sutures through the strength tissue of the abdomen. The sutures in can also be used to reapproximate the bladder support tissue to the pelvic sidewall. This is often referred to as a para vaginal defect repair and can be performed through the vagina or through the abdomen. This type of repair is primarily designed to correct a lateral defect. This is a day surgery procedure in most cases unless an abdominal approach is used.
Mesh or biologic material can be used to augment the cystocele repair. Generally augmentation of the cystocele repair is used when the bladder prolapse is more significant (Grade III or Grade IV) or if the bladder prolapse is recurrent. The mesh most often used is a soft widely pored polypropylene similar to that used in midurethral slings and in abdominal hernia repairs. Biologic materials include human dermis, human fascia lata, porcine (pig) dermis, and sheep intestinal wall collagen. Often this material is shaped to so as to be wide enough to span from pelvic sidewall to pelvic sidewall and from the bladder neck to the apex (deepest point) of the vagina. Sutures are used to connect the augment material to these areas. Some of the augments come in kit that make the placement of the mesh or biologic material easier. Usually the augment has arms that are placed through natural openings in the groin (obturator foramen) providing extra support by attaching to tissues in these areas. Given these repairs are more complex, more operative time is required and often the patient will require at least an overnight stay in the hospital.